Inspection on 20/09/05 for Broomgrove Nursing & Convalescent Home

This inspection was carried out on 20th September 2005.

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 &... 12/06/07

Broomgrove Nursing &... 03/03/06

Broomgrove Nursing &... 12/01/05

Broomgrove Nursing &... 10/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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 Unannounced 20 September 2005 09:00. 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 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. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broomgrove Nursing & Convalescent Home Address 30 Broomgrove Road, Sheffield, South Yorkshire, S10 2LR 0114 266 1311 0114 268 4276 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Broomgrove Trust Miss Susan Eyre Care home with nursing 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (36) of places Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12-Jan-2005 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 the 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. Although the home mainly 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 limited number of places for permanent care. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 20/09/05 between 9am and 1pm. Residents and staff were consulted and the inspector viewed the premises and checked records. What the service does well: What has improved since the last inspection? 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. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 7 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 standard(s) 1,3,4&5. The home provides the prospective residents and their families with sufficient information to make an informed choice. Before moving into the home service users take part in an assessment by the home’s manager/ qualified nurses to find out whether they are able to cater for the identified needs of the service users. Prospective service users are invited to visit the home and spend time among the residents to find out the suitability of the home before moving in. EVIDENCE: Five residents were consulted. The residents said that they and/or their relatives had the opportunity to visit the home and meet the residents and the staff at the home before deciding on moving in. Since most residents are self-funding the staff at the home visited the residents at their homes or at the hospitals and carried out assessments before agreeing to accommodate them at Broomgrove. The residents and the staff said that service users were invited to spend time at the home before accepting residency. However, the majority of the residents were those who had received convalescence and preferred to take up permanent residency. The home had copies of the service users’ written costed contracts which had been agreed and signed by both parties. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 8 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 standard(s) 7,8,10&11 All residents have care plans. In order to meet individual needs the care plans are completed fully at the earliest possible opportunity by staff. The staff ensure that the health and social care professionals from the hospitals and from the community are involved when necessary. The qualified nurses managed the medication. The residents are treated with respect and the staff value their right to privacy. Most relatives are consulted about funeral arrangements when the staff feel it to be appropriate, so that the residents’ last wishes are respected. EVIDENCE: During the inspection evidence was gathered from consulting service users, staff on duty and through observation. One care plan was checked briefly whilst checking some information about the service user. The information was available and the staff were helpful. The service users told the inspector that they were well cared for by the staff. One resident said that he/she continues to live at the home, which shows that he/she is satisfied and wanted the Inspector to note that the staff at the home give “super care”. Another resident who was waiting to go home said that the home was like a hotel and the staff were “smashing” and couldn’t ask for more. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 9 The Inspector asked service users whether they were involved in the planning of their care. They said that they wanted the staff to decide on the appropriate care they should have and that if they felt any changes should be made to the care they receive then they will tell the staff. The staff had a clear specification of their job role. The care staff gave personal care to service users and the qualified nurses offered nursing care. The nurses also supervised and gave support to the care staff. All service users had access to GP, dentist, chiropodist, optician and other professionals according to their needs. The supplying pharmacist had carried out an audit on 20/07/05 and the out come was satisfactory. The inspector ascertained through interviews and observation that particular regard was given to the service users’ privacy, dignity and respect by the staff. The staff had experience in looking after service users who were dying. They said the main aim was to keep the service users comfortable and maintain dignity. They also said that a critically ill service user was never left alone if the relatives were unable to attend. Staff had not received formal training on death and dying, but said that the qualified members gave them on the job guidance. The deputy manager said that this has been addressed by the training co-ordinator. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 10 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 standard(s) 12,13,14&15 The service users have the opportunity to exercise their choice in relation to routines of the day, personal and social relationships, religious observance, choice of food, frequency of meals and meal times. There was provision for leisure and social activities to stimulate the residents. Relatives and friends are encouraged to visit and residents are able to maintain contact with family, friends and members of the local community. Thus the residents are able to maintain outside contacts. Meals served at the home are of a good quality and the residents are offered a choice. The residents are able to have snacks and drinks in between meals if they so wish. EVIDENCE: The service users said that the home was flexible and did not dictate when should get up in the morning and go to bed in the evening. They said that the staff helped them keep in touch with family and friends. The service users said that they had some activities but often liked to read and relax. The residents and the relatives commented on the choice of food and how good it was. The staff were seen helping residents with meals. Special diets were provided according to the resident’s needs. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 11 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 standard(s) 16,17&18 The relatives and the residents are given the opportunity to raise any concerns and complain to staff or the manager. This is to enable residents to voice their opinion of the service and also for the staff to review and make improvements to areas of concern. The residents are enabled by the staff to exercise their legal rights and for those who lack capacity, an advocate service is offered. Such arrangements help residents to receive independent advice and help. The home has a complaints policy The management gives opportunities for staff to attend courses on adult protection and allegation of abuse. This is to protect service users and staff. EVIDENCE: The home had a complaints policy, which the staff were aware of. The staff told the inspector that when anyone complains, depending on the issue if appropriate they take immediate action to resolve it and then inform the person in charge. Not all of the staff were not familiar with Adult Protection policies and the procedures to follow if there were to be an allegation of abuse. The care staff said that they would tell the nursing sister. The nurses were aware of the procedures. Although this was correct the staff must be aware of the procedures and expected action to be taken by the management. Some staff had attended training in the above areas. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 12 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 standard(s) 19,20,21,22,23,24,25&26 The layout and the location of Broomgrove Trust is suitable for it’s stated purpose. The home is clean and residents’ rooms are personalised. Domestics are employed to carry out housekeeping duties. The rooms are naturally ventilated with windows conforming to recognised safety standards. The home has an adequate numbers of toilets and bathrooms. There is a maintenance programme in order to keep the home in good repair. The residents use the lounges during day and night. The laundry is sited away from the kitchen and food preparation areas, thus preventing infected and soiled clothing from being carried through these areas. EVIDENCE: The home has a routine maintenance programme. There had been some renewal of fabric and some decoration had taken place. The inspector found the grounds tidy attractive and accessible to service users. , It was noted that the dependency levels of service users had risen and as a result more service users were in need of moving and handling with the aid of a hoist. The staff suggested an extra electric sling hoist to help with the Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 13 moving of residents. The inspector made the deputy matron aware of this request. Staff were able to verbalise the infection control procedure and they identified hand washing as the most essential precaution. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,28,29&30 The staffing rotas are formulated taking into account the number of service users. The staff numbers and skill mix of qualified nurses and health care support workers are allocated so that the service users are able to receive appropriate care. There was documentation showing staff training and a thorough recruitment practice. Thus promoting a safe environment for service users. EVIDENCE: This was an unannounced inspection and on the day of the inspection the staff complement was adequate for the number of residents. During interviews the staff explained that the dependency levels of service users had increased and therefore service users are requiring more time and attention. A number of the health care support workers have obtained NVQ level 2 awards. The management are committed to training support workers up to NVQ level2. Four recruitment files were checked. Most information required by the regulation was made available in each file. Four staff training records were checked. The training co-ordinator said that these records were being audited and staff were being made responsible for areas of their expertise. Due to staff turnover the home was unable to achieve this. This will be checked on the next inspection. The staff who were interviewed had good understanding of the care needs of service users. The staff also had good support mechanisms among themselves to obtain assistance. The staff had worked over to fill in the gaps created by staff leaving. The deputy manager said that they were in the process of recruiting staff to replace those who have left. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37&38. The manager is a qualified nurse who is competent and experienced in the running of the home. The manager and her team ensure that their approach creates an open and positive atmosphere at the home. All staff have annual appraisals and formal supervision. Records of the service users, the staff and the home are kept safely at the home to adhere to the data protection act and maintain confidentiality. The manager ensures as far as is possible that the health and welfare of service users and her staff are maintained to provide a safe working place. EVIDENCE: The service users and the staff were very positive about the management at Broomgrove. They said that the manager was approachable and she listened to their comments. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 16 The manager is an experienced nurse. She has many years of management experience in both NHS and the private sector. The deputy manager is in the process of completing NVQ Level 4 in management. Care staff and nurses receive formal supervision. The staff said that the supervision covered all aspects of care practice, philosophy of care in the home and career development needs of the staff. All records requested for inspection were safely kept at the home. The staff and the service users said that they live in a safe environment and that if any repairs needed to be done, the handy person attended to them without delay. The staff verbalised what types of incidents and accidents were reported to CSCI and other organisations. The staff said that they received induction training on all safe working practice Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 x x 3 3 Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 22 16,18 Good Practice Recommendations It is recommended that the home explores the possibility of purchasing an electric sling hoist. The care staff should be familiar with the homes procedures although they may not be directly involved i.e. timescales for complaint investigation, keeping records of all complaints, what happens when an allegation of abuse is reported to the manager. Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 19 Commission for Social Care Inspection Ground Floor Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Broomgrove Nursing & Convalescent Home 20050920 Broomgrove X00015 UN Stage 4 S21772 V219877 J55.doc Version 1.40 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!