Inspection on 11/03/05 for Broomhill

Care Home For Older PeopleBroomhill92 Eastwood Road Brislington Bristol BS4 4RS11 March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Broomhill Address 92 Eastwood Road, Brislington, Bristol, BS4 4RS Email address No email Name of registered provider(s)/company (if applicable) Bristol City Council Name of registered manager (if applicable) Penelope Baxter Type of registration Care Home No. of places registered (if applicable) 40 Tel No: 0117 9779802 Fax No: 0117 9724091Category(ies) of registration, with (number of places) Old age, not falling within any other category (40) Registration number D050000734 Date first registered 31st March 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 31st March 2003 NO NO 15/11/04 If Yes refer to Part CBroomhillPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 311 March 2005 09:30 am Sandra Garrett X X X XID Code134014Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Lyn Groves ­ assistant managerBroomhillPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementBroomhillPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Broomhill. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.BroomhillPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Broomhill operated by Bristol City Council and is a 40 bedded home situated in the residential area of Brislington. The nearest shops are 300 yards away where there is a post office, newsagents, hairdresser, pub and supermarket. The home is on 3 levels with 2 lifts providing access to all areas of the building. There are 4 lounges around the home and a large spacious dining room on the 1st floor. All bedrooms are single and contain a wash hand basin. Toilets and bathrooms are close by. The garden is accessible with rails to assist the service users onto the patio area. The area has a new rockery with a water feature. A first floor balcony offers residents the opportunity to sit and look at views across to Bath and surrounding countryside.BroomhillPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Introduction This visit replaced the announced inspection due at the end of March. The inspector hadnt visited the home before and will become its permanent inspector from April 05. The visit was therefore an opportunity to meet residents, managers and staff. It was pleasing to note almost all requirements and recommendations from the last inspection had been met. However several new ones were made. These included (among others): staff training in respect of working with residents who have mental health needs, reviewing of care plans that reflect changes and raising the height of the main balcony to ensure residents safety. The assistant manager on duty Mrs Lyn Groves was welcoming and open to the inspection process. The inspector also spoke to the manager of Broomhill, Mrs Penny Baxter by phone on the day of inspection and met with her the following week to give feedback. Residents spoken to expressed high levels of satisfaction with life at the home. Choice of Home (Standards 1-6) One of three Standards assessed were met. One was nearly met. The inspector followed up requirements from the last inspection in respect of details to be inserted in the Statement of Purpose and the carrying out of assessments on potential residents. The inspector noted that day visits are offered before admission. In respect of the requirement regarding the Commissions details to be inserted into the Statement of Purpose this timescale had not yet been reached. It is therefore carried forward. The inspector noted that external assessments by management staff are not done before a resident is admitted. As this was raised at the last inspection, the inspector recommends that a way be found to undertake these. The outcome for residents is that they may not be able to be permanently accommodated if the home later finds it cannot meet their needs. Health and Personal Care (Standards 7-11) Two of three Standards assessed were met. One was nearly met. The inspector noted appropriate recording of how health care needs were being met and saw records of medical visits to the home. The manager had also devised a good record of residents last wishes in the event of their deaths that gave clear information about how they wish to be cared for and what they want to have around them. This is commended. However the inspector noted a lack of information in respect of preferred names, an assessed need and monthly reviews. A new requirement encompassing these issues is made. The outcome for residents is that they may not be treated with respect, assessed needs may be overlooked and not met if care plans are not regularly reviewed. Daily life and Social Activities (Standards 12-15) One Standard assessed was met. Residents were able to tell the inspector of the choices available to them and it was clear from records seen that residents are consulted and are able to have choice over many aspects of their lives in the home. This is commended. Complaints and Protection (Standards 16 ­18) One of two Standards assessed were met. One was nearly met. The inspector followed up a Broomhill Page 6 requirement from the last inspection in respect of complaints records and found this to be met. Residents had access to a complaints leaflet and were able to use it and the Commissions details were inserted. However not all complaints of alleged abuse had been referred to Social Services and Health (SS&H) under Department of Health guidance No Secrets and two of three such incidents were not reported to the Commission. The outcome for residents is that they may not be fully protected from harm and the Commission is unable to monitor such events on their behalf. Environment (Standards 19-26) Three of four Standards assessed were met. One was nearly met. The inspector noted that Broomhill provides a good Standard of accommodation and décor for its residents. The home was clean and hygienic at this visit and aids and adaptations for disabled residents or visitors are in place. The inspector was pleased to note residents had free access to bathrooms although found not all radiators were covered to protect them from risk of harm. A requirement is therefore made. The outcome for residents is that they may not be protected from harm or risk of harm if the environment is not made safe for them. Staffing (Standards 27-30) Two Standards assessed were not met. The inspector followed up a requirement from the last inspection in respect of keeping personnel records at the home. It was pleasing to note that recently appointed staff records were available that included all those required under legislation. However few photographs of staff members were seen in files and a new requirement is made. The outcome for residents is that they may not be protected from harm or risk of harm if staff cannot be identified. A requirement for training in working with people with mental health issues is also made due to the number and type of mental health impairments residents may have. The outcome for residents is that their assessed needs in respect of their mental health and their well-being in the home may not be met if staff arent given training in how to work with and care for them. Management and Administration (Standards 31-38) Five of seven Standards assessed were met. Two were nearly met. The inspector noted both the manager and assistant manager on duty at the visit were welcoming and open to the inspection process. The manager is qualified and experienced in the running of the home. Records seen were orderly and showed clear management of finances. However the inspector had noted that reports of monthly visits made by the team manager to monitor quality of care provided, had not been regularly sent to the Commission. A recommendation is made in respect of positive recording in residents care records. Also, issues raised in daily records must be monitored, transferred into care plans when necessary and managed positively. The outcome for residents is that the Commission is not made aware of internal monitoring done within the home that ensures they are cared for and protected. Further their changing needs may not be identified or appropriately met. The inspector noted fire safety records showed clear management of fire risk within the home. However a balcony on the first floor must be risk assessed and made safe. Specific risk assessments for residents who fall must be put in place. The outcome for residents is that they may not be kept safe or free from harm if the environment and their needs are not monitored.BroomhillPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)BroomhillPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Statement of Purpose and service user 31 March 1 5(1)(f) OP1 guide document to also include how service `05 users can contact the local C.S.C.I office. Care plans must be accurately reviewed and amended to reflect any changes for residents, with clear actions and outcomes recorded 2 15(1)(c) OP7 Care plans must record each residents preferred name Care plans must be reviewed monthly Any alleged incidents of abuse towards residents must be referred to Social Services and Health (SS&H) for immediate investigation and reported to the Commission for Social Care Inspection All bathroom radiators must be covered to ensure residents safety Photographs of each staff member must be kept at the home Training in working with people with mental health needs and behaviours that challenge must be provided and be regularly updated and ongoing for all staff Reports of visits to the home made by the responsible individuals representative must be sent to the Commission for Social Care Inspection at least monthly 1 June `05313(6)OP1830 April `054 5 613 (4)(c)OP2130 April `05 1 June `05 1 June `0519(5)(d) OP29 Schedule 4 18(1)(c)(i) OP30726(4)(c) (5)(a)OP3330 April `05BroomhillPage 9 All balconies must be risk assessed and a way found to minimise risk of falling from them. 8 13(4)(a) Manual handling and (where necessary) specific risk assessments must be done for each residents Notices of any incident/ill health/injury or death of any resident must be sent to the Commission for Social Care Inspection 30 April `05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The manager or an experienced member of staff should find a way to externally assess any potential resident and prior to emergency 1 OP3 admission to ensure the home is the right environment and assessed needs can be met. All care records should be written from a non-judgemental and person2 OP37 centred perspective, focussing on residents abilities not deficits * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.BroomhillPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO NO NA YES YES YES NO YES YES NO NO NO YES YES YES 8 X X NO NO YES NO X X 11/03/05 09.30 6BroomhillPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.BroomhillPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYESX If yes, please state what the extras are: 2 Key findings/Evidence Standard met? The inspector followed up a requirement from the last inspection in respect of entering details of the Commission for Social Care Inspection and how residents can contact it. The inspector didnt see details inserted although met the manager of the home at a later visit who said it would be done. The timescale for this requirement to be met was after the inspectors visit. Therefore its carried forward with the original timescale.BroomhillPage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? The inspector followed up two requirements from the last inspection in respect of ensuring the home carries out its own assessments of potential residents and confirms in writing to the resident or her/his relative/representative, that the home can meet her/his needs. The inspector saw records of a resident admitted just before inspection. This included a detailed Social Services and Health (SS&H) care plan that was comprehensive, detailed and identified lots of assessed needs. From reading this it wasnt clear whether the home would be able to meet the residents needs. The manager and assistant manager said they were also unsure. However the resident was still having the four-week trial and the manager said all matters would be discussed at a review meeting to be held at the home at the end of this period. The manager told the inspector that management staff tend not to go out to assess potential residents as they prefer to assess them in the homes environment to see how they will manage, during the four week trial period. During this time a care plan is drawn up with the resident/and or relatives. The care plan is signed by one of the management staff, together with the resident or her/his relative at the review meeting held at the end of the four weeks. The inspector saw copies of signed care plans that indicate the homes confirmation that assessed needs can be met. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.BroomhillPage 14 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The assistant manager told the inspector that prospective residents come to the home for a day visit so that their needs can be assessed. The inspector saw records regarding the day visit of a potential resident. The assistant manager also told the inspector that only one emergency admission had been accepted in the last twelve months. The manager later told the inspector that she insists on reviews being done by social workers after 72 hours as required by regulation. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This Standard is not applicable to this home.BroomhillPage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The inspector reviewed three care plans and noted the following: Each care plan contained a photograph of the resident Care plans were signed by residents Care plans showed evidence of review and changes made in pen with dates Care plans seen were comprehensive and detailed and one recorded evidence from the resident that her/his needs were being met. All the above is good practice. However the inspector noted the following: The inspector noted three residents had different names to those recorded. It was therefore not clear what the resident preferred to be called. One residents care plan had been reviewed on the 22 February 05 with `no change recorded. However the inspector found from reading daily records that the resident wasnt sleeping. The care plan didnt reflect this as an assessed need nor did it demonstrate that anything was being done about it. Further, no evidence was recorded of referral to the GP regarding a possible sleep disorder. No clear plan of managing the residents wakefulness was recorded and the daily records revealed only that the resident was persuaded or told to go back to bed The inspector saw that care plan reviews were not all being carried out monthly. Sheets with dates of reviews were seen yet these showed evidence of one, two or four monthly review. The inspector followed up a requirement from the last inspection in respect of consulting with residents then preparing written plans of how care is to be given in order to meet residents assessed needs. This was found to be met from the plans seen and residents comments were included. However a new requirement is made encompassing the issues noted above.BroomhillPage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X X3 Key findings/Evidence Standard met? The inspector saw records of GP visits and treatment recorded and also district nurse visits. Care plans reviewed included dental, sight and hearing needs and evidence was seen of these being met. The inspector saw appointments for chiropody booked. The inspector also saw in one residents care plan that s/he didnt want spectacles and this was respected.Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This Standard was not inspected at this time.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.BroomhillPage 17 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 4 Key findings/Evidence Standard met? The inspector saw several completed copies of a document the manager had drawn up to record residents last wishes. These were clear and detailed and reflected each residents wishes to be respected at the end of their lives. Residents had signed the forms after being consulted and having her/his wishes recorded. The inspector noted that if residents were unhappy about the form being completed this was respected. Wishes recorded included music to be played, things the resident wished to have with them and funeral details. The use of the document is very good practice and to be commended. The inspector noted that a number of staff have attended Loss and Bereavement training that is ongoing.BroomhillPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Residents the inspector spoke to told her of the choices available to them. Information about choices was also seen from residents meeting minutes dated October 04. These included residents requests for different meals, entertainments and information sharing. Residents said they are free to choose what they want to do, where they want to sit and have as much choice as they want. This is commended.BroomhillPage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.BroomhillPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 3 2 1 X X X 75 3 Key findings/Evidence Standard met? The inspector followed up a requirement from the last inspection in respect of ensuring complaints literature is updated following the Commissions name change. The inspector saw copies of the most recent complaints leaflet pinned up on the back of bedroom doors. This leaflet had the Commission for Social Care Inspections details inserted. The inspector reviewed the complaints file and saw a complaints leaflet that had been used by one resident fully completed. Complaints about quality of food, condition of the dining room and quality of care were seen recorded together with details of investigation and outcome. However please also see Standard 18.BroomhillPage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? The inspector followed up a requirement from the last inspection in respect of reviewing and updating the homes procedure on Protection of Vulnerable Adults. The inspector noted that a leaflet had been sent to the Commission together with the pre-inspection questionnaire. This leaflet though brief, set out the procedure to follow if abuse is suspected. The manager said all staff were in the process of being issued with the leaflet and many staff had done the Protection of Vulnerable Adults training. From this each had been given a copy of `No Secrets in Bristol that sets out the procedure to follow. This is good practice. However the inspector noted in the complaints file, letters in respect of two separate allegations of abuse towards residents by agency staff that had not been referred as Protection of Vulnerable Adults issues. Further a notice sent to the Commission about another issue was also not referred. A new requirement was therefore made.BroomhillPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Broomhill is a purpose built home set out over three floors. The home has a number of lounges and sitting areas and a good standard of décor throughout. The lounges particularly were decorated and furnished to make them homely although the inspector noted not many residents used all of them. Some residents were seen sitting in their rooms. The home also benefits from a garden area at the back that gives a pleasant space for residents to enjoy. This had lots of plants and a patio area. On the second floor the inspector saw a tea-room that was very well furnished that residents can use to eat with their visitors. However the manager said this and the `green lounge were not used often. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 9 Key findings/Evidence Standard met? This Standard is not applicable to this home.BroomhillPage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The inspector noted at least two toilets and a bathroom on each corridor. Toilets had aids and adaptations and all were clean. Bathrooms were unlocked and were clean and hygienic. One ambulift over a bath on the first floor was dirty on the underside and the inspector recommended this be cleaned and regularly monitored. However the inspector noted that not all radiators in bathrooms were covered and were hot to the touch. As bathrooms must be kept unlocked and available to residents a requirement is made to ensure the radiators are covered. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The inspector saw work being carried out to the recently installed automatic front doors to the home. This work had been carried out to make the doors accessible to disabled people but needed adjustment. The inspector noted an accessible shower room large enough for a wheelchair user and with a walk/wheel in shower. Throughout the home grab rails were seen in all corridors and there are two lifts. Each bedroom has a call system that was in use on the day of inspection. The inspector saw a large bookcase full of books in an alcove by the garden door. Many of the books were large print and some were audiobooks.BroomhillPage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This Standard was not inspected at this time. YES NO NO 40 X X X Standard met? 0 9 31X X X XBroomhillPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. Key findings/Evidence Standard met? 0 This Standard was not inspected at this time.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. Key findings/Evidence Standard met? 0 This Standard was not inspected at this time. (Please see Standard 21 above re radiators).Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. Key findings/Evidence Standard met? 3 The home was very clean at this visit. The inspector saw staff cleaning residents rooms all of which looked homely and individualised. The inspector noted a low level of odour particularly on the ground floor and a staff member said that carpets are regularly cleaned to combat this. The inspector noted an automatic air freshener dispenser in one corridor that dispensed a pleasant smell at regular intervals.BroomhillPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X X No. staff hours allocated No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X Nursing X X X X15 9 X Standard met? 0Key findings/Evidence This Standard was not inspected at this time.BroomhillPage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This Standard was not inspected at this time. 3 22 Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Key findings/Evidence Standard met? 2 The inspector followed up a requirement from the last inspection in respect of ensuring employment records required under the law are available at all times for inspection within the home. The inspector saw copies of personnel records in respect of two recently appointed staff. These included: Copies of the job applications Two references for each staff member Proof of identity e.g. passport with photo, birth certificate or drivers licence. This requirement was therefore met at inspection. However a new requirement is made to ensure each staff members file includes a photograph, as not all files seen included these.BroomhillPage 28 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. Key findings/Evidence Standard met? 2 The inspector followed up a requirement from the last inspection in respect of ensuring that staff receive training and induction appropriate to the work they perform. The inspector reviewed training records and noted the following: Some care staff had attended Loss and bereavement training that is ongoing Some care staff had attended Effective recording skills training that is ongoing Certificates for attendance at Protection of Vulnerable Adults training were seen New care staff had had manual handling, first aid and effective recording skills training. Induction sheets for new staff were seen, with dates completed and signed. The inspector noted that six staff had attended Mental health training in early March and further sessions were to be repeated in April and May for others. However the manager and assistant manager told the inspector that staff didnt find the training particularly relevant or helpful and the session lasted an hour and a half only. As the home has residents with mental health impairments and has been asked to admit another resident in this category, a variation to the registration must be applied for. Further, staff must have effective training that meets their needs, on working with this group of residents.BroomhillPage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The inspector noted that Ms Penny Baxter, the registered manager of Broomhill has many years experience working in care homes. She also has NVQ Level 4. The inspector met Ms Baxter whilst she was temporarily managing another care home locally and where residents and staff spoke highly of her competence and caring manner. The inspector noted that Ms Baxter has undertaken regular training to update her skills and knowledge. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Mrs Lyn Groves was on duty at this unannounced inspection. The inspector noted she was open to the inspection process and knowledgeable about the residents, the home and policies and procedures. The inspector also spoke to Ms Baxter by phone and met with her at a later visit. Both Ms Baxter and Mrs Groves demonstrated a high level of knowledge about their residents and their preferences. The atmosphere at this visit was calm and relaxed and residents praised the quality of the care they receive. This is commended.BroomhillPage 30 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The team manager for another home had spoken to the inspector in January `05. At that time she was able to confirm arrangements for independent quality assurance surveys to be formally carried out in the local authority homes from April 05. The inspector is aware that a meeting to discuss the new system had been held with all home managers recently. It was disappointing to note from records held at the Commission, that no reports of the team managers monthly visits to the home had been received since November 04. Further the inspector noted that when reports are sent they may arrive in batches some time after the events reported on. As these reports demonstrate internal monitoring of quality of care given to residents within the home is being carried out, a requirement is made. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The inspector noted both the homes registration certificate and the certificate of public liability on the wall in the entrance hall. Both were in date and current. The assistant manager gave the inspector copies of the latest budget analysis. From this the inspector noted expenditure overall was within budget and showed evidence of clear management.BroomhillPage 31 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? The inspector followed up a recommendation from the last inspection in respect of two staff members signing to say they both agree with amounts of residents money returned or received for safe keeping. The inspector carried out a check of residents monies and reviewed cash sheets. All were found to be correct and from these she noted two signatures where appropriate.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This Standard was not inspected at this time.BroomhillPage 32 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The inspector reviewed a range of records at this inspection. They included: The pre-inspection questionnaire Care plans and daily records Financial records Policies and procedures. All records were found to be orderly and well managed. Care plans were largely written from the residents perspective. All the above is commended. However the inspector noted daily records to contain lots of negative recording. The assistant manager told her that staff members are prioritised for effective skills recording training and the way they write care records is monitored and discussed in supervision. The inspector noted for one resident a trip to Cadbury Garden Centre had been identified as part of the care plan but the inspector couldnt find any reference to the visit having taken place, in key time records or daily records. For the resident who was having difficulty sleeping, daily records gave a lot of information about this. However in the inspectors opinion the records didnt demonstrate positive ways of helping the resident and could have been interpreted as negative. A good practice recommendation is made in respect of this. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 1 Key findings/Evidence Standard met? The inspector saw a balcony area at the front of the home on the first floor. From the balcony residents have good views over the surrounding countryside and said they like to sit out there in sunny, warm weather. However the inspector noted that the rails around the balcony were low and were made lower by the rails being supported on a fixed slab of concrete all the way round. This could act as a `step up to the rail and in the inspectors opinion created a dangerous hazard. The inspector reviewed the homes risk assessment file but couldnt find one in respect of the balcony. It was pleasing to note that the manager had contacted property services by the time she met with the inspector the following week. It had been agreed that the balcony was hazardous and work would be carried out to make it safe. As it wasnt clear what would be done or in what timescale, the requirement continues and a risk assessment put in place. For one resident whose pre-admission assessment and discharge letter from the hospital documented a number of falls, no manual handling or specific falls risk assessment was seen. The inspector reviewed the homes fire safety log and noted the following: Fire training records were up to date and included records of fire videos seen and questionnaires done following this Fire drills were being done monthly or two monthly and evidence of evacuations recorded The weekly fire alarm test was done at this visit and a resident told the inspector that this was what the noise was Records of fire safety testing were all up to date and done regularly. Broomhill Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorSandra GarrettSignature Signature SignatureRegulation Manager Lyn Davis Date 6th June 2005BroomhillPage 34 Public reports It should be noted that all CSCI inspection reports are public documents.BroomhillPage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.Please limit your comments to one side of A4 if possible No Comments.BroomhillPage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan bwhich indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONONOOther: enter details here BroomhillPage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.BroomhillPage 38 Broomhill / 11 March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000035843.V208845.R01© This report may only be used in its entirety. 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