Inspection on 15/11/04 for Broomhill

Care Home For Older PeopleBroomhill92 Eastwood Road Brislington Bristol BS4 4RSUnannounced Inspection15th November 2004 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 Bristol City Council Name of registered manager To be appointed Type of registration Care Home No. of places registered (if applicable) 40 Tel No: 0117 9779802 Fax No: 0117 9724091Category 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 5/11/03 If Yes refer to Part CBroomhillPage 1 Date of inspection visit Time of inspection visit Name of inspector 1 Name of establishment representative at the time of inspection15th November 2004 09:30 am Karen LynskeyID Code088243Velma Williams Baptiste & Pat Lewis.BroomhillPage 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 is a 40 bedded home situated in a residential area in Brislington. The nearest shops are 300 yards away where there is a post office, newsagents, hairdresser, pubs etc. 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 bathroom are close by. The garden is very accessible with rails to assist the service users onto the patio area. A new rockery with a water feature is a more recent addition enjoyed by the service users.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.) Brief Introduction The inspector undertook an unannounced inspection with a focus on: · evaluating compliance to previous requirements and recommendations; · evaluating standards not assessed during the previous inspection; and · monitoring compliance with core standards which promote the meeting of service users needs with regards to health, welfare and protection. On the day of inspection the home had occupancy of 38 service users with 2 service user vacancies. There were 14 requirements and 4 recommendations made during the previous inspection. Compliance was only evidenced for 6 of the requirements. Thus the majority of the requirements in this inspection report result as a breach of non-compliance to the Care Home Regulations (CHR) 2001 and National Minimum Standards (NMS) from the previous inspection report. In light of this non-compliance tight timescales for compliance have been set within this inspection report. CSCI will consider enforcement action if the registered person continues to fail to comply. General feedback was given to the acting manager and officer in charge on the day of inspection. The majority of the service users and visitor the inspector spoke with during the inspection commented positively on all aspects of the home. A selection of the verbal comments received state `I am very satisfied with the care, `the staff are excellent, `the food is good and `I have no grumbles. One service user feels her placement is inappropriate, but also was accepting of the fact that no suitable alternative place was available. She was generally unhappy but did not wish the inspector to explore any of the issues she expressed further. On the day of inspection the main gas supply to the home had been disconnected due to works on the road outside; the home took immediate action by informing service users and consulting on options for lunch. Staff at the home are to be commended for their rapid actions in keeping service users informed, offering choice and dealing with a potentially difficult stressful situation.Choice of Home (Standards 1-6) 0 of the 3 standards assessed were met. The Statement of Purpose and service user guide are a joint document which has been updated since the previous inspection. The inspector viewed the document: this was comprehensive and service user friendly, however it still did not give the contact information for the Commission in breach of requirement 1 made during the previous inspection. Emergency admissions continue to be placed by the EPH team. The acting manager stated Broomhill Page 6 no pre-admission assessments are undertaken when this occurs: this is in breach of requirement 2 of the previous inspection. Pre admission assessment documentation is made available to the home via the social work team. The home continues to accommodate service users with mental health needs; a requirement had previously been made for staff to receive appropriate training to meet the needs of the client group. The inspector randomly viewed staff training records which evidenced that this training had commenced for some individuals in general compliance with the requirement; however due to the complex needs of the client group the inspector feels all staff must receive appropriate training in the care of individuals with mental health issues including dementia care.Health and Personal Care (Standards 7-11) 0 of the 2 standards assessed were met. The inspector viewed 6 service user care files. Most of the documentation viewed contained identification of a range of holistic needs, however the plans of care were not prescriptive of the interventions required to meet the identified needs. Specific risk assessments were not available in breach of requirement 5 of the previous inspection. The inspector was concerned that daily reports and regulation 37 reporting procedures evidenced serious behavioural issues for a couple of service users. These had not been identified as a specific need in the ADL assessments; neither risk assessments nor care plans in management of the behaviours had been completed although staff were able to verbalise clear management strategies.Daily life and Social Activities (Standards 12-15) 3 of the 3 standards assessed were met. The inspector spoke to several service users who were happy with the range of activities provided and were happy to pick and chose those they wished to attend. Service users were looking forward to trips and a range of activities, which had been planned in consultation with them leading up to the Christmas period. The local community is close knit and visitors are actively welcome in the home. The inspector spoke to one visitor who said they were very satisfied with the care in the home. They praised staff for their commitment and support. The service users the inspector spoke with stated they enjoy their meals and felt they received a balanced diet.Complaints and Protection (Standards 16 ­18) 1 of the 3 standards assessed was met. The complaints policy was on public display, in the service user guide and a separate leaflet was available in service users bedrooms, it contained all required information, however is continues to refer to the inspectorate as the NCSC this organisation has been superseded by the CSCI in April 2004; thus the policy requires updating to reflect the change. Broomhill Page 7 The homes Adult Protection policy and procedure showed no evidence of review in breach of requirement 7 of the previous inspection. It does not clearly stipulate the line management responsibility for allegations of abuse made out of hours or refer to the interagency reporting procedure. Training records sampled by the inspector evidenced most staff have now received Adult protection training in compliance with requirement 7 of the previous inspection.Environment (Standards 19-26) 7 of the 7 standards assessed were met. Broomhill is a purpose built home, which has been converted to 40 single bedrooms. The layout is suitable for its stated purpose, and from the inspectors observation meets the service users individual and collective needs. There is ongoing evidence of routine maintenance and renewal of furniture and equipment, and the grounds are tidy, safe and accessible to service users. The home is bright, clean and well decorated.Staffing (Standards 27-30) 1 of the 3 standards assessed was met. The inspector was unable to inspect standard 29, as the records required were not available within the home in breach of legislative requirements. The inspector randomly sampled the training records for a range of staff. These evidenced a broad range of skills available amongst the staff team; however there remain gaps in the skills required to meet the needs of the service user group such as mental health, dementia care and palliative care training. The induction programme was a fairly comprehensive document but not based on the TOPSS standards. Most of the induction records viewed had been signed on the day of commencement of employ indicating that the new employee was competent and understood all areas of the induction process. The inspector finds it hard to comprehend that after one day all new employees are competent in their roles and have received and understood the whole of the induction process. TOPSS advises up to six weeks to satisfactorily complete an induction process. The inspector would also re-iterate the need to ensure the trainer and trainee are able to gather evidence of the learning via an observational or written record.Management and Administration (Standards 31-38) 3 of the 6 standards assessed were met. The registered manager for Broomhill has been seconded to another Bristol Social Service home; the deputy manager of Broomhill Ms Baptiste has been `acting manager in her absence. Ms Baptiste informed the inspector that the manager is anticipated to return in early January 2005. The inspector spoke to staff, service users and stakeholders all stated that the acting manager was approachable, and had created a positive atmosphere within the home. The acting manager has delegated responsibility for health and safety matters. The inspector viewed a range of documents with relation to health and safety: these evidenced Broomhill Page 8 robust procedures and compliance to requirements and recommendations.BroomhillPage 9 Requirements from last Inspection visit fully actioned? CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).NO Met (Yes / No) YESBroomhillPage 10 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 1 5.1(f) OP1 The Statement of Purpose and service user guide document to also include how service users can contact the local C.S.C.I office. The registered person must confirm in writing to prospective service user that the home is able to meet their needs following a full assessment. By 31/3/05214.1(d)OP3From 15/11/04 onwards314(1)OP3No service users to be admitted to the home unless a suitably qualified trained and experienced individual employed From within the home has completed a full 15/11/04 assessment and can confirm that the home onwards is suitable for the purpose of meeting the service users needs. Induction from 15/11/04 for all new staff Training for all staff by 31/3/05418(1)(c)The registered person must ensure that staff receive training and induction appropriate to the work they perform.BroomhillPage 11 515OP7The registered person must ensure in consultation with the service user or their representative a written plan is prepared, which identifies how their needs are to be met in respect of their health and welfare and that this plan is kept under review.By 31/3/05622(7)(a)OP16Ensure the complaints policy is updated to reflect the legislative change from NCSC to By 31/3/05 CSCI (April 2004). Review and update the homes procedure on Adult protection as set out in standard 18. Send CSCI a copy of the updated procedure.713(6)OP18By 31/3/05819 Sch 4.6OP29Ensure employment records required by legislation are available at all times for inspection within the home.By 31/3/05RECOMMENDATIONS 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 * Ensure staff receive induction training which is based on the TOPSS induction standards. Ensure training is learning-evidenced based and an observational or written record is kept. If service users are unable to sign the cash sheets for their money, then two staff members to sign to say they both agree with the amount returned or received for safe keeping.1OP302OP35* 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 12 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 NO YES YES YES NO NA YES YES YES NO YES NO NO NO NO YES NO YES 18 1 0 NO NO YES NO X 0 15/11/04 09.30 7.5BroomhillPage 13 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 14 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 extrasYESCHIROPODY, HAIRDRESSING.If yes, please state what the extras are: 2 Key findings/Evidence Standard met? The Statement of Purpose and service user guide are a joint document which has been updated since the previous inspection. Individual copies of the document were available to all service users; new admissions being given a personnel copy on admission. This is in compliance with requirements made during the previous inspection. The inspector viewed the document: this was comprehensive and service user friendly however it still did not give the contact information for the Commission in breach of requirement 1 made during the previous inspection.BroomhillPage 15 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 assessed during this unannounced inspection. It scored a 3 during the previous inspection. 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? At the time of inspection the inspector was informed that the home is only accepting emergency admissions. Bristol City Council has blocked beds in preparation for the closure of a sister home. Emergency admission being placed by the EPH team, the acting manager stated staff at the home are not undertaking pre-admission assessments, however social work assessment documentation is made available to the home. This is in breach of requirement 2 of the previous inspection. The acting manager has little say in the admission decision or whether the home can meet the service user needs or not. This continues to lead to inappropriate admissions of service users with a high level of mental health needs. The home has not had the opportunity to write to service users following pre admission assessment to state if their individual needs can be met or not at the home as no planned admissions are being taken. The inspectorate will monitor compliance to this requirement during future inspections. 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. 2 Key findings/Evidence Standard met? The home continues to accommodate service users with mental health needs; a requirement had previously been made for staff to receive appropriate training to meet the needs of the client group. The inspector randomly viewed staff training records which evidenced that this training had commenced for some individuals in general compliance with the requirement; however due to the complex needs of the client group the inspector feels all staff must receive appropriate training in the care of individuals with mental health issues including dementia care. This standard is therefore only partly met. 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection. It scored a 3 during the previous inspection.BroomhillPage 16 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? The home does not offer intermediate care.BroomhillPage 17 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? There was a range of documentation available in the individual service user care files from the pre admission assessments, activities of daily living (ADL) assessments, admission / contact information, visits from other health professionals and daily reports. Service user risk assessments were available for moving and handling. The inspector did not view any falls risk, nutritional risk, pressure sore risk, consent to restrictions or generic risk assessments, despite two service users daily reports indicating several falls and this remains in breach of requirement 5 made during the previous inspection. There was evidence of service user / relative involvement in several of the care files, some evidenced regular review whilst others did not. The inspector viewed 6 service user care files. The home utilises a core care planning system based on the ADL. Most of the documentation viewed contained identification of a range of holistic needs, however the plans of care were not prescriptive of the interventions required to meet the identified needs. The inspector was concerned that daily reports and regulation 37 reporting procedures evidenced serious behavioural issues for a couple of service users. These had not been identified as a specific need in the ADL assessments; neither risk assessments nor care plans in management of the behaviours had been completed although staff were able to verbalised clear management strategies.BroomhillPage 18 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 X0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection. It scored a 3 during the previous inspection. 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 only assessed with regard to compliance to the requirement made during the previous inspection with regards to staff training. Staff training records evidenced that senior staff had now received up dated training in medication management. 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 assessed during this unannounced inspection. It scored a 3 during the previous inspection.BroomhillPage 19 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. 2 Key findings/Evidence Standard met? As the home is registered for personnel care only as a service users condition deteriorates that are often transferred to more suitable accommodation or hospital thus very few deaths occur on the premises. The home has policies on managing the terminal stages of care, expected and unexpected deaths, which were viewed by the inspector and were comprehensive documents. Service users wishes when offered are recorded in their care file; the inspector visually evidenced this during the inspection. There is access to the local ministers who will attend the home at any time. Hospitality would be offered to relatives if need be where service users are being cared for in the terminal stages of illness. Training records did not evidenced staff training in palliative / terminal care. This has previously been discussed during inspections and should now be being planned into the annual training plan. Requirement 4 applies.BroomhillPage 20 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. 3 Key findings/Evidence Standard met? There was no specific change to the findings of this standard as reported in the previous inspection report. On the day of inspection several service users chose to attend `Bingo which was being held in the communal dining room. The inspector spoke to several service users who were happy with the range of activities provided and were happy to pick and chose those they wished to attend. Service users were looking forward to trips and a range of activities, which had been planned in consultation with them leading up to the Christmas period. The inspector observed the pm staff change over. This is primarily given by the officer in charge am to the officer in charge pm who then informs other staff of the key changes at a separate meeting. The change over was comprehensive detailing recent events / changes. 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. 3 Key findings/Evidence Standard met? The local community is close knit and visitors are actively welcome in the home. The inspector viewed the visitors book, which evidenced regular visitors to the home, there is also a visitors statement on display in reception indicating visiting / meal times etc. The inspector spoke to 1 visitor who said they were very satisfied with the care in the home. They praised staff for their commitment and support. There are no set visiting times, and there is a door entry system, which enable staff to be aware of visitors who come and go, thus ensuring the safety of those who live and work in the home. There are plenty of lounges and a small tearoom to receive visitors in privacy, but generally service users tend to invite family and friends to their bedroom.BroomhillPage 21 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection. It scored a 3 during the previous inspection. 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. 3 Key findings/Evidence Standard met? The inspector joined the service users at lunch in the large communal dining room. The meal was well presented and service users commented that it was tasty. The service users spoken to enjoyed their meals and felt they received a balanced diet. The dining tables were nicely presented with individual place settings. Staff members served, supervised and assisted service users discreetly in the dining room; the meal was unhurried. There is a four-week menu plan. The main meal of the day is also displayed on a board with an alternative choice. Service users make their choice the day before, but can choose an alternative on the day if they wish. The kitchen was clean and well maintained. The chef is present at times in the dining area during the meal times gauging service user feedback on the meals served. On the day of inspection the main gas supply to the home had been disconnected due to works on the road outside; the home took immediate action by informing service users and consulting on options for lunch; fish and chips from a local supply was a favourite along with a supply of cold meats, chips and beans heated in the microwave. Staff at the home are to be commended for their rapid actions in keeping service users informed, offering choice and dealing with a potentially difficult stressful situation.BroomhillPage 22 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 2 2 0 0 0 0 100 2 Key findings/Evidence Standard met? The complaints policy was on public display, in the service user guide and a separate leaflet was available in service users bedrooms, it contained all required information, however is continues to refer to the inspectorate as the NCSC this organisation has been superseded by the CSCI in April 2004; thus the policy requires updating to reflect the change. The complaints log was viewed and evidenced 2-recorded complaints since the previous inspection. One was in relation to food and one in relation to care of an individual following a fall. Both had been upheld and fully resolved using the homes complaints procedures.BroomhillPage 23 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. 3 Key findings/Evidence Standard met? Service users are able to participate in the political process, and are enabled to exercise their rights by voting during elections. The majority of service users tend to use their postal vote. Currently an advocacy service is not used, but the deputy manager said that if service users required an advocate she would access a resource locally. 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 02 Key findings/Evidence Standard met? The homes Adult Protection policy and procedure showed no evidence of review in breach of requirement 7 of the previous inspection. It does not clearly stipulate the line management responsibility for allegations of abuse made out of hours or refer to the interagency reporting procedure. The document available stipulates the inspector and contracts officer would be the only named persons in exceptional circumstances to be contacted. There is no other detailed reference to the CSCI or information on the procedure the manager should follow should an incident occur in the home, which would necessitate concerns being passed onto relevant agencies. The acting manager was able to verbally confirm appropriate reporting procedures using the interagency policy. The home had appropriately reported 2 regulation 37 notifications incidents thorough the POVA procedures. One incident related to an alleged theft and one incident to inappropriate behaviour of a fellow service user. Both incidents had been investigated and concluded appropriately. Training records sampled by the inspector evidenced most staff have now received Adult protection training. The acting manager informed the inspector that CRB checks have been completed for all staff. The inspector was unable to verify this, as records are not held within the home.BroomhillPage 24 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, which has been converted to 40 single bedrooms. The layout is suitable for its stated purpose, and from the inspectors observation meets the service users individual and collective needs. There is ongoing evidence of routine maintenance and renewal of furniture and equipment, and the grounds are tidy, safe and accessible to service users. The garden includes a rockery with water feature, which adds to the attraction of the external grounds. Rails have been installed to aid those less able individuals who wish to maintain their independence when going into the garden. There are sufficient toilets and bathrooms on all three floors and facilities for the disabled, which include ramps, rails, hoists and slings to assist with bathing. The home is bright, clean and well decorated.BroomhillPage 25 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. 4 Key findings/Evidence Standard met? The communal space available in the home is exceeds spatial requirements. The dining room is bright and well appointed with space for service users to move around freely without obstacles in the way. There are a number of lounges in use and a sitting room for those service users who wish to smoke. There is also a room upstairs where service users and relatives can make tea or coffee etc. One of the communal lounge areas contains a licensed bar, this is also a smoke area. A trolley service operates nightly from the bar serving service users who do not wish to go to the bar area. Several service users commented positively on this facility. The lounge areas have been tastefully decorated with furnishing appropriate to the client group e.g 3 piece suites, dressers, and feature fireplaces. Each communal area has a different focus; all are homely and welcoming. Lighting is sufficiently bright to facilitate reading etc, and all furnishings are of good quality. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? There is adequate provision of communal toilet and bathrooms close to all service user areas; these are clearly marked. Each bedroom has a wash hand basin. Sluices have been positioned on each floor.BroomhillPage 26 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? Broomhill is a purpose built home with internal environmental adaptations and equipment to meet the needs of the service user group. There is a lift to all floors, bath hoists, parker baths and toilet frames etc. There are grab rails around the home and call bells in each bedroom. Some service users use the balcony, but because the metal rails around this area are fairly low this could present a hazard for some confused service users. The risk assessment for the use of the balcony will need to be kept under constant review. The need to promote service user safety with regards to risk assessment was again discussed during the inspection; as it was wintertime the balcony was not in use. The manager feels there is ample storage space in the home and on observation there was no evidence of clutter or items of unwanted furniture stored in corridors.BroomhillPage 27 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 YES NO NO X X X X X XX X X X0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection. It scored a 3 during the previous inspection.BroomhillPage 28 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. 3 Key findings/Evidence Standard met? Each bedroom has been furnished to meet the individual requirements of the service users. Beds are suitable and at a safe height. There is one adjustable bed in use. The majority of bedrooms have been carpeted, bar two where more suitable floor covering has been laid for safety and hygiene reasons where service users have severe incontinence problems. Each room has been fitted with a lock and a number of service users have keys. Bedside cabinets have also been fitted with locks where service users are able to store their personal belongings. 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. 3 Key findings/Evidence Standard met? All rooms were naturally ventilated with most window heights affording sitting views outside the home. Central lighting was available in all rooms as well as bedside lights in most others. The bathing areas viewed had thermometers to monitor safe bathing temperatures; the inspector was informed that thermostatic controls were fitted. There was weekly monitoring records of bath temperatures to evidence safe limits, in compliance with requirement 8 of the previous inspection report. Random sampling of temperatures during the visit demonstrated they were within the upper safe limits. All the radiators in the home had been fitted with guards. 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. 3 Key findings/Evidence Standard met? The home was found to be very clean and free from offensive odours. There is an infection control policy in place, which covers food hygiene, laundry and specific diseases. The laundry room is well equipped with a sluicing facility for staff use. Most of the laundry is washed on the premises, with the exception of sheets, which are sent out to an external contractor. Washing machines have the specified programming ability to meet disinfection standards and the laundry floor finishes are impermeable.BroomhillPage 29 BroomhillPage 30 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 Nursing Care No. service users High No. staff hours X X X needs allocated 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 Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 14 X Standard met? 3BroomhillPage 31 The homes duty rota was checked which indicated that 4 care staff are on duty during the morning period, 3 during the afternoon and evening and during the night 2 waking and one sleeping staff member. This staff quota is slightly less during the weekend period. Apart from the officer in charge and care staff there are also domestic, catering, activity staff and a maintenance worker in post. The officers in charge also assist with some care work, during the inspection they were observed to be kept very busy with numerous administrative tasks and duties. At the time of the inspection there were 3 care staff vacancies and one domestic staff vacancy. These posts had been advertised and the acting manager was arranging interviews. Bank staff, overtime and the occasional use of agency staff were covering the vacancies. A number of staff have been employed in the home for many years and are experienced in the care of elderly people. The inspector was advised that the home has a budget to increase staff at peak times if this is thought to be necessary by the acting manager. During the week accessing the budget is via the team manager, but at weekends etc home managers are able increase cover if dependency levels indicate this is necessary. 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 4 23 9 Key findings/Evidence Standard met? Four care staff have NVQ at level 2, whilst 5 other have almost completed and 5 more are due to enrol for this course. The acting manager is currently undertaking NVQ at level 4. The acting manager feels the home is on course to meet the target of 50 of staff NVQ qualified by 2005. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? A minimum staff record is available within the home: these were randomly sampled by the inspector and do not contain the information required for inspection. They generally only contain name, date of birth, contact details, CRB reference number (no evidence of outcome) and evidence of training. This is in breach of requirement 10 of the previous inspection report.BroomhillPage 32 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. 2 Key findings/Evidence Standard met? The inspector randomly sampled the training records for a range of staff. These evidenced a broad range of skills available amongst the staff team; however there remain gaps in the skills required to meet the needs of the service user group as identified throughout the report. There was evidence of a rolling training programme for mandatory training and the acting manager was active in her management strategies to ensure all staff attended and kept themselves updated not only in their knowledge base but also their practice. The induction programme was a fairly comprehensive document but not based on the TOPSS standards. The document acts as a prompt for the trainer to discuss issues, systems and policies with new staff, who then signed to say the information has been given. Most of the induction records viewed had been signed on the day of commencement of employ indicating that the new employee was competent and understood all areas of the induction process. The inspector finds it hard to comprehend that after one day all new employees are competent in their roles and have received and understood the whole of the induction process. TOPSS advises up to six weeks to satisfactorily complete an induction process. The inspector would also re-iterated the need to ensure the trainer and trainee are able to gather evidence of the learning via an observational or written record. The CSCI will monitor this during future inspections.BroomhillPage 33 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 registered manager for Broomhill has been seconded to another Bristol Social Service home; the deputy manager of Broomhill Ms Baptiste has been `acting manager in her absence. Ms Baptiste informed the inspector that the manager is anticipated to return in early January 2005. Ms Baptiste is experienced in the care of elderly people. She has commenced N.V.Q.4 and although the anticipated completion date of this was April 2004, she has not completed mostly due to the pressures of work: the time scale has been extended. Ms Baptiste and her senior staff are familiar with the conditions associated with old age and have periodically undertaken relevant courses as they have become available. There are clear lines of accountability and the team manager visits at least monthly to discuss care management issues and oversee procedures in the home. 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? The inspector spoke to staff, service users and stakeholders: all stated that the acting manager was approachable, and had created a positive atmosphere within the home. The acting manager holds regular staff and service user meetings; the inspector viewed minutes of these which evidenced consultation in the running of the home and the seeking of other views re decisions to be made.BroomhillPage 34 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. 0 Key findings/Evidence Standard met? This standard was not fully assessed during this unannounced inspection. There has been little change since the previous inspection when it was scored a 2. This standard will form the basis for the next inspection. 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. 0 Key findings/Evidence Standard met? This standard was not assessed during this unannounced inspection. It scored a 3 during the previous inspection. 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 X2 Key findings/Evidence Standard met? The majority of service users have requested that their personal allowance is looked after by the home. For this purpose a safe is used to secure all cash and valuables held. The inspector checked cash sheets; the balances were found to be in order. Only one signature had been recorded on most occasions when cash is received or returned to the service user. The inspector recommended that if service users are unable to sign for their money, then two staff members should sign to say they both agree with the amount returned or received for safe keeping. Receipts are kept for all purchases bought on behalf of the service user. Each bedroom has a lockable drawer. Personal needs allowances are not pooled.BroomhillPage 35 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. 2 Key findings/Evidence Standard met? Comments in standard 29 apply re recruitment, and standard 30-re training. Requirements have been made. There was evidence of regular staff supervision within the home. Records are kept confidentially. 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? Regulation 26 and 37 records were available and completed as required. Some policies and procedures require review and updating as indicated in the relevant sections of the report. Records required for recruitment were not available for inspection.BroomhillPage 36 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. 3 Key findings/Evidence Standard met? The acting manager has delegated responsibility for health and safety matters. The inspector viewed the maintenance and health and safety records, which evidenced a monthly check on the premises, identifying areas of deficit and works undertaken to rectify deficits identified. The products used for cleaning were appropriately stored when not in use. From the records viewed by the inspector the majority of the staff had received up to date mandatory training. Water temperatures are being monitored and recorded weekly; records viewed by the inspector evidenced they were within recommended limits. A new system to manage the risk of legionella has been commenced. The fire logbook evidenced compliance to the weekly, monthly and annual checks alongside records of staff training and drills completed, which were in compliance with, recommend intervals. All records evidencing the regular routine maintenance of equipment, electrical and gas safety were in order. The inspector was informed that all windows above ground floor level were restricted; those randomly checked by the inspector further evidenced this. The inspector viewed the kitchen area, this was generally clean, tidy and well organised.BroomhillPage 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateKaren Lynskey Mark Dunford 4th March 2005Signature Signature SignatureBroomhillPage 38 Public reports It should be noted that all CSCI inspection reports are public documents.BroomhillPage 39 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 40 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. D.2 Please provide a written Action Plan which indicates how requirements are to be addressed and stating a clear timescale for completion which 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 YESAction 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 planNONOYESOther: enter details here BroomhillPage 41 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 DateBroomhillPage 42 Broomhill / 15th November 2004Commission 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.V193596.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!