Inspection on 23/02/06 for Broomhill Lodge

This inspection was carried out on 23rd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broomhill Lodge 20/12/06

Broomhill Lodge 03/11/05

Broomhill Lodge 10/03/05

Broomhill Lodge 27/01/05

Broomhill Lodge 04/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Broomhill Lodge 1 Broomhill Road Goodmayes Ilford Essex IG3 9SH Lead Inspector Stanley Phipps Unannounced Inspection 23rd February 2006 10:50 Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Broomhill Lodge Address 1 Broomhill Road Goodmayes Ilford Essex IG3 9SH 0208 590 3427 0208 590 4308 Jon@roselock.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Pamela Philp Mr. Alan Philp Mr John McGillick Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Moderate to high level of disability. Date of last inspection 3rd November 2005 Brief Description of the Service: Broomhill Lodge is a residential care home for eight younger adults, both male and female with a learning disability. The home is run by Alpam Homes, an organisation with a number of other similar schemes in which the service users may exhibit various forms of challenging behaviour. The building is situated in a residential street close to public transport and other local amenities. All bedrooms are single with all other facilities – shared. There is a large garden to the rear of the property and the premises are furnished in a way that values homely living. There are parking spaces to the front of the building as well parking on the street, which is not currently a controlled parking zone. The organisation also runs a day centre (Highview House) that is regularly attended by service users from the homes in the group. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second for inspection year 2005/2006, and was unannounced. It took place in just over four hours and was timed to meet with service users, follow up on outstanding requirements from the last inspection visit and to monitor the overall progress of the service. As part of the inspection, informal discussions were held with two service users and detailed discussions held with the manager. Several records were assessed including: menus, risk assessments, staff training records, the staffing rota, staff supervision notes, service user plans, policies and procedures and records pertaining to health and safety. A tour of the environment was undertaken and a visit was made to the day centre run by the registered providers. The inspection found that there were, some improvements since the last visit and this included compliance with most of the outstanding requirements previously made. There was one requirement that was repeated and this was with regard to the provision of formal supervision to staff. Although there has some improvements noted, the frequency of supervision still below the minimum standards. It must noted, that a continued failure to meet outstanding and required may have an adverse impact on the welfare of service users. As such the Commission would pursue enforcement to achieve compliance. What the service does well: Broomhill Lodge continues to provide a homely environment for its service users in which their independence, choice and interests are promoted to each of the individual’s maximum capacity. More importantly, the special needs of the group does not preclude them from living life to the full in that, their spiritual, social, personal and healthcare needs are provided for safely in the community. Staff remained committed and work closely with individuals to enable them to maximise their individual potential. All service users live a structured life that is best suited to their individual needs. Despite this life in the home is flexible. As part of enabling service users to maximise their independence and choice, staff work with the strengths of individuals and this creates a positive outcome for all service users individually and collectively. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 6 The service is also good at involving friends and families with service users and life in the home and this ensures that service users maintain a positive outlook on their life. The work of individual creations remained on show in the dining area of the home in a display cabinet and this enhances not only their pride but also their confidence and self esteem. The buzz and liveliness of the home was again present as the service users came in from lunch. The registered persons also ensure that arrangements are in place to monitor the service regularly i.e. on a monthly basis. This is a useful system in measuring the quality of the services provided by the home. The reports are generally brief covering key areas of the homes operations. What has improved since the last inspection? What they could do better: The registered persons need to review their assessment process to at some stage involve the registered manager or another appropriately qualified person working in the home to be a part of that process. This would ensure that service users are more suitably placed and supported. It is also a requirement that the needs of service users are recorded their individual service user plan and there was one case in which this could have been pertinently fulfilled. The reason being that all the medical information on Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 7 the individual concerned, was not made available prior to the admission. This stands to compromise the level and quality of support that could be given to the individual and needs to be handled differently in the future. From the visit, there was a need to ensure that staff are provided with twomonthly supervision at a minimum, as well as annual appraisals. This would enhance their support and development and as a result service users stand to benefit. Similarly supervision and appraisal is required for the registered manager to ensure that he is supported and developed in line with the service. As a follow on from this, the registered persons should notify the Commission via an action plan to demonstrate how he would achieve his NVQ Level 4 in Care Award. Finally as part of developing the service the registered persons are required to carry out an annual service user survey. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (1,3,5) All service users benefit from having updated information about the home. They also benefit from receiving contracts that fully reflect the services provided by the organisation. Improvements are required to the assessment process to ensure that the needs of service users could be fully met by the home. EVIDENCE: An updated statement of purpose was in place and available to service users. The document contains all information required by regulation and is in a format that is suitable to the service user group. It carries information that would assist prospective service users in determining the suitability of the home in relation to meeting their needs. A system is in place for determining the suitability of service users for the home. This was described by the registered manager who indicated that an assessment is made of the prospective by the registered manager of another service and one of the registered persons. Once this is done a decision is made to admit the service user, their details are sent to the registered manager and arrangements are made for the service user to move into the home. Neither the registered manager nor staff working at the home, are involved in the assessment process. Concerns were raised at the last inspection regarding admitting service users without detailed information – in this case medical information. The process described therefore would not provide service users with the confidence that the home could meet their needs. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 10 The registered manager has responsibility in law for the welfare of every service user for whom he is providing a service to, in that he should not admit a service user whose needs he cannot meet. Not having a say in the process practically compromises his legal position for which he is still responsible. In the most recent admission, the service user concerned is now exhibiting behaviours previously unknown to either of the individuals who carried out the assessment. The outcome is that the service user is unsettled with staff having to deal with behaviours that were unknown to them. This process must be therefore reviewed to ensure that the registered manager is involved in the assessment process. An integral part of admitting any new service user is the impact it has on the existing services already living in the home and the registered manager is in the best position to determine this. The current process is inadequate in assuring prospective service users that their needs could be met by the home. There was an improvement in the service users contract in that it now contains information about the services provided outside the home. This means service users are now fully aware of the providers obligations outside the home. This is positive and in the service users interests. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (6,10) Service users generally benefit from having their assessed needs reflected in their plan. However this practice must be consistent for every service user to ensure that their needs would be met. Sound arrangements were in place to promote the confidentiality of service users living in the home. EVIDENCE: It is usual practice that, the assessed needs of service users are reflected in their service user plans and this ensures that identified needs are acted upon. However in the case of the most recent admission, the individual’s medical details were made available to the consultant just prior to the inspection visit. The registered manager himself was not aware of the medical details that were with the consultant. It was therefore extremely difficult to see how the full medical needs of the service user could have been incorporated into the plan. This is because those needs were not available at the time of: both the assessment and the admission of the service user. This needs to improve. There was evidence that a policy on confidentiality was in place and staff spoken to showed an awareness of it. They knew how and when to share information held on service users and this was in line with policy. All records maintained by the home were held securely in the main staff office, so that Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 12 service users and their relatives are reassured that the protocol around the storage of information-protects them. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (14,16,17) At Broomhill Lodge service users enjoy a lifestyle that provides excellent leisure activities, good nutrition and one in which, their rights and responsibilities are promoted. EVIDENCE: There was evidence that the home provides a range of leisure activities that is suited to the interests and needs of individual service users. Some of these activities are provided at the day centre, while others are provided in the wider community. All service users seen on the day were exited and in tune with their activities. They had returned for lunch from the day centre and were preparing to go on a shopping trip and really looked forward to it. One service user remarked ‘ I love it when we go shopping’ and in the same motion issued a challenge for a game of pool. They were going to the Gallions Reach Shopping Centre to purchase clothing and personal effects. There was evidence that service users attend club nights three evenings per week and also regularly go to the cinema, theatre and bowling at Romford Bowling Alley. Plans were in place for a service user to visit a theatre in the West End towards the end of February and he was looking forward to it. One of the popular activities at the club is apparently entitled – ‘It’s a knock-out’ Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 14 whereby service users enjoy wrestling type games. They have great fun in a safe environment and this is positive. One of the service users showed a photo of his Halloween costume, which won him ‘costume of the year 2005’ in a competition held in the borough. He was very proud of this achievement. It was reported that they also attend a disco organised by MENCAP on a Wednesday and this has an established disc jockey. Up to six users regularly attend and from the feedback received – they thoroughly enjoy it. Service users therefore lead a hectic, stimulating and enjoyable lifestyle one in which, they wind down on Fridays by doing a bit of pottery. This is a strong area of the home’s operations. There was evidence that the management and staff, actively promoted service user rights in supporting them to take up their responsibilities. Service users were addressed by their preferred names and in the process of showing off his room a service user used his key to open his bedroom door. This individual also informed that staff knocks his door when they want his attention and he is in there. The home ensures that wherever possible relatives are also involved in promoting the rights of individuals. Service users rights were also enshrined in their contracts and evidence was provided to confirm that one relative regularly attended meetings/reviews on a service user’s behalf. In terms of advocacy the registered manager informed that this is accessed via Daffodils in Redbridge. Service users spoken to were satisfied with the meals that are provided by the home. There were menus available and service users were involved in determining their preferences. This is done primarily at their monthly service user meetings and records seen confirmed this. There is flexibility in that changes to the menu plan, are driven by service users and they are accommodated. One service user for example wanted sausage casserole and his choice was observed on the menu. Lunch on the day consisted of sardines on toast requested by two service users and egg and toast. Service users were relaxed while having their lunch in what could be best described as a comfortable environment. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (20,21) Service users receive satisfactory support with medication in ensuring that their healthcare needs are safely met. Adequate systems are also in place to support service users, should they become unwell and/or die in the home. EVIDENCE: A satisfactory medication policy is in place at the home. At the time of the visit none of the service users were independently able to manage their medication. As a result, appropriately trained staff were responsible for administering medication in the home. Although the medication the administration of medication was not witnessed on this visit, from talking to staff and observing the relevant records kept, it was clear that medication is safely handled in the home. The storage and disposal of medication was also satisfactory and in line with current guidance. A clear policy on death and dying is in place and this is accessible to staff. Although there were no deaths in the home, the registered manager confirmed that support and counselling would be made available to staff as and when necessary. Where possible the wishes of service users regarding death are noted in their case files. It is also very important to note that clear guidelines were in place to cover situations in which the health of a service user deteriorates. Guidelines for dealing with emergencies are appropriately posted for the benefit of staff. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) An updated complaints policy now provides service users and their relatives with clear avenues to raise their concerns and service users are protected from abuse by the adult protection protocols of the home. EVIDENCE: There was evidence that the complaints policy had been updated to include details of the Commission. This meant that service users and their relatives know what to do in the event that they were unhappy with the home’s handling of a complaint. There were low levels of complaints on record in the home and service users are generally satisfied with the support given to them. On the day of the visit, staff demonstrated their skills in listening and picking up cues from individuals if and when they are uncomfortable and most importantly – they act upon their observations. Appropriate interventions are therefore made at an early stage to ensure that service users are comfortable in their environment. A satisfactory complaints procedure was in place and this included guidance on whistle-blowing. The registered manager goes through the adult protection guidelines with staff to ensure that they are clear on the importance of taking action if they suspect, witness or had an allegation of abuse made to them. Staff spoken to demonstrated and understanding of what is required under the adult protection protocol. They are also provided with adult protection training and training was identified for one member of staff in May 2005. There were no adult protection matters in the home at the time of the visit and service users therefore remained safe at Broomhill Lodge. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (28,29) At Broomhill Lodge service users benefit from having communal spaces that are best suited to their needs and interests. They also have the assurance that their independence would be promoted to enable them to comfortably use their environment. EVIDENCE: The communal spaces at Broomhill Lodge are adequate for the needs of the service users group. There is a large lounge area that comprises a pool table and TV/entertainment area. A separate dining that is also spacious compliments the other communal areas. The home is decorated to a high standard and a sound maintenance plan is in place to ensure that high standards of cleanliness and hygiene are maintained. There is also a large garden that is used more frequently in warmer weather. On the day of the visit all service users were observed comfortably negotiating their way around their environment. At the time of the visit all service users were independent with regard to their mobility. As such specialist equipment is not currently provided by the home. However the registered manager confirmed that service users needs are kept under review. This is to ensure that any equipment or changes required to promote service user independence would be explored with the service user in conjunction with other relevant professionals e.g. an occupational therapist. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (31,32,36) Service users are supported by a staff team that has clearly defined responsibilities and is given specific training to meet their needs. Support for staff could be improved to ensure that service users receive the best quality care possible. EVIDENCE: All staff are given a copy of their job description, which clearly defines their individual roles in meeting the needs of service users. Staff spoken to demonstrated an understanding of their responsibilities in relation to the philosophy of care in the home. The also understood the needs of most service users and this influenced the interventions made with them. A key worker system is in place and this enables staff to get a good understanding of the support needs of each individual. Staff were also aware of the General Social Care Council’s code of conduct, which further clarifies their relationships with service users. Good quality care is provided and maintained as a result of the training provided by the registered persons. Key areas of training provided included: Challenging behaviour, adult protection, Food hygiene, Medication, Fire awareness and evacuation, Moving and handling. There was also evidence that three members have started their NVQ Level 2 in Care Award and the manager advised that this was in conjunction with the Learning Disability Award Framework training. This is useful as the primary need of the service user group is one of learning disabilities. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 19 Good support systems are in place for staff to enable them to carry out their duties effectively. They included: informal guidance, handovers, team meetings, staff supervision and appraisals. However from the records viewed supervision and appraisals could be more beneficial to staff if they are carried out in line with guidance. Supervisions are to be carried out at the minimum of six times per year and staff appraisals once per year. This was discussed in detail with the manager and he advised that a new form had been developed for appraisals. He also indicated that he is planning to carry the appraisals out in March/April 2006. Whilst the frequency of supervision has improved, it remained short of the requirements of this standard and must be complied with. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (37,38,39) A dedicated manager is in place at Broomhill Lodge and this ensures that the welfare and best interests of service users are provided for. As a way of improving the service, action is required to formally acquire the views of service users. EVIDENCE: The registered manager works closely with service users, staff, relatives and other professionals in ensuring that the needs of service users are met. As part of this, he attends training periodically to update his skills and knowledge. This is useful as the learning and development could be transferred to improving the quality of the service at Broomhill Lodge. He also attends a three monthly managers forum, which is chaired by the registered provider looking at issues such as staffing and staff training – issues that are essential to maintaining good standards of care. At the time of the visit the registered manager had not completed his NVQ Level 4 in Care Award, but the service manager was looking for establishment that would provide the elements he required, to achieve the award. In discussion with the registered manager it became apparent that he was not in receipt of formal supervision and this is a key Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 21 aspect of providing support to him. It is also required by the national minimum standard (43.3) and as such needs to be carried out. In speaking with service users and staff, they confirmed that he makes himself available and gives clear direction to them. During the inspection he was observed interacting with both groups and it was clear that he deported himself in a professional and courteous manner. All service users were comfortable with him and he showed a good understanding of the needs of the service as a whole. Staff are given opportunities to contribute their ideas to the service through supervision and regular team meetings. They are also provided with equal opportunities training as part of their induction and this is positive for the service as a whole. Feedback from stakeholders is generally received at service users reviews. The service is monitored on a monthly basis through conducting monthly provider visits to the home. These visits are carried out consistently and in line with regulation. As part of monitoring quality the views of service users are obtained informally and in service user meetings. However at the time of the visit, a service user survey had not been carried out. The manager indicated that he planned to carry one out in July 2006. Service user’s development is monitored at their annual reviews and the views of stakeholders are also obtained in a similar forum. Policies and procedures were up to date at the time of the inspection. In concluding whilst there are some systems in place for quality monitoring, action by way of a service user survey is required to improve in this area. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 4 28 3 29 X 30 x STAFFING Standard No Score 31 3 32 3 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 4 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 2 3 2 X X X x Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 12,13 Requirement The registered persons are required to review their assessment process to ensure that the registered manager or suitable person working in the home is involved at some stage in this process. This process must also consider all relevant details on service users. The registered persons are to ensure that the needs of service users are pertinently recorded in their service user plans at all times. This includes their medical needs. The registered manager is required to ensure that:1) all staff are given formal supervision in line with standard 36.4 of the National Minimum Standards for Younger Adults. (This is repeated requirement that must be complied with, without undue delay). 2) Staffing appraisals are carried out annually. The registered persons are required to provide regular formal supervision and an annual appraisal for the registered DS0000025889.V284367.R01.S.doc Timescale for action 15/06/06 2 YA6 12,13 15/06/06 3 YA36 18(2) 30/06/06 4 24(1)(b) 31/07/06 Broomhill Lodge Version 5.1 Page 24 5 24 manager in line with standard 43.3 The registered persons are required to carry out an annual service user survey in the home and publish the results. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA37 Good Practice Recommendations The registered persons should provide an action plan to the Commission indicating the steps planned for the registered manager to achieve his NVQ Level $ in care Award. Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broomhill Lodge DS0000025889.V284367.R01.S.doc Version 5.1 Page 26 - 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. 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