Inspection on 25/04/07 for Broomhills

This inspection was carried out on 25th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broomhills 02/04/09

Broomhills 07/04/08

Broomhills 26/09/06

Broomhills 05/01/06

Broomhills 10/08/05

Broomhills 18/03/05

Broomhills 12/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Broomhills Stambridge Road Rochford Essex SS4 2AQ Lead Inspector Ms Vicky Dutton Unannounced Inspection 25th April 2007 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broomhills Address Stambridge Road Rochford Essex SS4 2AQ 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) 01702 542630 01702 542553 www.runwoodhomes.co.uk Runwood Homes Plc Manager post vacant Care Home 47 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (47) of places Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 47 persons of either sex to be accommodated who are over 65 years of age. Up to 23 persons of either sex to be accommodated who are over 65 years of age and who have dementia. No more than 47 persons to be accommodated at any one time. Date of last inspection 26th September 2006 Brief Description of the Service: Broomhills is registered to provide personal care and accommodation for 47 elderly people, included in this number the home can provide accommodation for up to 23 service users who have dementia. The original house is a 100year-old building of character. There are thirty seven single and five double rooms, most with en suite facilities. The home is currently using three of the five shared rooms as single accommodation. There is a choice of lounges and a separate dining room. There is an activities room in part of the basement. Accommodation is provided on three floors and all areas can be accessed by the way of two passenger lifts. Broomhills is set in three acres of grounds. Local facilities are a mile and a half away in the town of Rochford. The home has a Statement of Purpose and Service Users Guide in place. A copy of the most recent inspection report was available and on display in the home. Current fees at the home were quoted as being from £425.00 to £550.00 per week. Additional charges are made for chiropody, newspapers, toiletries and some transport costs. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced ‘key’ site visit. The visit took place over an eight hour period. As two inspectors were present this equated to sixteen hours of input. At this inspection all the key standards, and the homes progress against requirements from the last inspection. Prior to the site visit the home had submitted a pre-inspection questionnaire, and provided additional information that assisted with the inspection process. At the site visit a partial tour of the premises took place, care, staff, and other records and documentation were selected at random and various elements of these assessed. During the site visit residents, visitors and some of the home’s staff were spoken with. As part of this key inspection questionnaires were sent out in the post to health and social care professionals. Surveys were provided to the home before the site visit took place, and many were completed and returned to the inspector. Staff surveys were given out during the inspection. The views expressed at the site visit and survey responses have been incorporated into this report. The inspectors were assisted at the site visits by the acting manager and other members of the staff team. An operations manager from the organisation also attended for most of the site visit. Feedback on findings was given throughout the visit, and summarised at the end. The opportunity for discussion or clarification was given. A feedback card on the inspection process was left at the home. The inspectors would like to thank the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: Broomhills provides a comfortable and caring environment for residents, and is welcoming to relatives and friends of residents. One relative said that ‘I think Broomhills feels like home rather than ‘a home.’ The staff are always very cheerful.’ Another said, ‘they are a friendly home, they always make you welcome and are great with my relative.’ Staff morale at the home was good, and staff were enthusiastic about their role. Both management and staff demonstrated a good understanding of residents’ individual needs. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents will have their needs assessed before they move into the home, and know that the home will meet their needs. People have the information they need to make an informed choice about where to live. EVIDENCE: Copies of the home’s recently reviewed Statement of Purpose and Service Users Guide were available in various places around the home. Survey responses and discussion with residents showed that people felt that they had received sufficient information about the home before moving in. The acting manager confirmed that copies of the statement of purpose are given to people when staff from the home carry out pre-admission assessments. The files of two recently admitted residents viewed showed that their needs had been assessed before they moved into the home. Assessment information was also available from local social services departments. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 9 The home’s training information identified that most staff had received training in dementia care, for which the home is registered. Two recent admissions to the home had been diagnosed as having epilepsy. The acting manager confirmed that a local practice nursed had conducted a training session about epilepsy with staff before these residents were admitted. Care plans demonstrated an understanding of the needs of these residents. The acting manager and staff observed/spoken with demonstrated an understanding of residents’ individual needs. Intermediate care is not provided at Broomhills. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be sure that they will have an individual care plan in place, but this does not always lead to their care needs being properly met. Residents know that they will be supported to maintain good healthcare. Residents are not fully safeguarded by medication practices at the home. EVIDENCE: Feedback from residents and relatives about care in the home were generally positive. One said that the care received was 101 , another from a relative that, the residents have everything they need and the staff bend over backwards to assist them. Staff spoken with and observed showed that they had a good awareness of residents’ individual needs. All residents felt that staff listened to what they said and acted upon this. Care planning at the home had improved a great deal since the previous inspection of the service. Those viewed provided a good basis for care to be delivered to residents. In particular it was positive to see that a resident Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 11 admitted only a few days before the site visit had comprehensive care plans in place. Some issues were however discussed with the acting manager. Care plans in place were not always adhered to by staff to ensure residents’ needs are met, and that they are cared for safely. For example, one resident’s care plan said that they should be assisted by two staff at all times due to potential behavioural issues. The home’s hairdresser was trying to assist this resident with washing their hair (a procedure they were known to dislike) on their own. This resident had a lot of bruising on their hands. Staff said, and some records confirmed that the resident’s skin was vulnerable, but there was no care plan in place relating to this. Not all bruising had been recorded in daily notes or on a body chart. Staff had tried to protect one frail resident and prevent them from rolling out of bed by placing a cushion under their mattress. There was no risk assessment or care planning information in place relating to this practice. These shortfalls leave both residents and staff vulnerable. Care plans at the home are regularly reviewed and residents/relatives involved where possible. Care records showed that residents are assisted to access appropriate healthcare services to meet their needs. Feedback from a visiting professional was that the home usually cared for well for residents and met their healthcare needs. The home has a good relationship with their local surgery. A practice nurse visits the home each week to offer advice, support and see residents as necessary. They have also been involved in providing staff training in relevant areas such as Parkinson’s disease and epilepsy. A doctor visits the home on a set day each week, (and other times as needed,) to hold a surgery. District nurses visit as necessary. Residents’ nutritional needs are assessed, and their weight regularly monitored to help identify any developing health needs. Nutritional records kept have improved since the previous visit to the home. Some anomalies were however discussed with the acting manager. Medication at the home is mostly managed through a monitored dosage system (blister packs.) Some practice issues were noted. One member of staff was signing the medication administration record before they had given the medicine to residents. Protocols for the administration of medicines prescribed to be taken ‘as and when required’ (PRN) were in place, apart from one. One medication prescribed on a PRN basis to modify behaviour was being signed as administered twice a day, with no record being kept on the back of the medication administration record (MAR) sheet. The care team manager (CTM) confirmed that this medicine was now to be given on a regular basis, so this must be addressed with the resident’s GP and proper instructions recorded. Some recording omissions were noted on the MAR sheets. This was particularly in relation to eye drops/ointments. There was inadequate evidence to show that staff have received appropriate training and monitoring Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 12 in the administration of medicines. The homes training matrix does not identify this training and the file of a care team manager who administers medication showed no evidence of medication training. A member of staff said that the supplying pharmacist comes in and trains staff on the medication system. The acting manager said that staff complete in house competency based training in line with the registered providers policies. During the site visit staff were observed and heard to treat residents with courtesy and respect. Residents spoken with felt that they were treated respectfully by staff. Dignity was preserved when personal care tasks were being undertaken. Some residents’ bedrooms have now been provided with net curtains to provide a greater level of privacy. It was however advised that the location of chiropody treatment be considered. Residents were receiving treatment in the visitor’s room with the door open, and the next resident to be seen waiting in the room with them. This does not ensure individual residents’ privacy. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle needs and expectations of residents are not always met at the home. Residents know that their visitors will be made welcome. Food at the home is good and enjoyed by residents. EVIDENCE: Feedback on the level of activity/occupation provided by the home was varied. Some residents felt that they had sufficient activity/occupation, others felt that ‘there has not been much in the way of activities lately’ and that they ‘would like to go out more to the shops or the theatre.’ The acting manager said that activities was an area that the home is currently working hard to develop. Some recent outings have taken place. This included visits to Tesco’s so that residents can purchase their own toiletries, and visits to a pub. Other residents regularly go to a local market. Residents spoke of enjoying a St. Georges day party, and an Easter parade. A weekly activities timetable was on display. This identified a range of activities, but was not adhered to on the day of the site visit, as no activity co-ordinator was on duty. During the afternoon care staff did undertake some activity with residents, but during the morning there was limited staff/resident interaction. Staff were busy with other tasks, and residents left largely unengaged in the home’s lounges. The home has a Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 14 separate activities area in the basement of the building. Work is needed to make this area more inviting for residents. Residents felt that they were offered choices in their daily lives. It was seen that residents are free to follow their own routines. Visiting at the home is very open and relatives are always made welcome. One visitor said that they were able to have lunch with their relative during their daily visits. The home has a designated visitors room. It was noted that this area is not very inviting, and staff have a tendency to use it for storage. The acting manager said that improvements for this area are planned, including new furnishings. Information on advocacy services was available and on display in the home. Resident’s rooms were personalised and showed that residents had been able to bring in items of personal furnishings and possessions. Residents made generally positive comments about the food provided at Broomhills. One resident, who used to work in the food industry, said ‘I can say that the meals are very well cooked and nutritious. We also have a choice.’ Lunch on the day of the site visit looked appetising. The tables were nicely laid (by a resident.) One resident had written a poem in praise of the home. One line of this said ‘The dining room looks a treat, just the place to eat your meat.’ Some residents were wearing tabards to protect their clothing. These were of poor quality and tatty. The acting manager said that new ones were on order. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others can be confident that any concerns or complaints will be listened to and appropriate actions taken. Residents are protected from abuse, but difficult behaviours may not always be well understood or managed by staff. EVIDENCE: Broomhills has a clear complaints process in place. All people surveyed or spoken with were clear about how to raise any concerns. Where issues had been raised people felt that these had been dealt with appropriately. A relative said ‘the manager is very concerned if problems occur and deals with them promptly.’ The homes complaint record showed that complaints had been properly looked into and recorded. Concerns raised with the home related to laundry issues and some care issues. Training records showed that most staff have received recent training in adult protection. Staff spoken with were aware of adult protection and whistle blowing procedures. As seen during the inspection some residents’ behaviour can make it difficult for staff to assist them. It was confirmed by the acting manager that staff have yet to undertake training in managing behaviour that may challenge. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Broomhills is a generally safe and pleasant place for people to live. EVIDENCE: Broomhills provides a comfortable and homely environment for residents. The home is set in a rural location a walk away from the main road. Public transport, particularly during evenings and weekends, is limited. This could present difficulties for staff and visitors. The home has pleasant grounds, which has seating available. Residents said that they enjoyed using the home’s garden. As part of this site visit a partial tour of the premises took place. Full details of findings were fed back to the acting manager. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 17 Since the previous visit to the home further redecoration has taken place. It was nice to see that bedrooms have been painted in different colours with residents able to have a choice. The home has a clear programme of internal maintenance and redecoration in place. The basement area of the home was flooded a few months ago. This area is used by residents for hairdressing and activities; the staffroom is also situated in the basement. The area still smells damp and, as recognised by the acting manager and operations manager, the flooring needs to be replaced, and the whole area brightened up. At this site visit the home appeared generally cleaner and there were only isolated pockets of odour. Residents feel that the home is kept clean and made comments such as ‘ the whole place is well cleaned daily.’ The laundry area is situated in the basement of the home. The area was cleaner at this site visit and clear cleaning schedules were in place to help maintain good hygiene. One wall in the laundry area was showing signs of damp. The plinths on which two washing machines are sited were in a poor condition. Although some staff said that they had received training in infection control, practice needs to be monitored. Dirty clothing etc. had been placed on the laundry floor prior to being placed in the washing machine. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that staff at the home are safely recruited and receive sufficient training to meet their basic needs. However, staffing levels/deployment are not always adequate to meet their holistic needs. EVIDENCE: Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 19 Residents and relatives spoke well of the staff at Broomhills. A relative said ‘The staff are very caring and friendly. Nothing is too much trouble even though some of their clients are difficult.’ A resident said ‘I find the staff very friendly.’ The staffing levels at Broomhills are currently maintained at: Six care staff and one care team manager (CTM) during the day and three care staff and one CTM at night. Staffing rotas showed that these levels are being maintained. The amount of agency staff used by the home has been reduced overall. This provides a greater consistency for residents. Residents generally felt that there was sufficient staff to meet their needs. One resident said that when they needed help staff normally came ‘within ten minutes.’ When call bells were tested during the site visit staff were prompt to respond. Relatives however felt that there were not always sufficient staff on duty and that there were ‘sometimes staffing shortages.’ As observed at the site visit, staff are very busy during the morning period, and there are limited opportunities for them to interact meaningfully with residents. Due to difficulties with recruitment no domestic cover is provided during the afternoons or evenings at the home. A relative commented ‘carers are taken away from caring to do the laundry.’ Staff spoken with felt that staffing levels were generally adequate but that on certain days that are known to be particularly busy (e.g. when the practice nurse or GP visits) ‘an extra member of staff would be very beneficial.’ The acting manager undertook to look into this. Staff also said that weekends can be hard when there is generally no manager/administrative staff around. These issues have been raised with the registered provider on previous occasions, and they have been asked to provide evidence that a full staffing review has been carried out. This has not happened. A member of staff felt that there was sometimes pressure from senior management to reduce staffing levels at the home. The acting manager confirmed that at the moment out of 34 care staff only two have completed a National Vocational Qualification (NVQ) at level two, and one at level three. It was reported that a further twelve staff are currently undertaking NVQ training. The files of four recently recruited staff were viewed as part of this site visit. In general it was evident that recruitment is carried out safety, with appropriate checks being undertaken to ensure that residents are protected. However one member of staff only had one personal character reference on file. No files had a current photograph in place. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 20 The home has introduced a Skills for Care based induction programme for new staff. This programme is started some weeks after staff have commenced work in the home. Before this staff complete an initial induction checklist that deals with health and safety, premises and resident care issues. The level of staff training at the home has improved. Staff spoken with confirmed that they had undertaken relevant training to help them to meet the needs of residents. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management at Broomhills is becoming more effective in promoting a safe environment for residents and staff. Residents can be involved in expressing their views about the quality of the service. EVIDENCE: Management at the home has made good progress in addressing the requirements made in previous inspection reports, and in improving the home for the benefit of residents. An acting manager has been in post at the home for about nine months. It was stated that an application for registration is going to be made. The acting manager has limited previous experience in a management role but, with the support of their line manager, they have achieved significant improvements in the home since the previous key inspection of September last year. The acting manager is currently completing Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 22 their Registered Managers Award and has completed other relevant qualifications. A deputy manager has recently been appointed. Although this post only provides two days supernumerary in the deputy role, with other shifts being worked as a CTM, it will hopefully strengthen the overall local management at the home. The registered provider has strategies in place to monitor the quality of the service provided at Broomhills. An annual audit is undertaken. This last took place at Broomhills in July 2006. The audits include the use of questionnaires to seek residents and others views on the service. The home also has other internal procedures that contribute to overall quality monitoring of the home. These include monthly manager audits, and weekly medication audits. The acting manager holds a weekly evening ‘surgery’ when they are available to any who wish to see them. Visits are undertaken by a senior manager in the organisation as required by regulations. Residents’ monies were sampled and were satisfactory. The home’s pre-inspection questionnaire identified that systems and services are monitored and maintained. Fire checks are regularly carried out but no records could be found of staff fire drills. Fire risk assessment sheets were in place. The home’s training matrix showed a good improvement in the level of staff undertaking and being updated in core training such as moving and handling, health and safety and fire awareness. Storage and other high risk areas are now protected by the use of keypads. During this site visit some health and safety issues were identified and discussed with the acting manager. This included that disposable gloves should be stored safely to protect residents. Safe use information should be available where potentially hazardous equipment such as roller irons are located. One member of staff was noted to be wearing clothing and footwear that was not appropriate for carrying out care/moving and handling tasks. A member of agency staff was wearing large loop earrings that could be a hazard to themselves and residents. A recent environmental health officer visit identified that the home’s kitchen needs work/replacing so that a satisfactory level of hygiene can be maintained. It was stated that this work is planned. Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Care planning at the home must identify, and be effective in meeting all residents’ assessed needs. Staff should be aware of and carry out instructions in care planning information. 2. OP9 13(2) Medication practices at the home must be carried out in line with established best practice guidance, and the Company’s own policies and procedures so that residents are cared for safely. Staff training in medication must be clearly identified. 3. OP27 18(1) Staffing levels/deployment at the 01/07/07 home must be reviewed to make sure that residents’ holistic needs can be met by the numbers and designations of staff provided. Staff and residents views and experience should be taken into Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 25 Timescale for action 01/07/07 01/07/07 account in relation to staffing levels. 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 OP10 Good Practice Recommendations The home should consider the best place for chiropody treatment to be carried out in the home. This should take into account residents’ privacy and health and hygiene needs. The home should continue to assess and address residents’ activity/occupational needs. Staff should receive training and guidance to help them assist residents whose behaviour may be challenging. The basement area of the home should be improved for the benefit of residents. Staff should be assisted to undertake NVQ training and 50 of care staff be trained to NVQ level two or above. Management at the home should make sure that staff dress appropriately so that they can care safely for residents. 2. 3. 4. 5. 6. OP12 OP18 OP19 OP28 OP38 Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broomhills DS0000018040.V337731.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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