Inspection on 07/04/08 for Broomhills

This inspection was carried out on 7th April 2008.

CSCI found this care home to be providing an Adequate service.

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 25/04/07

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 Michelle Love Unannounced Inspection 7th April 2008 09:30 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.V361950.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.V361950.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 broomhills@runwoodhomes.co.uk www.runwoodhomecare.com Runwood Homes Plc vacant post Care Home 47 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (47) of places Broomhills DS0000018040.V361950.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 25th April 2007 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 £374.50 for a contracted bed and £525.00 to £600.00 per week for a privately funded bed. Additional charges are made for chiropody, newspapers, toiletries and some transport costs. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection. The visit took place over one day and lasted a total of 10.5 hours, with all but one of the key standards inspected. Additionally, the manager’s progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document required by legislation detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the inspection surveys were forwarded from us to residents next of kin, placing authorities, healthcare professionals and staff who work within the care home. Comments relating to the above have been incorporated into the main text of the report. The manager, deputy manager and other members of the staff team assisted the inspector on the day of the inspection. Feedback on the inspection findings were given throughout and summarised at the end of the day. The opportunity for discussion and/or clarification was given. The operations manager from Runwood Homes PLC was present for part of the inspection. What the service does well: Residents seem to be happy and content living at Broomhills. Resident’s like their bedrooms as these are personalised and individualised to reflect people’s personalities and personal preferences. Visitors to the home are made to feel welcome and one relative confirmed that they are always made to feel welcome and are provided with refreshments. The quality of the food at the care home is good and residents’ comments regarding meals provided, was positive. Both the chef and kitchen assistants have a good relationship and rapport with residents. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 6 The home is situated within lovely grounds and provides the majority of residents with a lovely view of the surrounding area/gardens. Residents made positive comments about the patio area and the gardens. Staff morale at the home is good and both the manager and staff team demonstrated enthusiasm about their role and a good understanding of individual residents’ needs. The manager is not purely office based and spends a significant amount of time speaking with staff and meeting with residents and their representatives. 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 Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 8 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.V361950.R01.S.doc Version 5.2 Page 9 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to move into the home can be sure that their needs can be met. EVIDENCE: A copy of the Statement of Purpose and Service Users Guide is available in the main reception area and in various places around the home. The manager advised the inspector that prospective residents are given a copy of the Statement of Purpose and Service Users Guide as part of the pre admission assessment process. One newly admitted resident to the home was asked whether or not they had received a copy of the above documents, however the resident was unable to confirm, as they could not remember if this had been provided. Of those relatives surveys returned to the Commission for Social Care Inspection, all confirmed that they felt the management team of the home had provided them with sufficient information about the home’s facilities and services. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 10 Two care files for the newest residents admitted to the care home were examined and detailed that the management team of the home completed a pre admission assessment prior to admission for both people, so as to ensure that they are able to meet the prospective resident’s needs. Information recorded within both assessments was observed to be descriptive and contained appropriate information relating to the individual’s care needs. The manager was advised to ensure, that as part of good practice procedures, where a prospective resident is admitted on the same day as the pre admission assessment undertaken, the rationale for the decision is clearly recorded. In addition to the pre admission assessment undertaken by the home, information from individual resident’s placing authorities and/or hospital was available. The Annual Quality Assurance Assessment confirms that a pre admission assessment is completed so as to determine if the home can meet the prospective person’s needs. It also details that a visit is offered to the person and/or their representative. The manager was advised to ensure that information detailing the latter is clearly recorded. Intermediate care is not provided at Broomhills. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 11 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 and 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 they have an individual plan of care in place, however shortfalls in care planning, risk assessing and medication practices were highlighted which could have an adverse affect on outcomes for residents and their wellbeing. EVIDENCE: There is a formal care planning system in place to identify the care needs of individual residents and to specify how these are to be met by care staff. The care planning system remains detailed and makes reference to an individual’s health, emotional and social care needs. Additionally it includes formal assessments relating to nutrition, pressure area care, falls, dependency levels and moving and handling. As part of this inspection 2 care files were examined in full and a further 3 care files were partially examined. Staff, must ensure that individual resident’s needs are fully recorded, and include the interventions required so as to Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 12 ensure the appropriate delivery of care. For example one care plan made reference to the resident having a history of back pain and requiring no medication for pain relief. However, on inspection of the individual’s Medication Administration Record (MAR), medication for pain relief was prescribed. The care plan and medication profile had not been updated to reflect the person’s changed needs. Another care plan made reference to the person exhibiting both verbal and physical aggression on occasions. Records did not include information relating to the specific nature of aggression displayed or provide clear guidelines for staff as to how this should be managed or who to contact should the behaviour escalate. The above shortfalls, potentially place residents’ at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about individual people. The management team of the home must ensure that care plans are regularly updated and reviewed. The Annual Quality Assurance Assessment under the heading of ‘our evidence to show that we do it well’ details, “Our care plans updated monthly unless needed or the residents wishes or needs change”. This does not concur with the above findings. Following discussions with the manager it was evident that she had a good understanding of person centred care, however this knowledge needs to be communicated to care staff so that they have a better understanding. The manager was also advised to ensure that where information is recorded within the pre admission assessment, this is transferred to the person’s care plan and where appropriate a risk assessment is devised. It was disappointing that risk assessments were not devised for all areas of assessed risk. For example the care plan for one person detailed they suffered depression, required medication for pain relief and had parkinsons disease. No risk assessment was devised for any of the above, to detail how the risk areas were to be minimised by care staff. Care records showed that all people who reside in the care home have access to a range of healthcare provision and services as and when required. The manager advised the inspector that there is a good relationship with the local surgery and a practice nurse visits the care home each week to offer advice, support and to provide staff training. One relative spoken with confirmed that their member of family receives regular access to healthcare services and professionals as and when required and following any visit/treatment are always advised of the outcome. Staff interaction with residents during the morning was observed to be poor e.g. little or no verbal interaction by staff with residents prior to undertaking a task. The manager confirmed to the inspector that this was unusual and at handover in the afternoon she was noted to speak with staff. It was positive to note that interaction between residents and staff was much improved in the afternoon. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 13 The majority of medication is managed through a monitored dosage system (blister pack). Administration of medication to residents was observed during the inspection and this was seen to be satisfactory and storage systems within the home were appropriate. Shortfalls were identified in relation to there being no record of some medicines having been given to the resident when they were due, as the entries on the MAR chart had been left blank (tablets and creams). Where the prescriber’s instructions state 1 or 2 tablets to be administered, the actual dose administered was not always recorded. Several MAR records detailed that medication for some people was administered as PRN (as and when required), however the person’s medication was prescribed as a regular dose. This is poor practice and means that some people who do not receive their prescribed medication could potentially have their wellbeing and/or safety compromised. It was of concern that the MAR record for one person detailed that one medication should be administered once daily, however over a 5 day period, the record had been left blank and not signed by staff. When cross-referenced with the person’s daily care records, there was no evidence or rationale as to the reason for the omission. As a result of the above, an Immediate Requirement Notice was issued and the registered provider was requested to provide an action plan detailing how the above shortfalls were to be addressed. We questioned the manager as to the auditing processes within the home and were advised that the deputy manager is responsible for overseeing the home’s medication. It is disappointing that neither, the deputy manager or Care Team Manager’s had highlighted the above issue or discussed the above with the manager. On inspection of the training matrix, records indicate that the deputy manager and Care Team Managers have up to date medication training. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents could be sure of having their social care needs met, but they could be assured of good nutritious meals. EVIDENCE: We were advised that for the past 18-24 months, the home has intermittently been without an activities co-ordinator. The manager advised that activities, are being undertaken by the staff team, however on some occasions these have not been provided as regularly as hoped as a result of the above. Although there is a weekly activity programme on display, this is flexible so as to suit the needs of residents. The manager stated that an activities coordinator has been newly recruited and was due to commence employment the day after the inspection. On the day of the site visit, no activities were observed to take place during the morning, however staff were observed to play skittles and giant snakes and ladders in the afternoon. Residents were observed to enjoy the activities. Although the home has an activity room within the basement of the home, this is seen to be located within an isolated part of the building and consideration Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 15 should be made to either make the current facilities more inviting or to utilise another part of the building so as to encourage more resident participation. An activity folder evidencing activities undertaken at the home was readily available and included activities such as colouring, indoor skittles, cards, giant snakes and ladders, reminiscence, cooking, clothes party, quiz, music afternoon, hoopla and sing-a-long. Future planned activities include a summer BBQ, down memory lane and a clothes show. There was also evidence that a newsletter had been devised and it is hoped that these will be produced on a regular basis. Care plans were noted to record peoples personal preferences relating to social care activities. The manager was also advised to consider other activities such as memory boxes/objects of reference. Visiting at the home is very open and relatives spoken with advised that they are always made to feel welcome. The home has a designated visitors room, however as stated at the previous inspection, there is a tendency to use it for storage. One relative’s survey returned to the Commission recorded “It’s nice to know that I can visit my relative when I like”. Information relating to advocacy services was available and on display in the home. The lunchtime meal was observed in the dining room. The dining room was observed to be light and welcoming and offers residents’ lovely views of the garden. Dining tables were attractively laid with tablecloths, placemats, small vase of flowers, serviettes and condiments. The menu for the day was clearly displayed, however the manager was advised to consider devising this in larger print/simple language and/or pictorial so as to enable residents to make an informed choice. Residents were offered a choice of drinks and meals provided to residents were seen to be plentiful and attractively presented. Those people who required a soft diet/pureed meal also received an attractively presented plate of food, with each item of food portioned separately. On the day of inspection seating in the dining room was seen to be disorganised and not very well managed with several residents being seated and then relocated to an alternative seat and/or table. The inspector observed that not all residents who were moved were consulted by care staff as to the above. Interaction between care staff and residents was poor during the lunchtime meal, with little verbal interaction noted. The most positive interaction was observed between the kitchen staff and residents, and residents were seen to be responsive and welcomed the exchange. Care staff did not ask residents if they had finished their meal or if they wanted more food before removing the person’s plate, however kitchen staff were receptive and consulted residents. The manager also observed the lunchtime meal and expressed surprise at Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 16 staff’s lack of interaction and engagement with residents and advised that this was not their usual standard of working practice. Of those residents spoken with comments relating to the quality of food was positive. When asked as to the above, one resident grinned and gave the thumbs up sign. Other comments noted were “the food is lovely”, “I always enjoy my food” and “I have no complaints”. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 17 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 and 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 raised will be listened to and appropriate actions taken. The management of safeguarding within Broomhills, ensures that residents are protected from abuse. EVIDENCE: The home has a corporate complaints policy and procedure in place and this is displayed. It was positive from those relatives’ surveys returned to all were clear about how to raise any concerns. One relative confirmed to us that should they feel the need to raise any issues, they had faith in the management of the home to deal with it effectively. The complaints folder was examined and it was found that the majority of complaints detailed the specific nature of complaint, details of any investigation and action taken where appropriate. The manager was advised to ensure that details of the outcome relating to a complaint are recorded. One complaint record was observed to have been recorded as partially resolved, however no further information was recorded. We recognise that this complaint was dealt with by the previous home’s manager and not the current management team. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 18 Since the last key inspection, the management team of the home had dealt with one safeguarding issue. Following discussion with the manager and from inspection of records, there was appropriate evidence to indicate that appropriate action had been undertaken in line with local safeguarding procedures. Policies and procedures relating to safeguarding are readily available within the home. Staff spoken with demonstrated an awareness and basic understanding of safeguarding procedures and advised that should an issue arise, information would be passed to the person in charge of the shift. The manager when questioned demonstrated a good understanding of the above, including corporate policies and procedures. The training matrix showed that the majority of staff had received training relating to safeguarding. Since the last inspection 4 members of staff have received training relating to challenging behaviour. Although this is seen as positive it is hoped that more staff will receive this training in the future so as to ensure that staff are competent and feel confident to deal with any situations that arise as a result of individuals inappropriate/challenging behaviours. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Broomhills provides a comfortable, safe and homely environment for residents, which meets their needs. EVIDENCE: A partial tour of the premises was undertaken as part of this key inspection. A random sample of resident’s bedrooms were inspected and all were seen to be personalised and individualised with many personal items on display e.g. ornaments, photographs etc. Residents spoken with confirmed that they liked their personal space and were happy with the home environment. Issues highlighted at the last inspection relating to the basement have been addressed. This refers specifically to the flooring having been replaced. The manager was advised that a slight damp odour was noticeable within the hairdressing salon. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 20 The home environment was noted to be clean and odour free throughout the day. The laundry facilities were observed to be well organised. No health and safety issues were highlighted at this inspection. The home has a clear programme of internal maintenance and redecoration in place. The training matrix evidences that the majority of staff have received training relating to health and safety and fire awareness. Although infection control practices and procedures by staff were observed to be appropriate at this site visit, the training matrix does not detail as to whether or not people have received training relating to infection control. The Annual Quality Assurance Assessment details that 38 members of staff have received infection control training. A fire plan and fire risk assessment for the home is readily available. Records indicated a visit to the care home, was undertaken on 29/1/08 by the local Fire Authority and recommendations advised during the visit had been addressed. Records for fire drills evidence these are conducted regularly. Service reports for hoists and the passenger lift were available and these evidence at the time of the site visit that equipment was fully operational and in good working order. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 21 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 and 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 staffing levels are generally adequate to meet their needs and that staff receive sufficient training. Further development is required in relation to staff recruitment practices and procedures so as to ensure resident’s safe and wellbeing. EVIDENCE: The manager advised that staffing levels at the care home remain at 1 Care Team Manager (CTM) and 6 members of care staff between 07.15 a.m. and 21.15 p.m. each day and at night there is 1 CTM and 3 members of care staff between 21.15 p.m. and 07.30 a.m. The manager’s hours are supernumerary to the above staffing levels and she is scheduled to be on duty between 09.00 a.m. and 17.00 p.m. Monday to Friday. In addition to the above additional staff are employed to cover housekeeping, maintenance, cooking and laundry tasks. On inspection of four weeks staff rosters, these evidenced that the above staffing levels are being maintained and that the usage of agency staff is not too high. The latter is seen as positive as this provides a greater consistency for residents. The Annual Quality Assurance Assessment, under the heading of ‘how we have improved in the last 12 months’ details, “Agency use has been minimal providing a continuous care environment”. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 22 Staff spoken with advised the inspector that in general terms staffing levels were adequate to support and meet residents’ needs, however there were occasions as a result of staff sickness and agency staff not being able to provide cover until later in the shift that this placed an extra burden on staff and made the shift hard and very busy. It was evident at the inspection that staff are extremely busy throughout the morning shift and when dealing with external healthcare professionals and agencies. It was also noted that there is no kitchen assistant to provide additional support during the teatime meal. It was observed and staff confirmed that a member of staff is taken off the floor and utilised within the kitchen during this time. This reduces the numbers of staff on duty. One relative’s survey returned to the Commission recorded “It supplies my relatives basic needs. There do not appear to be sufficient staff to do more than this. Considering how much they charge I do not feel that they offer value for money”. Following discussion with the operations manager at the site visit, KPI (Key Performance Indicator) audits have been devised and completed so as to identify residents’ dependency levels, numbers of staff on duty at any one time, usage of agency staff and where professional agencies are involved. The files for 4 recently employed staff were examined. These evidence the majority of records as required by regulation being available, however some gaps were noted. These relate to no health declaration for one person, no evidence of a POVA 1st notification for one person, one written reference only for two people, no written reference from the employee’s last/current employer and a POVA 1st notification received after they had commenced employment. Current recruitment practices do not fully ensure that residents are safeguarded and this needs to be further improved and developed. We recognise of those files inspected that 3 members of staff, had been recruited by the previous manager to the home. A Skills for Care based induction programme has been introduced for newly employed staff and was evident within those files examined. Of those staff surveys returned to us, all confirmed that their induction had included everything they needed to enable them to undertaken their role effectively. The training matrix provided to the inspector details that 7 staff had attained NVQ Level 2 and 1 member of staff has achieved NVQ Level 3. It also details that the majority of staff have received training in core areas e.g. safeguarding, first aid, manual handling, dementia awareness, health and safety, food hygiene and fire awareness. The manager advised that specific training relating to the needs of older people is to be provided by the designated nurse practitioner allocated to Broomhills and includes Parkinson awareness, diabetes, infection control, continence, pressure area care and tissue viability. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 23 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst management arrangements are generally sound, shortfalls identified during this inspection, could affect outcomes for residents. EVIDENCE: The manager has been at the home for several years as a deputy manager and senior carer and has past experience of working in care within other privately run establishments. The manager has been in post as the manager at Broomhills since 3/3/08 and has attained her NVQ Level 3 in Health and Social Care and is currently undertaking the Registered Manager’s Award. Although the manager was employed previously as the home’s deputy manager, both she and the operations manager have recognised that the role of manager is significantly different and as a result of this, a comprehensive Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 24 induction has been undertaken. This is seen as positive. The manager advised that she receives regular support and advice from the operations manager and attends regular regional manager’s meetings. Although we recognise that there is further work required to ensure that some aspects as highlighted within the main text of the report comply with regulatory requirements and National Minimum Standards, it is felt that this will be achieved in time and with appropriate support and guidance provided to the manager. At the site visit the manager clearly demonstrated both commitment and enthusiasm to ensuring that improvements would be made and was responsive to criticisms/advice given by the inspector. Of those members of staff spoken with, all were complimentary regarding the manager and felt that she managed the home well and provided a good level of support and guidance. One staff survey returned to us stated, “Our home has much improved under new management and is an on-going work in progress that is improving every day”. Another survey recorded “I don’t think the care home can improve, on the way it is already being run. I’m satisfied that my relative is being looked after alright”. Relatives spoken with confirmed that they had seen a positive change in the management of the home over a period of time and felt that the manager was approachable. One relative survey recorded “Broomhill feels like a `home` in the real sense of the word and not an old peoples home”. All sections of the Annual Quality Assurance Assessment were completed and the information gives a basic picture of the current situation within the service. The evidence to support the comments made is satisfactory, however further information recorded within the document would have been useful to highlight what the service has done in the last 12 months, or how it is planning to improve. A random sample of staff supervision records, were inspected and these evidence that supervisions are regularly undertaken at the home. Of those staff surveys returned to us, all confirmed that the manager meets with them regularly. The registered provider has strategies in place to monitor the quality of the service provided at the care home. This includes an annual audit, seeking the views of residents, their representatives and others and monthly manager/operation manager audits. Additionally the manager holds a weekly evening surgery so as to have an opportunity to speak to visitors. There was evidence to indicate that regular staff meetings and CTM meetings are undertaken at the home and the minutes of these meetings were randomly inspected. The manager advised that resident meetings have been inconsistent in the past, however it is hoped that these will be conducted 4-6 weekly in the future. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 25 As stated previously, no health and safety issues were highlighted and there were appropriate policies and procedures readily available. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 3 X 3 Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 27 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 and ensure that these are regularly updated/reviewed to reflect the most up to date information. Previous timescale of 1/7/07 not fully met. Risk assessments must be devised for all areas of assessed risk so that risks to residents can be minimised. People who use the service must be protected by having suitable arrangements in place for the control, administration and recording of medicines. Previous timescale of 1/7/07 not fully met. Medication must be administered in accordance with the prescriber’s instructions so as to ensure people’s health and wellbeing. People residing at the care home must have their social care DS0000018040.V361950.R01.S.doc Timescale for action 01/06/08 2. OP7 13(4) 01/06/08 3. OP9 13(2) 07/04/08 4. OP9 12(1)(a) 07/04/08 5. OP12 16(2)(m) and (n) 08/04/08 Broomhills Version 5.2 Page 28 6. OP29 19 needs met to ensure they are stimulated and do not become bored. People must be protected by the 07/04/08 home’s recruitment practices and procedures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP3 OP12 OP15 OP18 Good Practice Recommendations Consider recording the rationale for the decision, whereby the pre admission assessment is completed and the prospective resident is admitted on the same day. Consider devising the activities programme in larger print and/or pictorial format so that residents can make an informed choice. Consider devising the home’s menu in larger print and/or pictorial format so that residents can make an informed choice. Staff should receive training and guidance to help them assist residents whose behaviour may be challenging. Broomhills DS0000018040.V361950.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V361950.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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