Inspection on 27/06/05 for Broxbourne House

This inspection was carried out on 27th June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broxbourne House 13/05/09

Broxbourne House 05/06/07

Broxbourne House 28/06/06

Broxbourne House 30/11/05

Broxbourne House 01/09/04

Broxbourne House 14/04/04

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

CARE HOMES FOR OLDER PEOPLE BROXBOURNE HOUSE 57 Barnsley Road Wakefield WF1 5LE Lead Inspector Mavis Pickard Unannounced 27 June 2005 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 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. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broxbourne House Address 57 Barnsley Road Wakefield WF1 5LE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 370004 01924 384650 Mr M Seeratun Mrs Ursula Owen Care Home - Personal Care only 21 Category(ies) of Old age, not falling within any other category registration, with number 21 of places Mental Disorder - over 65 - 21 BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/9/04 Brief Description of the Service: Broxbourne House provides residential care for 21 older people who may also suffer with mental health problems.The home is situated just outside the centre of Wakefield on the main Barnsley Road. Set in its own grounds there is a garden area to the front and side and car parking to the rear. The main entrance is to the rear of the home where there is an office and corridors leading to the lounges, dining room and bedrooms.A passenger lift is provided for those who require it and there are assisted bathing and showering facilities. Shared and single accommodation is provided and bedrooms are personalised and comfortable.The home is on a main bus route and is only a few minutes from the centre of Wakefield and a limited range of local amenities. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was found to be running well. People spoken to, who live at the home, said that they enjoy living at Broxbourne House and would recommend the home to others. On the day of this unannounced inspection, the home presented as being clean and bright. Residents, some of whom were sitting out in the sun, seemed to be relaxed and happy and said that the home meets their expectations. The registered manager was off duty and the provider, Mr M Seeratun, was available throughout the inspection. Staff on duty were going about their tasks in a relaxed way and were noted to have a pleasant relationship with residents. The atmosphere in the home is comfortable. What the service does well: What has improved since the last inspection? The home has been operating well for some time and records show that, at the previous inspection, the home met all the required standards. The daily recording systems continue to improve with an increased use of descriptive words to indicate service users’ choices and preferences. The owner said that several areas of the home, including some residents’ bedrooms, had been decorated since the previous inspection. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 6 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. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 & 6 No resident moves into the home before a full assessment of his or her need has been undertaken. The home does not accommodate people for intermediate care. EVIDENCE: The home’s policies are that all prospective residents will have a comprehensive assessment of their perceived need prior to admission. On examination of records, and on speaking with the provider, it is clear that prospective residents are assessed before being admitted to the home. The case files of two most recently admitted residents were examined. It was found that all contained a medical history including a diagnosis. The file contained a copy of the home’s and a care management assessment alongside a copy of the home’s terms and conditions of residence [contract]. The home’s Statement of Purpose states that they do not provide facilities for intermediate care. The registered person confirmed on the day of inspection that this remains the case. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 9 BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 All residents’ health, personal and social needs are set out in an individual care plan, which is regularly reviewed to ensure that their needs are met. Residents’ privacy is respected. EVIDENCE: Having inspected the case files of two newly admitted residents, the Inspector found that there was evidence that the residents’ health and social care needs are set out in an individual care plan. Both service users had a comprehensive care plan which sets out individual perceived needs in relation to that resident, eg. mobility, continence, eating and drinking, weight, social and activity etc. These plans give evidence of the perceived need, what action is to be taken to meet that need and goals which are aspired to, showing over time how these may be achieved. Care plans give evidence of health care needs including medication and the actions taken by the home to meet these needs. From speaking with people living in the home generally, and from direct observation of interaction taking place between residents and staff and BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 11 between residents and visitors during this unannounced inspection, the Inspector could see that residents are treated with respect and that their privacy is maintained. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 &15 The atmosphere in the home is welcoming and matches individuals’ expectations and preferences. The food provided is varied and choice is available. EVIDENCE: Residents spoken with during the inspection said that, although living in a care home can never be like living in their own home, they feel that Broxbourne House does ensure that, as far as possible, the lifestyle they have at the home is what they want. People said that they can retain interests that they have always had such as sport, and going out for a pub visit, meeting with friends and enjoying the company of their family. People said that they could receive their visitors at any reasonable time. Menus were inspected during the visit and found to be providing wholesome and varied meals. Residents spoken with said that, in their opinion, the food provided by the home is of good quality. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Residents’ legal rights are protected although the home admitted that two staff had been employed before their CRB/POVA check in relation to working at Broxbourne House was received. The responsible person will now work to the CRB/POVA legislation and to the Department of Health guidance. Not all staff have received training about protecting people from abuse. EVIDENCE: With reference to protection, the Inspector found that one recently employed staff member was working in the home and that, although she had a recent satisfactory Criminal Records Bureau [CRB] and Protection of Vulnerable Adults [POVA] check, this was from her previous employment. A second recently employed person also did not have CRB/POVA clearance. When spoken with, the owner said that he didn’t fully understand the process in respect to ensuring that no one works in the home until they have received CRB/POVA clearance to work in this home. The Inspector made the home’s responsibilities clear regarding this issue and accepted the home’s reassurances that in the future no staff will be allowed to work in the home before a current CRB/POVA check is received or that, whilst waiting for the full check to be received, a ‘POVA first’ check is undertaken. [Please refer to standard 29]. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 14 Staff training documentation was not made available for inspection and, from speaking with staff, it is clear that not all have received training in respect to adult abuse and the protection of vulnerable adults. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21&26 The provider ensures that the environment for people living in the home is clean, safe and well maintained, although not all residents’ facilities are readily available to them. EVIDENCE: The environment is clean, safe and well maintained. Maintenance records endorse this. Residents have access to comfortable indoor space. It was noted that, although the garden areas to the home are safe and attractive, residents were sitting on a bench in the car park. When asked, residents said that they would rather use the garden area but that there is no seating provided. This was discussed with the provider who said he would provide appropriate seating in the garden for the use of people accommodated. Residents’ bedrooms are well furnished, clean and suited to the needs of people accommodated. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 16 The home provides sufficient bathing facilities, however one bathroom was being used as a storage facility. This is not acceptable. Staff working in the home said that they receive health and safety training and are encouraged to check the general state of the home during their working day and report any concerns to the manager. The owner said that regular health and safety checks are undertaken at the home. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 The home employs sufficient qualified and experienced staff to meet the assessed needs of people accommodated. The responsible person has not worked to the CRB/POVA legislation and to the Department of Health guidance in respect of the employment of staff. It is not clear if progress is being made towards the expected 50 of care staff achieving National Vocational Qualification [NVQ] at level 2 or above by 2005. EVIDENCE: On the day of this visit there were sufficient staff to meet the needs of people accommodated. The Inspector spent several hours in the home and was able to observe the way in which staff interacted with residents and how they ensured that their daily needs were met. Residents said that staff did all they could to ensure that needs were met. Staff employment and training records were unable to be inspected. The owner was advised that such records are required to be made available for the purpose of regulation and that the person in charge must be able to ensure access to the files. With respect to service users at all times being protected by the home’s recruitment policy and practice, please refer to standards 16-18. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 18 Staff spoken with during the visit said that they had received training on such care-based subjects as health & safety, moving and handling, first aid and food hygiene. Records of how many staff have undertaken National Vocational Qualifications [NVQ] at level 2 or above were not available. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,38 The person in charge on the day of inspection exhibited a leadership style, which was noted by the Inspector to be inclusive and supportive to residents. Not all residents who wish to, have ready access to their personal finances. EVIDENCE: The registered manager was not available during this visit. The owner, who was the person in charge on the day of the visit, was familiar with the running of the home, understood the needs of residents and exhibited a leadership style which was noted by the Inspector to be inclusive and supportive to residents. From being in the home for several hours, it was clear that the home is run in the best interests of people accommodated and that their welfare is uppermost in the conduct of the home. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 20 Residents said, and the owner confirmed, that not all people living in the home have access to their own money. Some people do not have their personal allowances made available to them by their family and/or representative in a way in which they would wish. The owner was requested to look at the systems again to ensure that, where a resident has the capacity to manage their own finances or personal allowances, this is achieved. Health & safety records were examined where it was found that all required records were up to date and accurate. BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x 1 x x 3 BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 22 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 29 Regulation 19 Requirement The registered person must ensure that new staff are confirmed in post and work in the home only following satisfactory Protection of Vulnerable Adults[POVA] clearance. The registered person must ensure that residents control their own money except where they state they dont wish to or they lack capacity and that safeguards are in place to protect the financial interests of the resident. Timescale for action with immediate effect from 27-6-05 2. 35 12(2-3) with immediate effect and from 27-605 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. Refer to Standard 20 21 Good Practice Recommendations The registered person should ensure that appropriate seating and/or protection from the sun is provided for residents in the garden area of the home. The registered person should ensure that toilet and bathing facilities are not used as general storage facilities. J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 23 BROXBOURNE HOUSE Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 BROXBOURNE HOUSE J51J01_S6169_Broxbourne House_V220538_270605.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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