Inspection on 28/06/06 for Broxbourne House

This inspection was carried out on 28th June 2006.

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

The inspector 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 30/11/05

Broxbourne House 27/06/05

Broxbourne House 01/09/04

Broxbourne House 14/04/04

Similar services:

Abbey The

Snydale Care Home

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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 West Yorks WF1 5LE Lead Inspector Gillian Walsh Key Unannounced Inspection 28th June 2006 09:50 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 Broxbourne House DS0000006169.V296188.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. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broxbourne House Address 57 Barnsley Road Wakefield West Yorks WF1 5LE 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) 01924 370004 01924 384650 Mr M Seeratun Mrs Ursula Owen Care Home 21 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (21), Old age, of places not falling within any other category (21) Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 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 most bedrooms, although not en-suite, are personalised and comfortable. The home is on a main bus route and is only a few minutes from the centre of Wakefield and all services and amenities. The provider informed the Commission for Social Care Inspection on 28/06/06 that fees range from £359 to £360 per week. Additional charges include hairdressing, private chiropody and newspapers. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection an inspector from the Commission for Social Care inspection (CSCI) undertook a visit to the home. The visit started at 10am and finished at 5pm. Alongside this, the service provider was asked to complete a pre-inspection questionnaire which was returned prior to the site visit. Questionnaires were sent to residents, their relatives, visiting professionals and GPs. Of the 10 residents questionnaires sent out, 5 were received back. Three of these had all been completed by staff either with, or on behalf of, the residents and two had been completed with the support of the relative. Of the 10 relatives questionnaires sent out, 4 were returned. Of the 4 General practitioner questionnaires sent, 1 was returned, 1 of the 2 district nurse surveys was returned and neither of the 2 social worker questionnaires were returned. Relevant comments made within these questionnaires have been included within the body of the report. In writing this report, information and evidence was not only obtained by way of visiting the home, but information and evidence was obtained from notifications and information obtained by CSCI and from the last CSCI inspection report. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from service users and their families, staff, the home’s manager and proprietor and other relevant stakeholders, and undertook relevant observations and discussions appropriate to needs of the service users, taking into account their needs and communication needs. The inspector would like to thank residents and staff for their time and assistance during this inspection. What the service does well: Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 6 The relationships between residents, their relatives, staff and the provider are good. Residents and their relatives are very complimentary of the caring atmosphere within the home. Staff are kind and caring in their approach to residents and ensure that their privacy and dignity needs are met. What has improved since the last inspection? What they could do better: The registered person needs to develop a Statement of Purpose so that people have good information about the home. All prospective residents need to have an assessment to ensure that the home can meet their assessed needs. Residents must not be accepted at the home if their needs do not fall within the registration categories. Care plans need to be developed for all residents and these care plans need to be kept under review to ensure that residents’ current needs are identified along with a plan as to how these needs are to be met. Staffing levels need to be improved to maintain the care and safety needs of residents. To make sure residents’ quality of life is good, improvements must be made in relation to provision of activities, organisation of mealtimes and staff knowledge of adult protection systems. A number of environmental improvements are needed to protect residents’ safety. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 7 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 DS0000006169.V296188.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 Broxbourne House DS0000006169.V296188.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 (intermediate care is not applicable) Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. Prospective residents do not have the information they need to make an informed choice about where they wish to live, and are not provided with a statement of terms and conditions on admission. The systems operated by the home do not ensure that people move into the home after having had their needs assessed and are assured that these will be met. EVIDENCE: The Service User Guides seen on the visit had not been reviewed and contained very out of date information about fees and other additional charges. The registered provider said that the Statement of Purpose is incorporated into the Service User Guide and is not available as a separate document. None of the files seen contained a statement of terms and conditions from the home. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 10 Two of the five residents’ care plan files seen did not contain a pre-admission assessment. The registered provider confirmed that this process had not taken place for one resident who had been admitted for emergency respite care, although he had been to visit the resident immediately prior to their admission to the home. The pre- inspection questionnaire completed by the registered person and returned to the Commission stated that a number of the current residents are suffering from dementia. As the home is not currently registered to accommodate people with dementia, the registered provider said that he would apply to the Commission for a variation in this regard. Broxbourne House DS0000006169.V296188.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service and is particularly affected by the potential outcomes for residents where care plans are not developed or reviewed. The staff at the home do not always ensure that individual’s health, personal and social care needs are set out in the individual plan of care. The systems operated by the home ensure that people’s physical health care needs are assessed appropriately. This does not always include mental health and behavioural needs. The systems operated by the home ensure that residents are protected by the home’s policies and procedures for dealing with medicines. The work of the staff ensure that people feel that they are treated with respect and that their right to privacy is upheld. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 12 EVIDENCE: Five residents’ care plan files were examined during the site visit. One of the files for a person who had been at the home receiving respite care for a month did not include any information other than the person’s name, address, GP and social worker. No assessments had been undertaken and no care plans had been devised. Care plans had been developed in the other four files and, whilst several were well written and gave clear information about the needs and abilities of the individual and how these needs should be met, others did not. One of the resident’s care plans was very out of date and did not reflect their current needs, particularly in relation to safety and mobility. Two files did not contain care plans for pressure area care despite the residents being cared for on air flow mattresses and having waterlow assessments which indicated that they were at high risk of developing pressure sores. One resident who had been losing weight steadily over the previous weeks had not had a care plan developed for this need. None of the care plan files contained nutritional assessments and the home’s manager confirmed that this assessment had not been undertaken for any of the residents at the home. Another care plan seen described how, in order to manage the resident’s behaviour, their mobility aid should be removed. Discussion took place with the manager and the proprietor about how this could be a form of restraint and that wherever a resident’s behaviour presents a risk to other residents and cannot be effectively and appropriately managed within the home, referral should be made to appropriate health and social care professionals. Positively, some care plans included detail of residents’ abilities and preferences although only one of the plans seen included a care plan for social and recreational needs. None of the files seen included care plans relating to mental health needs where the resident is suffering from confusion or dementia. Daily records in all of the files were good, giving good detail of how residents spent their days and care interventions made. Evidence was available to demonstrate that residents’ physical health care needs are appropriately met through referral to district nursing services, GPs chiropody etc. As described above, appropriate help is not always being sought for behavioural or psychological problems. One of the GP questionnaires returned to the Commission makes comment that the GP is not able to see their patients in private. The manager said that the home has very good relationships with GPs and district nurses and that district nurses are supportive in educating care staff to care for residents with particular needs. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 13 One district nurse comment card said that “communication with the home is good” and that the home feels “homely”. Systems for the receipt, storage and administration of medication were checked and were satisfactory at the time of the visit. One GP comment card said that medications are “not always” appropriately managed in the home. Medications awaiting return to pharmacy, although kept in a locked room, are not locked in cupboards. The manager was advised that this practice should be commenced to ensure safety in storage of medication. Staff were observed to treat residents with respect and residents spoken with were very happy that they were treated with respect and kindness. Broxbourne House DS0000006169.V296188.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The services offered to people at the home does not fully ensure that people can get involved in activities and events that satisfy their social and recreational interests and needs. This is mainly due to a lack of staff availability. Residents maintain contact with family and friends as they wish. Residents’ personal choice and preferences are considered by staff at the home. Little choice is offered to residents regarding meals and staff are not available in sufficient number to fully support residents with their meals. EVIDENCE: Evidence was available within care plans that residents’ personal preferences with regard to routines of daily living are considered by staff delivering the Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 15 care. Preferred bathing routines and rising and retiring times are recorded in most care plans. Only one of the care plans seen included details of the person’s interests and needs relating to leisure and social activities. Dedicated activities staff are not employed at the home and, although care staff try to engage residents in activities, this is very ad hoc due to the staff being busy with caring and domestic duties. Care staff were, however, planning a trip to the seaside for residents in August. Once each month an activities company visits the home to deliver activities to residents for an hour and a half. A communion service is also held at the home on a monthly basis to which residents of all denominations are welcomed and the manager said that one resident who is a member of the Salvation Army received regular visits from fellow members. One resident spoken with was busy potting and caring for plants in their room and had been supported to do this by staff supplying compost etc to enable this activity. For a short time during the afternoon, care staff engaged residents in looking at and discussing memory cards. Other than this and some people receiving visitors, the majority of residents did not engage in any meaningful activity throughout the day. One relative comment was that their relative could not engage in any of the activities due to their disability. Discussion took place with the registered provider about either employing dedicated activities staff or ensuring that care staff are available in sufficient number to dedicate time to engaging all residents, whatever their abilities, in activities suitable to their needs and abilities. Relatives confirmed, through questionnaires and verbally, that they are welcomed to the home whenever they choose to visit. It was clear, through observation, that staff maintain very good relationships with relatives and visitors to the home. Meals are taken mainly in the dining room which does not, at the moment, provide a pleasant environment in which to enjoy meals. (Please see section 5, environment). Table cloths are not used and the table mats are mismatched and worn. On the day of the site visit, the cook said that residents had enjoyed a cooked breakfast and were therefore having a light lunch. Lunch was chicken nuggets with cauliflower cheese, mixed vegetables, home made chips and mashed potatoes. No alternative was available although one resident who said they did not want the meal was offered a sandwich or some toast. The majority of the meal was nutritious and nicely presented although the chicken nuggets, one of which was sampled by the inspector, appeared to lack any nutritional value and was most unpleasant in taste and texture. Discussion took place with both the cook and the registered provider about the appropriateness of serving such poor quality food to elderly people. The registered provider said that chicken nuggets were only served approximately Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 16 once each month. The manager explained that, previously, the cook asked each resident for his or her choice of meals on a daily basis. This had not been the case recently but the manager hoped that this system of offering choice would be re-introduced. The serving of the lunchtime meal was a little disorganised as, at times, the cook was the only member of staff in the dining room. Other staff were busy assisting residents with their meals in other areas of the home. As a result of this, one resident did not receive their meal until staff were alerted to the situation by the inspector. Three of the five resident questionnaires received by the Commission said that they “usually” enjoyed the food at the home and one resident said, during the visit, that the meals were “more than sufficient” and were “better than an hotel”. The manager said that, due to the cook’s hours of work, care staff prepare the teatime meal and all meals at weekends. Broxbourne House DS0000006169.V296188.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The systems operated by the home ensure that people can raise concerns and complaints, and feedback shows that they are confident that their complaints will be listened to, taken seriously and acted upon. Staff do not know the correct procedures to follow if alerted to suspected or alleged abuse. EVIDENCE: The complaints file contained evidence that complaints made to the home are dealt with efficiently and correctly. Discussion took place with the registered provider and the home manager about how all complaints and concerns, however minor, should be documented along with the outcomes. The manager said that some staff have received training in adult protection but neither she, the registered provider or other members of staff spoken with had knowledge of how to refer potential adult abuse situations within Wakefield’s local policies. A recent situation involving two residents had not been referred appropriately although the police and social workers had been notified. One resident’s file indicated that the resident had been displaying some inappropriate behaviour toward female staff and residents. No referral through adult protection procedures had been made. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 19 and 26. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service and is particularly affected by the risks to health and safety. People could be at risk due to some poor maintenance within the environment. Some areas of the home would benefit from a deeper clean. EVIDENCE: Redecoration has recently taken place in the corridor areas and some bedrooms, which is of a nice standard. Other areas of the home, however, are still in need of some redecoration and reorganisation. A number of wheelchairs were being stored in the main lounge which affected the arrangement of furniture and easy access to all of the area. The lounge therefore appeared cluttered and untidy. Discussion took place with the manager about more appropriate storage of wheelchairs. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 19 The dining area is in urgent need of attention. The carpet had come away from the gripper rods leaving exposed nails, which could present a health and safety risk to both residents and staff. The dining room furniture is dated and damaged and was very dirty with previous food and drink spillages. Some of the vinyl coverings on the chairs were torn and the foam padding was exposed. Walls and flooring in the dining room were also dirty. The majority of the bedrooms have half carpet and half vinyl flooring, in several rooms the floor coverings had come out from underneath the metal carpet strips and presented a trip hazard. The registered provider made repairs to the most urgent area during the visit. One bedroom carpet was very ruched and the vinyl flooring in another was torn which also present trip hazards. Some bedrooms are in need of redecoration where borders have been torn off or the decoration is mis-matched and worn and some of the bedroom furniture is in need of repair or replacement. Several of the wall lights by resident’s beds did not have shades or covers, leaving the bulb exposed. Some commodes were rusty and in need of replacement. The door to the laundry room was wedged open and bottles and tubs of bleach and residents’ creams were on shelves within easy reach. The landing area on the upstairs stairwell had a small balcony rail overlooking the staircase. The balcony was only at waist level and therefore presented a potential risk to residents falling over the balcony. The registered provider made arrangements during the visit for a joiner to higher the level of the balcony rail. The home employs one cleaner who works for approximately 6 and a quarter hours Monday to Friday. At weekends, cleaning is incorporated into care staff duties. Three of the residents questionnaires received by the Commission said that the home was “usually” clean and two relatives commented that there were times when the home was not as clean as it could be. Some of the commodes in bedrooms were in need of cleaning. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service and is particularly affected by staffing numbers and recruitment policies. Staff are not available in sufficient numbers to meet the needs of residents. Residents are not protected by the home’s recruitment policies and practices. Staff training is ongoing although further training is needed in some areas. EVIDENCE: Current staffing levels are manager plus two care staff in a morning and 2 care staff in an afternoon. Care staff in an afternoon are also responsible for preparation of the teatime meal, washing up and some cleaning. Care staff are also responsible for the laundry within the home and for engaging residents in activities. One cleaner is employed Monday to Friday but care staff are responsible for cleaning at weekends. Two of the residents questionnaires received said that staff are “usually” available when they need them. Staff spoken with said that they did not always think there were enough of them to fully meet with residents’ needs and observations during the visit, particularly at mealtimes, confirmed this. An immediate requirement regarding staffing levels was made during the visit. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 21 Currently 50 of care staff hold the NVQ level 2 award in care and the home uses the TOPSS induction and foundation programme. Training is ongoing in areas such as moving and handling and health and safety but training is required in adult protection procedures. Of the four staff records examined only one person had a criminal records bureau clearance, one person only had one reference and one person did not have a staff file at all. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. People 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 their responsibilities fully. The home is run in a manner that ensures the best interests of the service users. The systems and procedures operated at the home make sure that the service users’ financial interests are safeguarded. The systems operated by the home do not always ensure that the health, safety and welfare of people living and working at the home are promoted and protected. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home’s manager is a registered nurse who has completed her registered managers award and is also an NVQ assessor. A quality monitoring system is in place with questionnaires sent out on an annual basis. The manager then puts together a resume of the outcomes. Discussion took place about how this system could be developed further and how the outcomes should include an action plan for improvement and development of the service. The report as a result of this process should be available to residents and their relatives, the Commission and any other interested persons. Visitors spoken with were very happy about the quality of service offered to their relatives in the home. The home’s manager holds small amounts of residents’ money, where this is requested by the resident or their family, within the home’s safe. Systems for recording transactions and balances were checked and found to be accurate. Some issues in relation to the maintenance of the building (see environment section) were highlighted. The registered provider gave information to the Commission within the preinspection questionnaire that all maintenance checks for systems and equipment in the home are carried out and are up to date. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 24 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 1 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X X 2 Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4(1)(2), Schedule 1 5(1)(2)(3) 6(a)(b) Requirement Timescale for action 31/08/06 2. OP2 3. OP1 OP3 4. OP3 5. OP7 OP12 The registered person must compile and keep under review, a Statement of Purpose and Service User Guide. The Statement of Purpose must be made available to all service users and their representatives and a copy of the Service User Guide must be supplied to each service user. 5(c) All service users must be provided with a statement of terms and conditions of residence or contract if purchasing their care privately. Section 24 The responsible individual must Care ensure that the home does not Standards accept service users who do not Act. fall within the homes categories of registration. 14 No service user shall be admitted to the home without having been assessed by a person trained to do so. 15 Care plans must be developed and kept under review for all residents. Care plans must be developed in consultation with the resident or, where necessary DS0000006169.V296188.R01.S.doc 31/08/06 28/06/06 31/07/06 31/07/06 Broxbourne House Version 5.2 Page 26 6. OP8 13(1)(b) the residents representative and must include detail of residents social, recreational and spiritual needs as well as health and personal care needs. Arrangements must be made for 31/07/06 residents to receive where necessary, treatment, advice and other services from any other health care professional. This must include mental health as well as physical health care. The registered person must ensure that no person is subject to restraint unless there are exceptional circumstances. A programme of activities must be arranged and maintained within the home, which suits individual needs and abilities. Residents must be offered a choice of wholesome and nutritious food. Meals should also be served in a congenial setting with staff available to ensure residents safety and to offer assistance as required. Staff must receive training to ensure that appropriate procedures are followed to protect residents from, and to report, suspected or actual abuse. • All areas of the home to which residents have access must be free from hazards to their safety. • All areas of the home must be kept clean and reasonably decorated. At all times suitably qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for the health, safety and welfare of service users. DS0000006169.V296188.R01.S.doc 7. OP8 13(7) 31/07/06 8. OP12 16(2) (m,n) 2(i) 31/07/06 9. OP15 31/07/06 10. OP18 OP30 13(6) 31/08/06 11. OP19 OP38 13(4)(a) 23(2)(d) 31/07/06 12. OP27 18(1)(a) 28/06/06 Broxbourne House Version 5.2 Page 27 13. OP29 19(1) Schedule 2 Staff files must contain the information required in Schedule 2 of the Regulations. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP26 OP33 Good Practice Recommendations The registered person should ensure that all medications are kept within locked cupboards. The home should be clean and tidy at all times. The quality monitoring systems should include a report, made available to any interested parties, which details the actions to be taken by the home to develop and improve quality within the home. Broxbourne House DS0000006169.V296188.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office 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 DS0000006169.V296188.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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