Inspection on 05/06/07 for Broxbourne House

This inspection was carried out on 5th June 2007.

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

The inspector 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 28/06/06

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 Stephen French Unannounced Inspection 5th June 2007 8:30 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 Broxbourne House DS0000006169.V341947.R02.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.V341947.R02.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 201016 Mr M Seeratun Mrs Ursula Owen Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (21), Old age, not falling within any other category (21) Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 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 in July 2007 that fees are £389 per week. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide, copies of which can be obtained by contacting the home. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit carried out on the 5thh June 2007. The inspector arrived at the home at 08:30 am and left 3:00pm. During this visit the inspector spoke to some of the service users, visiting professionals, some of the staff and the home’s management team. The inspector read some care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection 10 questionnaires were sent to the home to obtain peoples views about living at the home. On writing this report no questionnaires had been returned., Some people in the home are very frail and would not be able to complete a questionnaire. There were twenty people resident in the home on the day of this visit. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and information about the home completed by the manager. The inspector would like to thank the manager, provider and staff for their hospitality and assistance during this visit. The visit has concluded that people’s health and social needs are being met and that people are happy with the services the home offers. What the service does well: People’s needs are assessed prior to them entering the home to ensure their needs can be met. Each person has a care plan which informs the staff of the actions they are to take to support the person in maintaining their health and welfare. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 6 People spoken to said that the home offers social activities which suits their needs and that the food was very nice. The home has a friendly homely atmosphere and people’s bedrooms are personalised with their own items. There are adequate numbers of competent trained staff on duty to meet the needs of the people. The home is well managed and the views of the people who live there are taken into account. What has improved since the last inspection? What they could do better: Care plans should be more detailed in places to ensure staff know what they need to do to meet the needs of the people. This should include completing nutritional assessments for all people who live in the home and those that are at risk have a specific care plan put into place. The manager should record in the care plan that the monthly reviews have been discussed with the person or their relative. At least one fresh vegetable should be served with the main meal. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 7 Consideration should be given in redecorating and replacement of furniture around the home such as, bedrooms and replacing the dining room furniture to improve the environment in which people live. The manager should complete monthly audits on areas such as care planning medication and the environment to ensure the home is meeting the expectations of the people who live there. The manager should receive regular formal supervision from the proprietor to ensure she is working to the aims and objectives of the home. The fire alarm system should be tested weekly to make sure it is in working order Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broxbourne House DS0000006169.V341947.R02.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.V341947.R02.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): 1,3,6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s needs are assessed prior to them moving into the home and they have the information they require in order to make a choice. EVIDENCE: Following a requirement made during the last inspection visit the information booklet, the statement of purpose was examined. This booklet informs the prospective resident about the home and the services it offers. It was found that this had been updated and now contains the relevant information. This ensures that prospective admissions to the home have the information they require in order to make a choice as to where they live. The manager said that should a person whish to move into the home she receives a community care assessment from a person’s social worker. This Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 10 assessment determines the level of care, which the person will require. Following receipt of this assessment the manager said that the proprietor of the home then visits the person and completes a pre admission assessment. This assessment helps the home to decide if they will be able to meet the needs of the person. Completed assessments were seen for three recently admitted people and one person spoken to informed the inspector that the proprietor had visited them in hospital prior to them moving into the home. The manager said that the home does not offer intermediate care. Broxbourne House DS0000006169.V341947.R02.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): 7,8,9,10 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service People are treated with respect, but their health would be better ensured if more detailed care planning systems were in place EVIDENCE: The manager said that each person has a care plan. This plan informs the staff of the actions they are to take to ensure the persons health, social and psychological well being is met. During this visit five peoples care files were examined, these contained information gathered from the pre admission assessment and community care assessment. Care plans were in place for issues identified in these Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 12 assessments, and risk assessments were in place for such things as tissue viability, moving and handling and falls. It was noted that two people had lost weight over a period of two months. Although there were care plans in place surrounding poor dietary intake, and staff had acted appropriately in involving the GP there were no nutrition assessments in place. Completing a nutritional assessment would confirm that the staff had identified that the people were at risk and a detailed plan could be put in place highlighting to staff the need to monitor this closely. One care file examined had care plans which had been wrote in 2004, as peoples needs and capabilities change the care plans should be reviewed to ensure that staff have up to date information on how the persons needs are to be met. Evidence was seen in these files, and confirmed by people who live in the home, that they are able to make decisions about how they spend their day; this included what time they rise and retire and where they take their meals. Staff record a daily entry in the persons care file detailing what support they have given to the person that day. These were very descriptive and gave a good account of the person’s social and psychological well being. Care files were reviewed monthly, however there was no evidence to suggest that the person or their relative had been involved in this monthly review. This was discussed with the manager who said that she discusses the care plans with the person or their relatives but does not record this. One district nurse who was visiting the home said that staff were very good at contacting them as soon as they thought the person required specialist nursing intervention. Two people spoken to said that they were aware that staff kept information on them. Care staff spoken to were also aware of the contents of peoples care files confirming that they were aware of the peoples needs. The manager said that trained senior care staff are responsible for the administration of medication. Should a person wish to continue to self medicate, then a risk assessment would be completed. The staff would then support the person in maintaining their medication. The stock balances of five peoples medication was examined, it was difficult to audit the balances of some of these medications as the staff had not recorded the amount of medication which had been carried forward from the previous month. By examining the medication administration records it was confirmed that people receive their prescribed medication at the correct times. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 13 People spoken to on the day of the visit said that the staff were very nice and were always around to help. One person said that most of the care staff were good. Staff were seen attending to people in a caring and professional manner, one carer was seen assisting a person to the bathroom and was interacting with the person in a friendly appropriate manner. Broxbourne House DS0000006169.V341947.R02.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): 12,13,14,15 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s recreational and social needs are met and the meals are good. EVIDENCE: The manager said that social activities within the home are organised and supervised by a student from age concern. She works four days a week and spends one day at collage. Records are kept on a daily basis of what activities have taken place and who has joined in. Records examined confirmed that social activities take place daily and these include, amoungst other things, shopping trips, quizzes, board games and for those people who have enduring mental health problems memory games. People spoken to said that they were happy with the activities which are on offer. One person said that the staff often take her to the shop, another person said that she was looking forward to the homes annual trip to the seaside. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 15 Visitors are welcome to visit the home whenever they wish, this was confirmed by people spoken to. The manager said that relatives could visit in either one of the communal lounges or in the person’s own room. One visitor spoken to said that the staff always make them very welcome and they are offered a cup of tea regardless of the time of day. They also said the home was very homely and on the day of the visit the inspector observed one relative giving the proprietor advise on where pictures should be hung on corridor walls. Since the last visit to the home the proprietor has reviewed the menu, this was seen and contained a variety of choices of hot meals. On the day of the visit the choice of lunch was chicken in mushroom sauce or fish in sauce with carrots cauliflower and mashed potatoes. On a tour of the kitchen it was noted that there were no fresh vegetables stored. When asked about this the manager said that frozen vegetables are usually used. A discussion between the manager and the inspector took place about the benefits of having at least one portion of fresh vegetable with the main meal. The inspector tasted the chicken lunch, which was very tasty. People spoken to said that the meals were very nice and that there was always a choice available. The manager said that one of the service users helps to peel the potatoes for lunch and they enjoy being able to help. The manager said that meals could be eaten in either the dining room or in their own room if they wish. Staff were observed assisting those people who required help with their meals in a sensitive manner. The mealtime was very relaxed and unhurried and there was soft music playing in the background, the dining room tables were set with place mats, cutlery and condiments. There were adequate numbers of staff in the dining room to enable them to assist people and ensure people were not waiting for their lunch. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service People are confidant that complaints will be investigated fully and that they are protected from abuse. EVIDENCE: The home has a complaints policy, which is contained in the service users guide. The manager said that each person is given a copy on admission and this is kept in the person’s room. During a tour of the home these were seen in peoples bedrooms. It was noted that a copy of the complaints policy was not on view in the home. A copy should be on view so that anyone entering the home who wishes to make a complaint has the information they need. This was discussed with the manager who said she would make sure a copy is displayed in the reception area. The manager said that complaints and concerns are investigated by herself or the proprietor. Evidence was seen in the homes complaints log that a complaint received in August 2006 had been handled appropriately and in a timely manner. There have been no other complaints received by the home or the Commission for Social Care Inspection. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 17 Surveys received by the commission confirmed that relatives and people who live in the home were aware of the homes complaints policy. The manager said that staff receive training in the protection of vulnerable adults as part of their induction training as well as annually. Staff training records examined confirmed that this training had taken place. Three staff spoken to by the inspector gave good responses to questions asked on this subject confirming that they were aware of the actions they must take should they suspect any form of abuse taking place. Broxbourne House DS0000006169.V341947.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service People live in comfortable surrounding were only minor redecoration and replacement of furniture is required to further improve the environment EVIDENCE: As part of this visit a tour of the home was conducted. This included a number of people’s bedrooms, communal lounges, dining room and bathrooms and toilets. People’s bedrooms were homely and contained personal items such as photographs ornaments and small pieces of furniture. The manager said that people are able to hold the keys to their rooms if they wish. Some of the Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 19 bedrooms seen were in need of redecoration and some of the furniture was looking tired and worn, replacing these would improve the environment for the person who’s room it is. In one room it was noted that the electric wall socked was coming away from the wall, this could be dangerous and needs to be repaired. Another room had an odour of urine and the manager said that the staff continually clean the carpet to try and prevent the odour. Two people spoken to said that they were happy with their room. There is a large lounge area and a smaller seating area in the dining room where people can sit and watch television or listen to music. The lounges are homely in style and decorated to a satisfactory standard. Since the last visit a new carpet has been laid in the reception area and along corridors, which has improved the look of the home. There is a small dining/lounge area were people have their meals. It was noted that the area were the dining tables were was very small and the tables were close together there was no room for staff to be able to get behind people to serve their meals. The dining tables and chairs were dated and could do with renewing and the dining area should be enlarged to provide more space for people to be able to manoeuvre round. There are communal bathrooms and toilets within close proximity to people bedrooms and lounge areas. There are a number of specialist bath’s, which enable the staff to assist people with mobility problems to bath safely. There is a shower for people who prefer a shower. Apart from the bedroom identified there were no unpleasant odours detected in any part of the home and the standard of cleanliness was very good. Broxbourne House DS0000006169.V341947.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service People are cared for by adequate numbers of trained staff. EVIDENCE: The staff duty rota was examined for the months of April and May 2007, this confirmed the staffing numbers within the home to be, AM; 1 senior carer and 3 care staff PM; 1 senior carer and 2 care staff Nights 1 senior carer and one care assistant Staff sickness and holidays are covered by staff doing overtime, agency staff is rarely used so people are looked after by staff who know them. People spoken to said that they thought that there were adequate numbers of staff on duty to meet their needs. Staff spoken to said that the staffing within the home was good and that they have time to spend chatting with people. On Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 21 the day of the visit staff were seen sitting outside in the garden with some of the people who live in the home confirming that they had time to socialise as well as seeing to peoples personal care needs. Five staff details were checked and these confirmed that the home is carrying out the appropriate checks prior to employing staff to ensure the people are safeguarded from abuse. The manager said that, new staff employed by the home complete an induction course within six weeks of the joining the home. This course gives the new staff member the information they require in order to care for the people living in the home. Records examined and staff spoken to confirm that this training is taking place. Evidence was seen in training records checked that staff have received training in such things as moving and handling, adult protection and food awareness. Since the last visit a number of staff have completed a course in dementia care. Staff spoken to said that this training had helped them to understand the care needs of people who have enduring mental health problems. Broxbourne House DS0000006169.V341947.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is well managed and the views of the people who live there are taken into account EVIDENCE: The manager is a qualified nurse who has managed the home for the last twelve years. She is supported by the proprietor of the home and a deputy manager. She is aware of the needs of the people who live in the home and people spoken to said she was very nice and always available if they needed to speak to her. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 23 To ensure the home is meeting the expectations of the people living there the home sends out questionnaires annually to seek their views on the care that they receive and what the home could improve. The last survey was done in August 2006 and the inspector saw the results of the survey, which contained positive comments. The manager said that she was due to re issue surveys to make sure people were still happy with the service. People can also express concerns and raise issues they may have in the residents meetings which take place on a three monthly basis, minutes were seen of the last meeting held on April 3rd 2007. There was discussion with the manager about measures, such as formal monthly quality audits on such things as care plans medication and health and safety that could monitor whether the quality of care provided meets peoples expectations The manager said that staff supervision takes place. During these sessions staff are able to discuss, amongst other things, training issues and the aims and objectives of the home. Supervision records examined during the visit, and staff spoken to confirmed that these had taken place. The manager however does not receive formal supervision from the proprietor but said that they often discuss issues when they arise. The manager was advised that these sessions should be recorded. People are able to keep small amounts of personal monies within the homes safekeeping. This enables them to be able to purchase small items such as sweets, newspapers and pay for hairdressing. Three amounts of people’s personal monies were checked and the balances tallied with the records held by the home. Movement and handling training has been provided to the majority of staff members this year, staff confirmed this when interviewed. There are policies and procedures in place surrounding health and safety and the manager is aware of her responsibilities towards the people who live in the home and staff. The manager said that regular fire safety checks are carried out and recorded. The fire alarm test log book was examined and it was found that the last fire alarm test was 21/5/07, this should be carried out weekly to ensure the system is working, the manager said that she had been on annual leave and had assumed the proprietor had done these checks. Staff receive training in fire prevention. The homes fire risk assessment and fire policy was examined and was found to be in order. Certification in relation to servicing of gas electricity and electrical equipment is in place and up to date. Broxbourne House DS0000006169.V341947.R02.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Broxbourne House DS0000006169.V341947.R02.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 OP7 Regulation 15 Requirement Care plans must be developed and reviewed in conjunction with the person or their representative. Timescale for action 31/08/07 2. OP26 16(2) k Nutritional risk assessments must be in place and where a risk is identified a specific care plan must be in place directing staff in the actions they are to take to prevent further deterioration in the persons health. The registered provider must 31/08/07 keep the home free from offensive odours. The bedroom identified as smelling of urine must have the carpet renewed or an alternative floor covering used to prevent the odour reoccurring. Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations To ensure a clear audit trail can be done on all the medication held within the home the stock balances of the previous months medication should be carried forward and added to the new balance. This will enable the manager to ensure medication is given as prescribed and at the correct time. At least one portion of fresh vegetables should be served with a meal. The homes complaints policy should be displayed in the reception area so that anyone entering the home has the information they need to enable them to make a complaint. The registered provider should consider extending the dining area and renewing the dining tables and chairs to ensure staff and people who live in the home have enough room to manover around the tables. Consideration should be given in redecorating and renewing the furniture in some bedrooms. The manager should complete formal audits on areas such as e.g. environment, choice of meals and produce an action plan on how any shortfalls can be addressed. The manager should receive regular formal supervision from the registered provider to ensure she is meeting the aims and objectives of the home. The fire alarm system should be set off weekly to ensure it is in working order. 2. 3. OP15 OP16 4. OP19 5 6. OP24 OP33 7. 8. OP36 OP38 Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Broxbourne House DS0000006169.V341947.R02.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!