Inspection on 16/10/07 for The Broughtons Care Home

This inspection was carried out on 16th October 2007.

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

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

Other inspections for this house

The Broughtons Care Home 28/07/06

The Broughtons Care Home 17/02/06

The Broughtons Care Home 10/10/05

The Broughtons Care Home 14/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Broughtons Care Home 2 Moss Street Great Clowes Street Salford Manchester M7 1NF Lead Inspector Adele Berriman Unannounced Inspection 10:00 16 October 2007 th 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 The Broughtons Care Home DS0000062302.V335547.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. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Broughtons Care Home Address 2 Moss Street Great Clowes Street Salford Manchester M7 1NF 0161 708 9033 0161 792 8144 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) Broughton Care Limited Mrs Doris Nordskog Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides accommodation for a maximum of 37 service users, who require personal care only by reason of old age (OP) 12th January 2007 Date of last inspection Brief Description of the Service: The Broughton’s provides residential accommodation with personal care for up to thirty-seven service users within the category of old age (OP). Accommodation is offered in 36 rooms, 35 single and one double, 31 of which have en-suite facilities. Lounge and dining facilities are located on the ground and first floors. These are arranged in group-living situations accommodating 8 or 9 people. The home is situated in a residential area of Salford close to local amenities and transport systems. Parking facilities are available at the front and side of the property. Fees for the home range between £317.92 and £364.41. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this visit taking place. This visit was unannounced and took place on Tuesday 16th October 2007. The visit began at 10.40am and ended at 8.30pm. During the visit time was spent talking to several residents, care staff, the cook and the manager of the service. Time was also taken to assess records and the policies and procedures of the home. Prior to the visit survey forms were sent to a number of randomly selected residents to gain their views on the service they receive. Five completed survey forms were returned. Six staff members also completed a survey form and gave their views on the service offered at the home. Survey forms were sent to a selection of General Practitioners who support the residents at the home. One of these surveys was returned. A comfortable, relaxed atmosphere was observed during the visit. All residents spoken to during the visit stated that staff treated them with respect. All five residents who responded to the service user survey stated that staff listened and acted on what they said. During the visit staff were seen supporting residents in a respectful manner. Four residents stated in their service user survey forms that they always received the medical support they needed and one person stated that they usually did. All residents who spoke to the inspector stated that they were able to receive visitors at anytime. Residents spoken to during the visit stated that there was always an alternative available at mealtimes if they did not wish to have food off the menu. Three people who responded to the service user survey stated that they always liked the meals at the home and two people stated that they sometimes did with one resident stating “menu could be improved, more variety.” All residents who responded to the service user survey and who were spoken to during the visit stated that they knew who to speak to if they had a complaint about the service. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 6 All staff who responded to the staff survey stated that they know what to do if a resident, their relative or advocate had concerns about the home. Residents commented positively about the service they received from the staff team. Four residents who responded said that staff were always available when they needed them and one person said that they usually were. One resident stated on their questionnaire that “I get told off for not asking for help when needed.” On the 4th October 2007 The Broughtons received an award from Salford City Council for outstanding achievement in the independent, community and voluntary sector focusing on improving the quality of services amongst service users, carers and the public. What the service does well: What has improved since the last inspection? A new system had been introduced at the home for the management of medication. Staff commented that the new system was much better to manage. Improvement had been made to how the home manage the ordering of medication to minimise excess medication being stored. With regard to residents who are unable to manage their own money, the system managing and storing of residents personal finances had been developed and residents monies were being put into an account and managed by social services. Improvements had been made to the content of the monthly summaries written by staff. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Broughtons Care Home DS0000062302.V335547.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 The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to moving into to the home. However, failure to record detailed information gained about the person may result in their needs not being fully met. EVIDENCE: The homes statement of purpose was available at the home. The document gave information about the service provided and was written in large print. Prior to a resident being admitted to The Broughtons the manager and deputy manager of the service visits the individual to carry out a pre admission assessment to ensure that the home has the facilities to meet their needs. A set format for the recording of pre admission assessments was in use. The pre admission assessments of the six most recently admitted residents were The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 10 assessed. Several of these assessments contained little information about the individual and three of the assessments were incomplete. The manager of the service demonstrated a newly revised pre admission assessment format for future use. However, this format did not give the opportunity to record the needs and wishes of people in all aspects of their day to day lives. It is essential that all information about a person’s needs and wishes is recorded to minimise the risk of their needs and wishes not being met. The Broughtons does not offer intermediate care facilities. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not reflect the full needs of the residents or reflect the service that is delivered by the staff team. Residents healthcare is promoted by the staff team contacting local health professionals when required. EVIDENCE: Each resident had a care plan. Six care plans were assessed during the visit including the care plans of the people who had most recently moved into the home. Some care plans contained detailed information about the resident, however, some care plans failed to demonstrate how a persons needs were to be met, for example, one care plan stated under the section titled continence needs “is incontinent during the night” but the document did not state how this need is to be supported by staff or any products that may be used. There was evidence that monthly evaluations of information regarding residents were being carried out and recorded in the care plan folder. Some evaluations contained detailed information about the person. However, it was The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 12 evident that information about the individual was not being reflected in their care plan. For example, the evaluation for a resident in September and October 2007 stated that the resident had a catheter in place, however, there was no reference to a catheter in the residents care plan. Records for another resident demonstrated that they used an ‘ambilift’ for bathing, however, there was no mention of this in the residents care plan. It is essential that residents care plans contain up to date information of their needs and wishes and inform staff of the actions they need to take to ensure that these needs are met. Daily records formed part of residents care plans and a selection of these records were assessed. Some records contained more information that others and it was evident, from observations made during the visit that the care and support being delivered to residents was not reflected in daily records. For example, general statements were being made in the daily records that contained little information, for example, “X wandersome, good diet at all meals – assisted to the toilet” and “X wandersome at times did sit down for short periods good diet”. Daily records did not demonstrate what social and recreational activities/interaction had taken place. It essential that detailed up to date records of care and support delivered/offered to residents are maintained. Each resident was registered with a GP and all residents spoken to during the visit confirmed that staff would call their GP for them on their request. Records demonstrated that residents were also in receipt of visits from district nurses and community psychiatric nurses when required. Four residents stated in their service user survey forms that they always received the medical support they needed and one person stated that they usually did. All residents spoken to during the visit stated that staff treated them with respect. All five residents who responded to the service user survey stated that staff listened and acted on what they said. During the visit staff were seen supporting residents in a respectful manner. Improvements had been made to the overall management of medication since the previous inspection. A new Monitored Dosage System had been implemented and staff involved with managing the medication stated that procedures had improved since changing to the new system. The system for controlled drugs was checked and was being managed appropriately. The majority of medication administration records were completed appropriately. However, not all the details on the handwritten records had been completed. It is essential that a detailed record of all medication administered is maintained at all times. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about the food they eat. Further development of the service is required to ensure that residents have the opportunity to have their social and recreational needs met. EVIDENCE: It was evident from discussion with several of the staff team that some residents carried out activities outside of the home. No formal activities/recreational activities programme was available, however, the manager of the service stated that residents occasionally went out and about in the community with staff and that an entertainer visited the home on a monthly basis. There was little evidence documented to demonstrate that residents needs and wishes in relation to their leisure, social and cultural interests were considered. Two residents who completed a service user survey stated that there was usually activities arranged at the home to take part in and two said that there sometimes was. One resident stated that there were never any activities for them to take part in. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 14 Visitors were seen entering the home throughout the visit. All residents who spoke to the inspector stated that they were able to receive visitors at anytime. During the visit a resident raised concerns that he was not always able to access a call bell in a particular lounge. The resident later spoke to the manager of the service about his concerns who said that she would address the situation. Several resident’s bedrooms that were visited contained personal and treasured items that the resident had brought with them to the home. One resident explained to the inspector that she had her own telephone installed in her bedroom so she was able to keep in regular contact with her family. Meals were served in one of several dining rooms. The menu for the week was displayed in a board outside of the kitchen. The cook stated that the weekly menus had recently been changed. Residents had the choice of cereals toast and fruit or a cooked breakfast. Alternatives were available to residents for the lunchtime and teatime meals. The cook demonstrated a good knowledge of individual residents food choices/likes and dislikes and stated that the menu was adapted to meet the needs residents with specific needs, for example, diabetes. In the event of a resident moving into the home with a specific cultural or religious dietary need that could not be fully prepared in the kitchen, the appropriate foods would be sought from an alternative source. Residents spoken to during the visit stated that there was always an alternative available at mealtimes if they did not wish to have food off the menu. Three people who responded to the service user survey stated that they always liked the meals at the home and two people stated that they sometimes did with one resident stating “menu could be improved, more variety.” The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of and confident in the homes complaints procedures. EVIDENCE: A copy of the homes complaints procedure was available in the foyer of the home and a copy was available in each bedroom. Since the previous inspection four complaints had been received by the home, all of which had been responded to within 28 days. A record of the complaints was maintained along with the details of the outcome of the investigation and the date of the response to the complainant, however, there was no record of who had carried out the investigation into the complaint. All residents who responded to the service user survey and who were spoken to during the visit stated that they knew who to speak to if they had a complaint about the service. All staff who responded to the staff survey stated that they know what to do if a resident, their relative or advocate had concerns about the home. A copy of Salford safeguarding adults policy was available. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 16 Information available demonstrated that seven staff had received training in 2006 around safeguarding adults. The manager stated that she was in the process of arranging further safeguarding training for all the staff team. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a pleasant environment in which to live. EVIDENCE: The home is set within its own maintained grounds with a fully accessible garden to the rear of the property. A ‘handy person’ is employed at the home to carry put general maintenance and regular checks and testing of equipment. Several areas of the home had been redecorated since the previous inspection as part of a on-going redecoration programme. The manager also stated that a toilet in the first floor of the accommodation was to be adapted and a shower installed to offer residents an alterative choice to bathing. The home was comfortably furnished to meet the needs of the residents, however, the carpets in the first floor lounge were extremely stained. The The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 18 manager stated that several carpets around the home had been renewed and others were in the process of being renewed as part of the on-going redecoration programme. The home was clean and tidy at the time of the visit. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the staff team, however, staff would benefit from having access to regular up to date training for their role. Failure to carry out essential recruitment checks may place people at unnecessary risk from harm. EVIDENCE: At the time of the visit the manager, the deputy manager, a senior carer and three carers were on duty to meet the needs of the residents with the additional support of a cook and ancillary staff. Throughout the visit the staff team demonstrated a detailed awareness of resident needs, likes and dislikes. The majority of staff who responded to survey stated that there are enough staff employed to meet the needs of all the people who use the service. Residents commented positively about the service they received from the staff team. Four residents who responded said that staff were always available when they needed them and one person said that they usually were. One resident stated on their questionnaire that “I get told off for not asking for help when needed.” The staff files of the four most recently recruited staff were assessed during the visit. Not all files demonstrated that appropriate recruitment procedures The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 20 had taken place, for example, one application form was incomplete, two files contained only one written reference and there was evidence that some references had been received after the person had commenced employment. The date and identification numbers of Criminal Record Bureau (CRB) checks were available on the staff files. No CRB had been received for one member of staff and there was evidence that a member of staff had commenced working at the home without an appropriate POVA first check being carried out. It is essential that appropriate checks and references are sought for all new employees prior to them taking up appointment to ensure that any risk from harm is minimised. Personal files and training records for the manager and deputy manager of the service were not available at the home. A record of all training undertaken by the manager must be maintained at the home to demonstrate their continual development. There was evidence that some but not all staff had received training in some aspects of their role. The manager stated that she was in the process of arranging more training for staff. It is essential that staff receive up to date training in all aspects of their role to ensure that all support is delivered safely. The majority of staff delivering care at the home had completed or were working to their National Vocational Qualification level 2 or 3 in care and the cook was undertaking a national Vocational Qualification level 3. Four staff who completed survey forms stated that that they regularly met with their manager to get support and discuss how they were working and two staff stated that they often did. Staff made positive comments about the support they received from the management of the home and stated that the staff team deliver a good service to the residents. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records, policies and procedures within the home do not fully reflect the service provided to residents. Failure to maintain up to date policies, procedures and risk assessments may result in a person being put at unnecessary risk of harm. EVIDENCE: The manager of the home had been in post for several years and had many years experience of working in a social care environment. The manager had achieved her NVQ level 4 award, Registered Managers Award and is an NVQ assessor. The manager operates an ‘open door’ policy and during the visit residents were seen entering the office throughout the day. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 22 To assess people’s thoughts and views about the service, questionnaires are circulated for both residents and visitors. The manager stated that the next questionnaires will be circulated in November 07. On the 4th October 2007 The Broughtons received an award from Salford City Council for outstanding achievement in the independent, community and voluntary sector focusing on improving the quality of services amongst service users, carers and the public. The manager stated that monies belonging to residents that were unable to manage their own finances were referred to and managed by Salford social services and that only money required on a day to day basis is managed by the service. The manager gave an example that a clothing show had been organised in the near future and if an individual wishes to purchase anything the bill for the purchases would be managed by social services. A procedure was in place for the recording of accidents. However, the completed accident reports were stored collectively and therefore did not protect individuals’ personal information. Accident records demonstrated that ten falls had been recorded between 17.08.07 and 13.10.07 for one resident, however, no information relating to these falls was included in the residents monthly evaluation for August and September nor was there any information recorded in the individuals’ care plan. A risk assessment was in place for the resident and their risk of falling from not using their walking stick but this information was outdated. Other records demonstrated that the resident’s mobility was poor and a wheelchair had been ordered. It is essential that all risk assessment are updated on a regular basis or when a persons needs change to ensure that all known factors are considered when the risk is assessed. Some policies and procedures were available to protect the health, safety and welfare of residents and staff. Several of these polices were seen by the inspector. The manager of the service stated that several of the policies and procedures were currently in need of review as they were outdated. It is essential that up to date policies and procedures relating to all aspects of health and safety are available at all times to ensure that any risk to people are minimised. There was documentary evidence that the fire detection system, call bell system and the hot water temperatures around the building were being tested on a regular basis. The most recent recorded fire bell test was 12.10.07. The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Pre admission assessments must be completed in full to record all the needs and wishes of the residents and to ensure that the service is able to meet these needs. Daily notes that form part of the care plan for an individual need to detail all care and support that has been delivered/offered and be written in an appropriate manner. Care plans are required to fully demonstrate the current needs of individuals and need to be reviewed and updated on a regular basis. Requirement not met from 21/02/07. Timescale for action 19/11/07 2. OP7 15 19/11/07 3. OP9 13 Hand written medication 19/11/07 administration records must be completed in full to ensure that a full record of what medication has been administered to DS0000062302.V335547.R01.S.doc Version 5.2 Page 25 The Broughtons Care Home residents is maintained. OP14 4. OP19 5. 6. OP29 12 23 18 All residents must have access to 19/11/07 a call bell at all times to ensure that they are able to request support when needed. Residents must have access to 19/11/07 clean carpets throughout the home at all times. The home must ensure that 19/11/07 appropriate procedures relating to staff recruitment are adhered to at all times. Requirement not met from 21/02/07 Residents must only be supported by newly recruited staff once appropriate Criminal Record Bureau/POVA first checks have been made. 7. OP30 18 OP38 8. 13 All staff and management at the 26/11/07 home must have the opportunity to attend training for their role. A record of all training undertaken by individuals’ must be maintained. Policies and procedures to 26/11/07 protect the health, safety and wellbeing of all must be reviewed and updated on a regular basis. All known risks to individuals must be reviewed and updated on a regular basis to ensure that all know information is considered when calculating a risk. The Broughtons Care Home DS0000062302.V335547.R01.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. 2. 3. Refer to Standard OP7 OP12 OP16 Good Practice Recommendations It is recommended that daily records are written using appropriate terminology. It is recommended that residents are consulted in a regular basis about their choices of social and recreational activities and that these choices are recorded. It is recommended that all records and completed investigations of complaints contain the name and signature of the person who carried out the investigation. It is recommended that all staff have the opportunity to attend adult protection awareness training. It is recommended that people involved in the recruitment of staff have an up to date awareness of the Criminal Records Bureau and POVA first procedures. It is recommended that all completed accident records are stored in a manner that protects individuals’ personal information. 4. 5. 6. OP18 OP30 OP38 The Broughtons Care Home DS0000062302.V335547.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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. 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