Care Home: Broadoak Grange

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What the care home does well The staff give committed and dedicated care to the residents. ‘I am happy in the home and the staff look after me well’ The home provides a clean and welcoming place to live in. The home gives the residents good home cooked food and provides choices in what they have to eat. The manager and the staff welcome visitors into the home and communicate well with them. The home has a good recruitment practice, with all the required documentation in them. This makes sure that, as far as possible, the residents are safe. What has improved since the last inspection? The Statement of Purpose has been written and now contains all the required information to give potential residents they need to make a decision about the home. The home has returned the Annual Quality Assurance Assessment to us when we asked for it. The home has also completed all the recommendations made at the last inspection. What the care home could do better: A pre admission assessment should be put in place and a visit to the prospective resident made by the manager or a senior member of staff. This would make sure that the home has a thorough knowledge of the residents needs and that the home can meet them.Broadoak GrangeDS0000001648.V376467.R01.S.docVersion 5.2The home should make sure that all the residents needs are documented so that they have all the care that they should have. The manager could consider completing supervised medicine rounds with the staff, auditing the medicines and the records and putting a signature sheet in place. These practices would make sure that staff are administering correctly and there was a record of who had given the medicines. The activities programme could be looked at with the residents to give them the activities that they want. The complaints form could be made clearer to make sure that there is a sequence of events to follow. The chairs that are worn and dirty could be replaced. Key inspection report CARE HOMES FOR OLDER PEOPLE Broadoak Grange Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Thea Richards Key Unannounced Inspection 13th May 2009 09:45 DS0000001648.V376467.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoak Grange Address Sandy Lane Melton Mowbray Leicestershire LE13 0AN 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) 01664 562008 01664 562008 Mr John Nunn Mrs Barbara Elsie Nunn Tendayi Noko Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (10) Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within Category PD(E) may be admitted to the Home when there are 10 persons of Category PD(E) already accommodated. Service User Numbers No person to be admitted to the home in categories MD(E) or DE(E) when 10 persons in total of these categories/combined categories are already accommodated within the home. 20th May 2008 Date of last inspection Brief Description of the Service: Broadoak Grange Residential Home is a care home providing personal care and accommodation for 33 older people with a physical frailty and/or mental health needs. The home is owned by the Registered Providers Mr and Mrs Nunn and is part of fifteen homes owned by the Broadoak Group of Care Homes. The home is situated on the outskirts of Melton Mowbray and can be reached by private and public transport. There are local shops close to the home. The accommodation is a purpose built, two- storey home with two lounges and two dining rooms on the ground floor. There are bedrooms on both floors and the first floor can be reached by stairs or by a passenger lift. There are single and shared bedrooms, all of which have en-suite facilities. Outside, there is a well - maintained garden, with seating and a greenhouse, which is easily reached for the residents to use in the better weather. The current registration certificate from the Commission for Social Care Inspection is available in the reception area with an up to date insurance certificate. The latest report from the Commission for Social Care Inspection is available in the managers’ office. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. The home can be contacted by telephone, or fax. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 5 The current level of fees range from £343.00 to £460.00 pw. There are extra charges for hairdressing, chiropody, newspapers and personal items. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 Star. This means that the people who use this service experience good quality outcomes. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we (throughout the report the use of ‘we’ indicates the Care Quality Commission), spent four hours reviewing information received by the Care Quality Commission (CQC) since the last inspection on 20th May 2008. The visit took place on the 13th May 2008 and lasted six hours. During the visit we checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that we looked at the care provided to three of the residents. To achieve this, the residents were spoken with. We spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. We checked how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. We looked at the Annual Quality Assurance Assessment that the home sent to us when we asked for it. This contained information about the home and their progress during the year and their plans for the future. It also contained numerical information about the residents and the staff. We looked at the comment cards sent to staff, families and residents with their views of the home. During the visit we spoke with the registered manager, the staff and the residents and their families. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 7 What the service does well: The staff give committed and dedicated care to the residents. ‘I am happy in the home and the staff look after me well’ The home provides a clean and welcoming place to live in. The home gives the residents good home cooked food and provides choices in what they have to eat. The manager and the staff welcome visitors into the home and communicate well with them. The home has a good recruitment practice, with all the required documentation in them. This makes sure that, as far as possible, the residents are safe. What has improved since the last inspection? What they could do better: A pre admission assessment should be put in place and a visit to the prospective resident made by the manager or a senior member of staff. This would make sure that the home has a thorough knowledge of the residents needs and that the home can meet them. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 8 The home should make sure that all the residents needs are documented so that they have all the care that they should have. The manager could consider completing supervised medicine rounds with the staff, auditing the medicines and the records and putting a signature sheet in place. These practices would make sure that staff are administering correctly and there was a record of who had given the medicines. The activities programme could be looked at with the residents to give them the activities that they want. The complaints form could be made clearer to make sure that there is a sequence of events to follow. The chairs that are worn and dirty could be replaced. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 9 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 Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents’ needs are not adequately assessed, but they do have the required information to make an appropriate choice of home. EVIDENCE: The Statement of Purpose has been re-written and now provides all the required information that prospective residents need to make an informed choice about the home. There was no evidence that a pre admission assessment had been made by the home in any of the files looked at. Those residents who had been placed by the local authority had assessments in place. A senior member of staff Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 11 should make a visit to the prospective resident to make their own assessment of their needs to make sure that the home could meet those needs. The manager told us that there was no pre – admission assessment form in place and that no visits were made. A pre admission assessment would make sure that that the staff in the home have the right information before the resident moves in and that they can meet their needs. It also makes sure that the resident meets someone from the home who they can recognise, which makes the move into care easier to manage for them. A family spoken with whose relative had been admitted recently had not had a visit or an assessment made. They told us that they had not received any written information about the home, but had made a visit. They thought that this had been because their relative had been admitted as an emergency. They told us that they were very happy with the care that their relative was having. The home does not offer intermediate care facilities. The current registration certificate from the Commission for Social Care Inspection (CSCI) and up to date details of insurance cover are displayed in the entrance of the home. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff meet the care needs of the residents as identified in the care plans with privacy, dignity and respect. EVIDENCE: The care plans for the ‘case tracked’ residents were found to contain good individual evidence of care, which reflects the care being given to the residents. The home are using new care plans in the home that contain thorough information and are much easier to follow than previously. They could consider putting one care need on one page, which would make them easier to follow and for the staff when reviewing them. A care plan that we looked at had an important need missed and the manager should make sure that all identified needs and their treatment are documented. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 13 There were risk assessments in place where risks to the residents have been identified. These described how each risk was to be managed to keep the resident and the staff safe. There are records of visits by professional staff, such as Doctors, district nurses and chiropodist. This shows that the residents are having the right medical care given to them. The residents, the families spoken with all said that they were happy with the care being given and that they had medical attention whenever they needed it. A family who we spoke with told us that they had not been happy with the care previously but were now very happy. A comment received: ‘They look after us very and I am happy here’ There are records of the residents’ weight, which makes sure that they are not losing or gaining large amounts of weight. The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. Staff spoken with were aware of the residents care needs. There is documented evidence of the review of the care plans but the residents or their families have not been signed them. The residents and the families spoken with on the day of the visit told us that they had the opportunity of being involved. When the staff were giving care and speaking with the residents they were seen to be doing so with dignity and respect. The residents spoken with were happy with the way staff treated them and said that they were very kind. Medicines are given by the senior staff in the home, who have all completed a ‘distance learning’ package for the safe handling of medicines. They also have regular updates from the pharmacist who supplies the home with its medicines. The staff told us about the training and we saw the records for this. Medication records were correct and the staff spoken with were fully aware of the process for the ordering, receipt, administration, storage and disposal of the medicines. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 14 The staff were seen to be giving out the medicines correctly and making sure that the residents had taken them. The controlled (dangerous) medicines were checked and they and the records were found to be correct. The manager does not undertake ‘supervised ‘ medicines with the staff to make sure that they are completing them correctly. Audits of the medicines and the medicine sheets are not being undertaken to make sure that they are being signed and they are correct. There is not have a staff signature sheet in place, which would make sure that signatures could be recognised in the future. There is a policy in place for self -medicating, but there were no residents selfmedicating at that time. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have their social, spiritual and nutritional needs met. EVIDENCE: The staff were seen to be spending individual time with the residents. The T.V was on in both of the lounges, which the residents were enjoying. The residents spoken with were happy with the activities that take place but would like more. The families spoken with felt that there could be more activity in the home. There was evidence in the daily records and in the care plans about the activity that the residents do take part in. All the families spoken with said that they were made very welcome in the home, which we saw whilst we were there. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 16 The residents spoken with said that the food was good and that they had a choice of what they had. The menus were varied and were discussed with the residents individually. We spent time talking with the residents at lunch- time. The meal looked plentiful and well presented and the residents were enjoying it. A resident told us that she was happy in the home, that she liked her bedroom and enjoyed the food, but thought that there could be more activities. The religious needs of the residents are met by the service held in the home monthly and by individual clergy visiting as requested. A hairdresser visits the home every week, which the residents enjoy. Broadoak Grange DS0000001648.V376467.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if they needed to. This can be made available in a large print, which makes sure that as many people as possible can read it. There is a form to record complaints on but it could be re-written to include the dates and signatures when complaints were made and resolved. This would give them a trail of how a complaint was progressing and how and when it was resolved. The residents and the families spoken with were aware of the policy and were aware of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. The home or the Care Quality Commission have not received any complaints since the last inspection. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 18 The residents and the families spoken with and through the surveys were aware of the policy and were aware of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. The staff spoken with were aware of Safeguarding and whistle blowing and said that they had had training in these areas. They would report it to the senior carers or the management and were aware of who to go to if there was no response. The records seen confirmed this. All staff have either got an NVQ at level 2 or have started the award, during which they receive training in safeguarding. They were confident that the management would handle any issues correctly. The accident book was looked at and had been completed correctly with all accidents documented on separate sheets, which retains confidentiality. There was information displayed in the home letting people know where they could get an advocacy service if they needed it. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are protected by the policies and procedures in the home to provide a safe environment. EVIDENCE: Broadoak Grange is a purpose built home on two floors with two lounges and dining rooms on the ground floor. There are bedrooms on both floors and the stairs or the passenger lift reach the first floor. The home was clean and welcoming on our arrival. The two lounges and dining rooms were clean and bright, but the decoration could be updated. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 20 Some of the chairs in the lounges were looking worn and torn in places and it was noted that some had an unpleasant odour coming from them. The provider was apparently in the process of replacing chairs. We saw that there were new chairs in an upstairs room that had been there since last year when we visited the home. The bedrooms seen had been personalised and have had new furniture, which is in a lighter finish that has brightened up the rooms. The residents spoken with were happy with their rooms and said that they were able to bring their own things in with them. The kitchen was found to be clean and well kept and has had a recent environmental health inspection that was found to be satisfactory. The bathrooms were clear of any items that could cause a hazard for the residents. One of the bathrooms did have a bottle of bath foam in it but this was removed before the end of the visit. The garden is pleasant with a patio area that is easily reached by the residents. The residents and the families spoken with were happy with the cleanliness of the home. There are dedicated cleaning staffing the home undertaking the cleaning, who have had training in health and safety. We saw that the cleaning products were stored in a locked cupboard. There are separate staff employed who do the cooking. The staff spoken with, the records seen on the visit confirmed that this was the case. The cook told us that he had regular supplies of good quality food and that the residents could have choices in their meals. Hot water temperatures have been checked and documented as correct. The fire alarm testing and the fire drills were up to date. The staff spoken with told us that they have regular fire drills and training. There was an up to date registration certificate from the Commission for Social Care Inspection and a public liability insurance certificate displayed in the entrance hall. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents’ needs are met and the recruitment policy and the training protect their safety. EVIDENCE: The duty rota reflected the number of staff on duty on the day of the visit and all the shifts covered by the four weeks seen. The residents, staff and families spoken with felt that there were enough numbers of staff on duty to look after their needs. We looked at two staff files and the required information was complete in both of them. This included evidence of identification, adequately completed application forms, two written references, a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults check. The application forms that we looked at still did not have enough space on it to give details of previous employment. However we were told that there was another one being produced. This is necessary to make sure that prospective staff have the right experience and that any reasons for gaps in employment can be explained. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 22 The manager makes sure that all the required documentation is in place before an employee starts work. This was confirmed by the staff spoken with who told us that they could not start until they had all the paperwork in place. There was evidence of improved staff training including induction and the staff spoken with confirmed that they had received recent training in moving and handling, first aid, infection control, health and safety, food hygiene, medication, safeguarding of vulnerable adults and equality and diversity. The staff that we spoke with told us about the training and this was supported by the manager and the training records. The staff told us that they were much happier now that they were getting an increase in their training. We were told that the registered provider was being very supportive in the training plans. The home has an excellent record of staff with a National Vocational Award (NVQ), 100 of the staff either have achieved the award or are undertaking it. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. The residents and the families spoken with felt that the staff were well trained to do their job. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a home that is run and managed in their best interests. EVIDENCE: The manager was available throughout the visit, she has been working in the home for a year, has achieved the Registered Managers’ Award and is registered with the Care Quality Commission. The residents are seen regularly on an individual basis and at meetings, as are the families and discussions are held on how the home is meeting their needs. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 24 The provider is now holding meetings with all the managers in the group of homes that helps them to be supported and to share ideas to improve the homes. The manager tells us in the Annual Quality Assurance Assessment that she is going to make sure that an annual quality questionnaire sent to the residents and their families. We received positive comments from the residents and the families amongst which were that there was good communication with the home and that the staff were very supportive of them and their relative. Families and staff told us that the home had improved in all areas since the new manager had been in post. All of the health and safety records were found to be up to date. The residents’ accounts were seen and all in order with two signatures on entries and receipts obtained for purchases. The annual quality assurance audit asked for by the Care Quality Commission had been returned to us This gives us information about the home, the residents and the staff. There was evidence in the records and from staff spoken with that there is regular staff supervision taking place and the records seen confirmed this. Formal supervision of the staff gives them and their ‘line manager’ the opportunity to discuss work and training issues and needs. There are regular staff meetings held, confirmed by records held and by the staff. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 25 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 3 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X 3 X 3 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 Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 26 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 (1) Requirement The registered provider must make sure that a pre -admission assessment is completed by a suitably qualified person for every resident before admission to the home. (This requirement was made at the last inspection) Timescale for action 30/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations That all of the identified needs of the residents are documented. That the manager puts in place regular, supervised medicine rounds for the staff, that she undertakes regular audits of the medicines and the MAR sheets and that a staff signature sheet is put in place. That the activities programme is reviewed to include the interests of the residents. That the complaints form is reviewed to make it clearer to follow the progress and outcome of a complaint. DS0000001648.V376467.R01.S.doc Version 5.2 Page 27 3. 4. OP12 OP16 Broadoak Grange 5. OP19 That the identified chairs that were worn and dirty are replaced. Broadoak Grange DS0000001648.V376467.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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