Care Home: Broadoak Lodge

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What the care home does well The staff give good care with dignity, privacy and relate well to the residents. `I have good conversations with the staff ` The residents have a clean and pleasant home to live in. The home gives the residents good, fresh home cooked food and gives them choices in what they have to eat. The residents have activities arranged that recognize peoples` interests. 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 water temperatures for all the bedrooms are now within the recommended range. The manger is now sending the required notifications to the Commission for Social Care Inspection for any untoward incident that has happened in the home or to one of the residents. CARE HOMES FOR OLDER PEOPLE Broadoak Lodge Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Thea Richards Unannounced Inspection 5th August 2008 09:00 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 Broadoak Lodge DS0000001816.V369874.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. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoak Lodge 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 481120 01664 481120 Mr John Nunn Mrs Barbara Elsie Nunn Mrs Christine Mary Carne Care Home 27 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number disorder, excluding learning disability or of places dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (27), Physical disability (4), Physical disability over 65 years of age (4) Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one may be admitted into the home in categories PD or PD E when there are already 4 persons of that category accommodated in the home. Service User Numbers. No person to be admitted into the home in categories MD, MD(E) or DE(E) when 5 persons in total of these categories or combined categories are already accommodated in the home. No one under the age of 55 years can be admitted to the home. 3. Date of last inspection 5th October 2007 Brief Description of the Service: Broadoak Lodge Residential Home is a care home providing personal care and accommodation for 27 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. Christine Carne has been the manager for several years. The home is situated on the outskirts of Melton Mowbray and can be reached by private and public transport. There is limited parking to the front of the home or in the road. There are local shops and other amenities close to the home. The accommodation is a purpose built two- storey home with two lounges and a dining room on the ground floor. There are bedrooms on both floors and the first floor can be reached by stairs or by a stair lift. There are single and shared bedrooms, all of which have ensuite facilities. Outside, there is a well - maintained patio area with seating and flower beds, 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. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 5 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. The current level of fees is £ 465.00 There are extra charges for hairdressing, chiropody, newspapers and personal items. Broadoak Lodge DS0000001816.V369874.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 Commission for Social Care Inspection), spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 5th October 2007. The visit took place on the 5th August 2008 and lasted four 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 we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and their families. 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 was looked at. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. We read the survey forms that had been returned to us from the residents and the staff. We had two returned from the residents and two from the staff. During the visit we spoke with the homes’ owner, the deputy manager, the staff, the residents and families and visitors to the home. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should be updated to include all the details required by the national Minimum Standards. Consideration could be made to include the results of the annual quality assurance audit into the Statement of Purpose. The home must make sure that appropriate lifting aids are used and the staff are instructed not to use illegal lifting practices. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 8 There could be a signature sheet in place to make sure that the staff signatures and initials can be identified. The front door should be locked to make sure that the staff are aware of the visitors who are in the home. The home should consider giving the residents choice when redecorating the bedrooms to make sure that they suit their taste. The home should make sure that the repairs in the home are completed as soon as possible. The complaints policy should include the contact details for Social Services, so that they can be contacted in the event of a complaint. Consideration should be made to redesign the staff application form to give more space for the candidates’ previous employment dates. The staff should be given the opportunity to attend training on how to deal with residents with challenging behaviour. The staff should have the opportunity to have formal supervision with their ‘line manager’ to discuss their work and training needs. 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. Broadoak Lodge DS0000001816.V369874.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 Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are always assessed before moving into the home and they have good information to help them make an informed choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had seen the Statement of Purpose and had been given the terms and conditions. The Statement of Purpose and Service Users’ Guide should give people the information that they need to know about to help them make a decision about the home. The Statement of Purpose does not contain all the information that is required by the national minimum standards, although the service user guide does have some of the informatin. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 11 Consideration should be made to include the results of the homes’ annual quality audit. This will give the prospectiv resident and their family a view on what people who use the service think about it. Providing a comprehensive Statement of Purpose & Service Users’ Guide results in good information for the residents, making sure that they they can get the most suitable care. The manager or a senior member of staff always visits prospective residents before they are admitted to the home and there is a thorough pre admission assessment form in place. This was seen in the care plans looked at and confirmed by the residents and the families spoken with. ‘The manager visited me in the hospital’ This makes sure that that the manager and the staff in the home have the the right information before the resident is admitted, so that they can get the best care. It makes sure that the home can meet the residents’ needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. The families spoken with confirmed that they were given the opportunity to visit the home before their relative came in and that they had a months’ trial to see if they liked it. Members of the staff spoken with said that they always knew what the residents’ needs were before they moved in. The suveys that were returned to us from the residents told us that they had good information before they were admitted to the home. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home with an up to date insurance certificate. The latest report from the CSCI was available in the managers’ office. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available 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: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents and reflected the care that the residents needed. The residents and the families spoken with told us about the care that they needed and that they were happy that they received it. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in the care plans, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 13 and other health professionals when they needed to. A district nurse spoken with told us that the standard of care in the home was excellent and that there was good communication with the home. She told us that the staff were always aware of the needs of the residents and informed her quickly of any changes that she needed to know about. They were also aware of what they were able to do and informed her if they needed her support and help. There was evidence that the care plans had been reviewed regularly and had been signed by the resident to say that they had seen the care plan and agreed with it. Signing the careplans makes sure that the resident and/or their families were involved and aware of the care to be given and that they were happy with it. The residents and the families spoken with told us that they had been involved and were happy with the care being provided. The daily record of care is up to date and described the residents day or night, which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. We saw residents being treated with dignity and respect when staff spoke with them and undertook their care. The staff sat down with the residents and spoke with them giving reassurance by touching their hands and talking directly to them. Staff seen giving care mainly did so in the right way, giving the residents privacy where needed, particularly when moving them. Staff were senn to be moving residents without using the right equipment and using unsafe practices. There are records of the residents meals and drinks that make sure that the residents are eating and drinking properly. There are records of the residents’ weight, which makes sure that they are not losing or gaining large amounts of weight. The staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. This information was confirmed in the surveys that were returned to us. There were risk assessments in place to cover all the identified risks for the residents and how the staff should manage those risks. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 14 Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had training to give medicines. This was by the pharmacist who supplies the medicines and all the senior staff have completed a distance learning training in the safe handling of medicines. We saw that the medicines were administered individually and the residents were seen to be taking them. The medicines are packaged by the chemist into a ‘monitored dosage system’ where each tablet is in a separate pop out card. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The manager carries out a monthly written audit of the medicines and the medicine sheets to make sure that they are correct. There was a self-medicating policy in place but there were no residents looking after their own medicines at that time. The manager could put a signature sheet in place so that the staffs’ signatures and initials are easily identified. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. The residents have their social, spiritual and nutritional needs met. very well. EVIDENCE: The staff were seen to be spending individual time with the residents, some of whom were having their nails done. The T.V was on in the lounge, for part of the visit, which the residents were enjoying. During the visit there was music on and most of the residents joined in the Communion service that was held after lunch in the small lounge. The staff, the residents and the activities programme confirmed that there were regular activities such as, bingo, quizzes, sing-a-longs and trips out. There was to be a trip out to Rutland Water on the day following the visit. The residents spoken with were happy with the level of activities and said that they had plenty to do. The families spoken with felt that there were enough activities for the residents to do. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 16 ‘ I enjoy going out to the shops’ one of the residents told us. There was evidence in the daily records and in the care plans about the activity that the residents 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. 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. The cook was seen to be spending time with the residents during the meal and was asking them what they would like and getting it for them. ‘They look after me well’ The hairdresser visits once a week, which the residents said that they appreciated. The religious needs of the residents are met individually and through the monthly service held in the home. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the 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 in the home if they needed to. The contact details for Social Services are not in the policy. This can be made available in a large print and other languages, which makes sure that as many people as possible can read it. The home had received one complaint since the last inspection on 5th October 2007. This was dealt with and resolved satisfactorily. The Commission for Social Care Inspection has not received any complaints in this period. The residents and the families spoken with were aware of the policy, 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. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 18 The staff spoken with were able to describe how they would deal with an allegation of abuse, knew the areas where abuse could happen and could describe the process that they would go through if they suspected any abuse. They confirmed that they had had training in safeguarding adults and whistle blowing and the deputy manager and the records seen supported this. All of the staff have either got an NVQ at level 2 or have started the award, during which they receive training in safeguarding as well as the training given in the home. They were confident that the management would handle any issues correctly. We looked at the accident book, which had been completed correctly. There was a large print notice in the reception area advertising the Age Concern advocacy service, so that the residents can find an independent advocate if they need to. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 25, 26. Quality in this outcome group is good This judgement has been made using available evidence including a visit to the service. The residents are protected by the policies and procedures in the home to provide a safe environment. EVIDENCE: Broadoak Lodge is a purpose built home close to the centre of Melton Mowbray. When we arrived we could open the front door and despite ringing the bell we had to go to find the staff. This could mean that the staff do not know who is in the home. The home was clean and welcoming on our arrival. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 20 There is a large and a small lounge, and a dining room on the ground floor with bedrooms on both floors, all of which have en-suite facilities. The stairs or a stair lift can reach the bedrooms on the first floor. The lounges and dining room were clean and bright, with suitable seating for the residents. Some of the bedrooms seen had been personalised and were mostly found to be clean. One of the bedrooms was found to be very dusty and was shown to the deputy manager, who had it cleaned before the end of the visit. The bedrooms were all decorated with the same colour that looked dark and dirty in places, although the rooms had been decorated in the last year. Consideration could be made to let the residents choose the colours for their rooms and/or choose decoration that makes rooms individual, brighter and more personal. The residents spoken with were happy with their rooms and said that they were able to bring their own belongings in with them. One of the bedrooms had broken drawers on a chest of drawers and a broken wardrobe door. The use of a shared room is discussed and agreed with the residents before they are admitted to the home and their privacy is maintained by the use of screens and each resident has their own storage for their belongings. The bathrooms were clean and clear of any items that could cause a hazard for the residents. There is a lovely patio area that is accessible to the residents and makes a pleasant place to sit for them. The residents and the families spoken with were happy with the cleanliness of the home. There are staff employed to complete the cleaning in the home and they have had training in health and safety. The cleaning products are stored in a locked cupboard. The kitchen was clean and has recently had an inspection from the environmental health department who classed it as excellent and awarded them a 3 star certificate. The records for hot water testing were up to date and all the temperatures were within the recommended levels. Fire alarm testing and the fire drills were up to date. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The recruitment policy and the training meet the residents’ needs and 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 had good numbers of staff. The residents, staff and families spoken with felt that there were enough numbers of staff on duty to look after their needs. ‘ They always come when I want them’ 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 form did not have enough space on it to give details of previous employment. 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 Lodge DS0000001816.V369874.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 and in the surveys returned to us, which told us that they could not start until they had all the paperwork in place. There was evidence of staff training, including induction and the staff spoken with confirmed that they had received recent training in moving and handling, medication and first aid. Staff have completed training in looking after people with dementia, but further training in how to cope with challenging behaviour could be considered. The residents and the families spoken with felt that the staff were well trained to do their job. A member of staff told us ‘ I am really happy with the work and the training that I get’ All of the staff either hold a National Vocational Qualification (NVQ) at least at level 2 or are in the process of completing 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. Broadoak Lodge DS0000001816.V369874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents benefit from management that is committed to their safety, care and needs. EVIDENCE: We were accompanied by the deputy manager as the manager, who has managed the home for many years was on annual leave. The manager has completed the registered managers’ award and is registered with the Commission for Social Care Inspection. There are regular meetings held for the residents and for their families as well being seen on an individual basis, to discuss activities and menus in addition as to how the home is meeting their needs. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 24 There is an annual quality questionnaire sent to the residents and their families and the questionnaires that we saw on the visit confirmed this. The families and the residents told us that they had completed the questionnaires. 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. The residents’ accounts were seen and all in order with two signatures on entries and receipts obtained for purchases. There was no evidence in the records or from staff spoken with that formal staff supervision is taking place, although they regularly talk with the manager. This is not written down. 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 spoken with. Broadoak Lodge DS0000001816.V369874.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 X 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 X X X 2 X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? None 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 OP8 Regulation 13 (5) Requirement That appropriate lifting aids and techniques are used to transfer the residents. Timescale for action 30/08/08 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 OP1 Good Practice Recommendations That the Statement of Purpose should be updated to include all the details required and contained in schedule1 of the national minimum standards. That consideration is made to include the results of the annual quality questionnaire into the Statement of Purpose. That a signature sheet is put in place to identify the staffs’ signatures and initials. That the complaints’ policy is updated to include the contact details for Social Services. The residents could have a choice in colour scheme in their bedrooms. That the maintenance in the home is completed promptly. DS0000001816.V369874.R01.S.doc Version 5.2 Page 27 2. 3. 4. 5. 6. OP1 OP9 OP16 OP19 OP19 Broadoak Lodge 7. 8. 8. 9. OP25 OP29 OP30 OP36 That the front door is kept locked to keep the residents safe from unknown people. Consideration could be made to redesign the staff application form to allow more space for dates of employment. That the staff could be given the opportunity to attend training on how to deal with people with challenging behaviour. That the staff are given the opportunity to have regular formal supervision with their line manager that is documented. Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Broadoak Lodge DS0000001816.V369874.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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