Care Home: Broadwaters

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well The home meets the needs of people referred to the home. Residents health and social care needs were being met through good care planning. Residents social and recreational needs are met as the hoe has staff dedicated to providing activities. Residents can receive visitors when they choose. The home provides a good standard of food and choice of meals are offered. Residents are treated with respect and dignity. The home has a well publicised complaints procedure and the staff have been trained in adult protection. The home provides a comfortable, clean and safe environment for residents. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 The home is suitably staffed to meet residents needs. The staff team is well trained and recruited in line with Regulations. It was agreed that there would be more monitoring of residents` records where they deposit money for safekeeping and that residents should sign these records where possible when they deposit or withdraw money. What has improved since the last inspection? The home now relies less on the use of agency staff, having worked hard to recruit permanent and relief bank staff. Recruitment practices have improved and the home now complies with the Care Homes Regulations 2001. What the care home could do better: The home should ensure that decisions as to who is admitted to the home remains with the management of the home. Medication administration records must be completed in full to record all medicines administered to residents and we recommend that opening dates for medications with a `use by` are recorded when they are opened. Key inspection report CARE HOMES FOR OLDER PEOPLE Broadwaters 55 Wick Lane Tuckton Bournemouth Dorset BH6 4LA Lead Inspector Martin Bayne Key Unannounced Inspection 26th May 2009 09:00 DS0000032041.V375662.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. Broadwaters DS0000032041.V375662.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 Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadwaters Address 55 Wick Lane Tuckton Bournemouth Dorset BH6 4LA 01202 423709 01202 429923 michael.twigg@bournemouth.gov.uk 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) Bournemouth Borough Council Michael Frederick Twigg Care Home 29 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (29) of places Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Dementia (Code DE) The maximum number of service users who can be accommodated is 29 14th May 2007 2. Date of last inspection Brief Description of the Service: Bournemouth Borough Council Social Services Directorate manages Broadwaters. Situated in the Tuckton area, local shops, cafe and a library are within half-mile level walking distance of the home. There are pleasant riverside walks with a ferry into Christchurch. The home provides respite/short stay, assessment and intermediate care/rehabilitation for 27 older people who live in the Borough of Bournemouth. The service enables individuals to remain living in the community for as long as possible by providing respite for carers and helping service users to regain or learn skills, and improve their health so they can return home after a hospital stay or alternatively prevent admission to long term care. The home is purpose built with a passenger lift to all three floors. Separate facilities are provided for the 16 service users receiving intermediate care on the first and second floors and the 10 respite care service users and one permanent service user accommodated on the ground floor. All bedrooms are for single occupancy and do not have en-suite facilities, but there are sufficient bathrooms and toilets available on each floor. Extensive grounds that are easily accessible surround the home and garden furniture is available. The staff group for the intermediate care service includes health care professionals either employed or contracted to work in the home and the establishment works closely with the local Primary Health Care Trust and the Community Assessment and Rehabilitation Team. Fee Range: - Full fee:- £461.00 per week. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 5 See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx Broadwaters DS0000032041.V375662.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 the people who use this service experience good quality outcomes. We, the Commission, carried out an unannounced key inspection of Broadwaters Care Support Centre on the 26th of May 2009 between 9:30am and 5:15pm. The inspection was carried out by one inspector, but throughout the report the term ‘we’ is used, to show that the report is the view of the Commission for Social Care Inspection. We were assisted throughout the inspection by the Registered Manager, Mr Twigg and also by other members of the staff team. We carried a tour of the premises and met with some of the residents who were able to provide information as to what it was like to live in Broadwaters. Throughout the inspection we used the personal files for three residents to track the records and care provided to residents as required under the Care Homes Regulations 2001. Information that also helped form the judgements within this report was also taken from the returned Annual Quality Assurance Assessment (AQAA). What the service does well: The home meets the needs of people referred to the home. Residents health and social care needs were being met through good care planning. Residents social and recreational needs are met as the hoe has staff dedicated to providing activities. Residents can receive visitors when they choose. The home provides a good standard of food and choice of meals are offered. Residents are treated with respect and dignity. The home has a well publicised complaints procedure and the staff have been trained in adult protection. The home provides a comfortable, clean and safe environment for residents. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 7 The home is suitably staffed to meet residents needs. The staff team is well trained and recruited in line with Regulations. It was agreed that there would be more monitoring of residents’ records where they deposit money for safekeeping and that residents should sign these records where possible when they deposit or withdraw money. What has improved since the last inspection? What they could do better: 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. Broadwaters DS0000032041.V375662.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 Broadwaters DS0000032041.V375662.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 36 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 needs of residents admitted to the home were being met with preadmission assessments having taken place; however the home must ensure that systems are in place to ensure that the management of the home retains the final decision as to who is admitted to the home. EVIDENCE: Since the last inspection the home’s registration has changed allowing for two more people to be accommodated at the home in the category of dementia. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 10 The Service User Guide has been amended to reflect this change. At the time of the inspection there were three vacancies and there was one person admitted for dementia care needs. The ground floor of the home provides a service for people in need of respite care, or a period of assessment or in the event of an emergency placement. The home also continues to provide a long term placement for one person on this floor. We were told at this inspection that the home was now working with this person to move to another service, as their needs would be better served in a specialist home providing long term placements. The upper two floors are dedicated to the provision of intermediate care. We found that all requirements as detailed in the standards for older people concerning intermediate care were being met. Intermediate care is provided on the first and second floor of the home and is therefore separate from the respite care area. Equipment and therapies for treatment are provided and residents are supported by a team including physiotherapists and occupational therapists. We discussed referral procedures and policies for admitting residents to Broadwaters. Concerning referrals for respite care, care managers carry out an assessment of need for new people referred to the home. Where people return for planned respite care, the home uses the assessment that has already been completed. We recommend that systems are put in place to ensure that when people return for respite care there is confirmation that the needs of the person remain the same. In the event of a person’s needs having changed, a new assessment should always be completed. In respect of intermediate care referrals, these come through the local hospital whilst some emergency admissions can be made by the out of hours services. To maintain compliance with the Care Homes Regulations 2001, the home must ensure that they retain the final decision of whether the home can meet a person’s needs. The home provides a very specialised service and should ensure that any admissions are in line with the service’s aims and objectives. At the time of the inspection there was one person initially admitted for an assessment for four to six weeks, whose residency had had to be extended whilst waiting for appropriate accommodation and this person had been in the home for four months, which means that a bed is not available for other referrals. We looked at the personal files for the residents we tracked through the inspection and found that pre-admission assessments had been carried out to ensure that their needs could be met at the home. Broadwaters DS0000032041.V375662.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 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 benefit from their health care needs being met through good care planning arrangements and through being treated with respect and dignity. There could be improvement in completion of medication administration records. EVIDENCE: We looked at the care plans for the three residents we tracked through the inspection. One of these people had been admitted for respite care, whilst the Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 12 other two were admitted for intermediate care. We found that in the case of all three people there were care plans in place that had been developed from the initial assessments. There was also evidence that residents or relatives had been involved in the care planning with their signing to this effect. We also found that risk assessments had been written to ensure that care is delivered in a safe manner. Skin care, nutritional and moving and handling assessments had been carried out for each person. We recommend that the care plans make it clear the purpose of the person’s admission, whether this was for respite, assessment or intermediate care, as this was not recorded. Concerning the meeting of health care needs, the home has good systems in place to ensure that these are met. For residents admitted for intermediate care, the home has a contract with a local GP for two mornings a week. Residents admitted for respite care retain their GP for their stay, or in the event that they are out of the catchment area for their GP, they register for temporary residency with one of three GP practices in the area, who share this work. During the inspection we saw many examples of where medical needs were being appropriately referred with action taken. During the inspection we spoke with a number of the residents, all of whom had positive things to say about their stay at the home. One person had been in residential care for a period of five years before being admitted to Broadwaters for a period of rehabilitation and was soon to be discharged to independent living. They told us of how successful their stay at Broadwaters had been. All the residents said that the staff were courteous and paid attention to their privacy and dignity. We looked into how medication was being managed in the home. Many of the residents of the home take control of their own medication as part of their rehabilitation programme. We saw examples of risk assessments that had been carried out for people who manage their own medication. We were told that the home was planning to change medication procedures so that residents have their medication stored within their individual rooms, rather than being administered from the medication trolleys, the system in place at the time of the inspection. All the staff who administer medication to residents have had training in safe medication administration and we saw a record of staff signatures at the front of the medication administration records. We also saw that know allergies were recorded at the top of their medication administration records, where a photograph of the person was also displayed. This is good practice and ensures that medication is administered to the right person. We looked at the medication administration records for the residents on the ground floor and found there were gaps within the records. A requirement was made concerning completion of the medication administration records. We saw that where hand entries were completed they were signed and checked by a second member of staff, which is good practice. We looked with the medication trolleys and saw that medicines were being stored correctly. The home also has a controlled drugs cabinet that meets new regulatory Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 13 requirements. The home has a separate dedicated fridge for storing medicines requiring refrigeration, which had a maximum/minimum thermometer to ensure that medicines were being stored within the correct temperature range. We saw that in some instances, but not all, that the date of opening was being recorded for medicines with a prescribed ‘use by’ date. We recommend that this practice is adopted for all medicines that have a shelf life to ensure that they are not used after the recommended period. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 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 benefit from the social and recreational needs being met, through being able to have visitors and from being provided with a good standard of food. EVIDENCE: Concerning the meeting of residents’ leisure and recreational needs, the home employs two part activities co-ordinators, equivalent to a full time post to ensure that these needs are met. We were told that there is no rolling programme of activities, as residents are only admitted for short term care and needs therefore change with each resident admitted. When a person is admitted to the home, an individual profile is completed that addresses their recreational needs. We saw that a short life history had been sought for the Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 15 person admitted in the dementia category to assist the staff in knowing the needs of this person. We were told that activities were arranged in the evenings for the residents admitted for intermediate care, as during the daytime they are involved in their rehabilitation. On the day of our visit we spoke with the activities co-ordinator who was working with an individual and they told us about the programme of activities that were arranged for the week. We saw that residents’ spiritual and cultural needs are assessed at the point of admission. We were told of an example where the home had catered to the needs of a person of Jewish faith. There are no restrictions on people wishing to visit the home, so that residents can stay in touch with families and relatives. Concerning the food provided at the home, each resident is subject to a nutritional assessment when they move to the home to ensure that their dietary needs are met. We saw examples of where peoples’ individual likes and dislikes were recorded. We saw that for the main meal of the day there was always a choice of two main meals and desserts and residents can also request a salad or lighter meal. Specialist diets are catered for. The residents we spoke with told us that the food was of a good standard. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 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 benefit from a well publicised complaints procedure, with complaints taken seriously. They also benefit from the staff being trained in adult protection. EVIDENCE: The procedure for making complaints remains the same as at the time of the last inspection. By virtue of being accommodated in a service run by the local council, residents have access to the council’s complaints procedure. The Service User Guide informs of residents’ rights to complain and so residents and relatives are well informed of how to make a complaint. The home maintains a log of both complaints and compliments. We were told of one complaint that was being dealt with under the formal complaints procedure and it was evident that this was being taken seriously and the complainant would be responded to. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 17 All staff have been trained in the protection of vulnerable adults and the home has copies of the all the relevant policies and procedures. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 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 benefit from a safe and well-maintained environment. EVIDENCE: Since the last inspection the home has been granted a variation to accommodate two more people. The registration of the home now allows for the home to accommodate two people in the category of dementia. To assist orientation of residents with dementia, signage around the home has been improved. Since the last key inspection the home has purchased new hospital Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 19 type beds for residents and some assistive technology has been introduced into the home. The home is located in a quiet residential area with views across the river. One residents told us that they found the location very pleasing and uplifting. Since the last inspection the grounds have been developed providing more outside furniture and plants. We found the home to be clean throughout and there were no unpleasant odours. Residents told us that the home was always clean and well-presented. The home has a dedicated laundry area equipped with sufficient machines to meet the laundry needs of the home. Bed linen is sent to out to external launderers. We saw from a training matrix provided to us that all the staff receive infection control training every two years. We also saw that gloves and protective clothing was provided to the staff and that alcohol gels dispensers were place strategically around the home. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 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 benefit from the home being sufficiently staffed to meet residents’ needs, from the staff being recruited in line with Regulations and through the staff team being trained appropriately. EVIDENCE: Since the last key inspection patterns of staffing and new staff rosters have been introduced to make staffing more responsive to residents’ needs. At the last key inspection we recommended that steps be taken to reduce the reliance of the home upon agency staff to meet staffing levels. We were informed at this inspection that a big recruitment drive has filled all vacant posts and the home has taken on five relief staff of their own to cover periods of sickness and annual leave. This has helped the home’s budget and also provides more consistent staffing to support residents. The home has also taken on three volunteers to support residents, befriending them and helping meet their social needs. Earlier in the year the staff team were nominated for the ‘Proud of the Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 21 Crowd’ award, which is part of the BBC’s achievement award and the staff team were included in the three finalists. The home has a Registered Manager, deputy, seven day assistant managers and three night managers. On the ground floor during the daytime, there are four care staff to support the residents and on the upper floors, two rehabilitation assistants as well as the supporting team of rehabilitation staff. The residents we spoke with said that staffing levels met their needs. At the last key inspection a requirement was made concerning recruitment of new staff as all the required documentation for a sample of new staff was not on file. We looked at the recruitment records for three staff appointed since the last key inspection. We found that all the required records and checks required by Regulation were in place, save evidence of a statement by the person employed as to their physical and mental health. It was explained that staff complete a health declaration, but this is kept with the Council’s Personnel Department. It was agreed that should the home keep a copy of the interview checklist that is sent to the Personnel Department. This would be sufficient evidence of the health declaration being undertaken, as it makes reference to the person completing the health questionnaire. The returned AQAA informed us that about 90 of the permanent care staff team have achieved the level of NVQ level 2 or above. We were provided with a staff training matrix which informed us of the training achievements of the staff team. We saw that training was well organised and that staff receive all mandatory training before they can go on to undertake more specialist training. All staff receive induction training that complies with ‘Skills for Care’ standards. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 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 home is well run in the interests of the residents. EVIDENCE: Mr Twigg, the manager has been registered with the Commission as Registered Manager since the time of the last key inspection. He has had over twenty years experience in care and is a qualified RGN/CMS also holding the Registered Manager’s Award and NVQ level 4. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 23 In general we found that the home was well-managed and run in the interest of the residents. Visits to the home are made by senior representatives of the Council unannounced to oversee the management of the home as required under Regulation 26. Residents complete questionnaires about their stay at the home and this is feedback into reviews of the service to ensure customer satisfaction and continual development of the service. The home safe keeps sums of monies on behalf of residents should they wish. We looked at the records for three residents and checked that this tallied with the monies held. We recommend that where residents have capacity, they should sign the records of money deposited or withdrawn as well as the staff. On one records we found a small anomaly. The records and balances of money are regularly checked and audited but it was agreed that there would be more frequent checks to ensure that records are procedures are tightly followed. The AQAA informed that there were systems in place to ensure that equipment was being serviced to required timescales. We did not identify any hazards as part of our inspection. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 X X X X X 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 2 X X 3 Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement You are required to ensure that medication administration records are completed in full with no gaps within the records. Timescale for action 12/06/09 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. Refer to Standard OP3 Good Practice Recommendations We recommend that procedures and policies for admitting new residents to the home are reviewed to ensure that up to date pre-admission assessments are in place for all new admissions and that the management of the home has the final decision as to who is admitted to the home. We recommend that care plans inform of the reason for a person’s admission to Broadwaters, whether this is for a period of assessment, respite or intermediate care. We recommend that where medications had a prescribed use by date that the date of opening is recorded so that the medication is not used beyond this recommended period. DS0000032041.V375662.R01.S.doc Version 5.2 Page 26 2. OP7 3. OP9 Broadwaters 4. OP35 We recommend that where residents have capacity, they should sign the records of money deposited or withdrawn as well as the staff. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 27 Care Quality Commission CQC South West PO Box 1251 Newcastle Upon Tyne NE99 5AN 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. 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. Broadwaters DS0000032041.V375662.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!