Care Home: Broadway Lodge

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What the care home does well People said the home provided a friendly and welcoming environment for them to enjoy and they receive care in a way that respects their privacy and dignity. People who live at the home said: " The staff are very good they take care of me, I am happy with the care and I have nothing to complain about". And " The girls work very hard indeed, they have a lovely way about them". The proprietors are dedicated and treat the people who live there as if they were part of their own family.People are well cared for and helped to keep pride in their appearance. A wide variety of activities are available to people living in the home. Staff receive training to ensure that care is provided by staff who have relevant knowledge of how to give care safely. Environmental improvements are undertaken to ensure the home is pleasant for people living there and their relatives. What has improved since the last inspection? Information about the home has been updated to make sure people who are considering moving in to the home can make an informed decision about if the home is the right place for them. People are assessed to find out what needs they have and this assessment is now recorded straight away, to make sure that no important information about people`s needs is lost. Care plans have been improved to make sure they reflect people`s current needs, they are individual and detailed to make sure staff have clear guidance about how to meet people`s needs fully. Medication systems have been vastly improved. Staff have received further training in how to give medications safely and there is a new chemist supplying the home with a better quality of service. These combined improvements make sure that people`s health and wellbeing is now protected by the systems in place. Staff position themselves at the person`s eye level when assisting people to eat or drink to make sure they can help them more easily. Food, which is stored in the fridge and dry store has the " best by" dates recorded on it, so that people are receiving food, which is safe for them to eat. People`s social needs are recorded in more detail to make sure that people`s preferred social activities continue to be made available. The complaints procedure is now up to date and gives the Commission`s correct contact details, so that people can contact us if they want to. Management and staff have undertaken a lot of training to make sure everyone is aware of the steps they should take to protect people from abuse. All staff have undertaken fire training and a training matrix has been created for all staff to make sure that staff have their knowledge and skills regularly updated. Quality assurance systems have been introduced to make sure that the systems and services provided in the home are checked and monitored to ensure the quality of the care and services being delivered to people is of a good standard. The proprietors have improved their knowledge and understanding of the information the Commission for Social Care Inspection must be sent about accidents or incidents, which occur in the home. They are continuing to look at our web site to see what changes they need to make to comply with current legislation. Fire doors are not held open by inappropriate means and window restrictors are now fitted to help protect people`s health and safety. Hand washing facilities are now present in all areas of the home to make sure infection control measures are in place. What the care home could do better: An updated medication policy should be made available to staff at all times to make sure they are all fully aware of the new systems that are now in place to help protect people`s health and well being. CARE HOMES FOR OLDER PEOPLE Broadway Lodge 151 Fulford Road Fulford York YO10 4HG Lead Inspector Denise Rouse Unannounced Inspection 23rd October 2008 09:15 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 Broadway Lodge DS0000015790.V372817.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. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address 151 Fulford Road Fulford York YO10 4HG 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) 01904 621884 Mr Houssen Mohamud Baccus Mrs Swadeka Mohamud Baccus Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th May 2008 Brief Description of the Service: Broadway Lodge provides personal care and accommodation for up to 18 older people. The home is located in Fulford and is within easy reach of the local shops and on a main bus route to the centre of York. There are pleasant gardens to the front and back with ramped access allowing disabled access. Limited car parking is available. The accommodation is over two floors and spread over two houses linked together by a corridor. There are single and double bedrooms available. The first floor is reached either by a flight of stairs or a passenger lift. The registered providers manage the day-to-day running of the home. Information is available in the service user guide and statement of purpose about the services the home has to offer. The last Inspection report is also made available to people. Weekly fees charged on 23 October 2008 ranged from £362.71 to £490. Extra charges are made for hairdressing and chiropody. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 5 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. The accumulated evidence used in this report has included: A review of the information held on the home’s file since its last key inspection. Information submitted by the registered provider in the Annual Quality Assurance Assessment. Surveys received from six people living at the home, one health care professional and one member of care staff. An unannounced visit to the home, carried out by one inspector and a pharmacy inspector, which lasted one day. Evidence was gained by direct observation during the site visit which involved talking with people living at the home, visitors, the proprietors and other members of staff. Inspection of records, including care profiles, medication administration records and staff files. As well as some of the home’s policies and procedures. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People said the home provided a friendly and welcoming environment for them to enjoy and they receive care in a way that respects their privacy and dignity. People who live at the home said: “ The staff are very good they take care of me, I am happy with the care and I have nothing to complain about”. And “ The girls work very hard indeed, they have a lovely way about them”. The proprietors are dedicated and treat the people who live there as if they were part of their own family. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 6 People are well cared for and helped to keep pride in their appearance. A wide variety of activities are available to people living in the home. Staff receive training to ensure that care is provided by staff who have relevant knowledge of how to give care safely. Environmental improvements are undertaken to ensure the home is pleasant for people living there and their relatives. What has improved since the last inspection? Information about the home has been updated to make sure people who are considering moving in to the home can make an informed decision about if the home is the right place for them. People are assessed to find out what needs they have and this assessment is now recorded straight away, to make sure that no important information about people’s needs is lost. Care plans have been improved to make sure they reflect people’s current needs, they are individual and detailed to make sure staff have clear guidance about how to meet people’s needs fully. Medication systems have been vastly improved. Staff have received further training in how to give medications safely and there is a new chemist supplying the home with a better quality of service. These combined improvements make sure that people’s health and wellbeing is now protected by the systems in place. Staff position themselves at the person’s eye level when assisting people to eat or drink to make sure they can help them more easily. Food, which is stored in the fridge and dry store has the “ best by” dates recorded on it, so that people are receiving food, which is safe for them to eat. People’s social needs are recorded in more detail to make sure that people’s preferred social activities continue to be made available. The complaints procedure is now up to date and gives the Commission’s correct contact details, so that people can contact us if they want to. Management and staff have undertaken a lot of training to make sure everyone is aware of the steps they should take to protect people from abuse. All staff have undertaken fire training and a training matrix has been created for all staff to make sure that staff have their knowledge and skills regularly updated. Quality assurance systems have been introduced to make sure that the systems and services provided in the home are checked and monitored to Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 7 ensure the quality of the care and services being delivered to people is of a good standard. The proprietors have improved their knowledge and understanding of the information the Commission for Social Care Inspection must be sent about accidents or incidents, which occur in the home. They are continuing to look at our web site to see what changes they need to make to comply with current legislation. Fire doors are not held open by inappropriate means and window restrictors are now fitted to help protect people’s health and safety. Hand washing facilities are now present in all areas of the home to make sure infection control measures are in place. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broadway Lodge DS0000015790.V372817.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 Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 (6 not applicable) People who use this service experience good quality outcomes in this area. People are assessed so that their needs are known and can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Pre admission assessments are carried out by the proprietor, the assessment provides good information about people’s needs and their preferred social activity. Information from care managers and discharging hospitals is gained which helps to make sure people’s needs are known and can be met. The statement of purpose and service user guide has been rewritten and contains all the relevant information about what the home can offer people. The last inspection report is displayed in reception and is accessible to everyone who visits the home. People thinking of moving into Broadway Lodge are able to visit the home and stay for a meal, a day or a trial period. The proprietors are dedicated and spend a lot of time with people to answer their questions and support them, which can help people when they are making a decision about if this is the right place for them. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 10 One relative said “ My mother came into the home this year. I did not think she would settle, but she did so immediately”. Intermediate care is not undertaken. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,and 10. People who use this service experience good quality outcomes in this area. People’s care needs are known and can be met, care documentation has improved to make sure staff are aware of what help people need. Medication systems in place help protect people’s health and well being. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People’s care needs are now more clearly recorded, the information is personalised and reflects in enough detail what people can do for themselves and what they need help with. This makes sure that staff are aware of the care people need and this can be provided. Care documentation was being reviewed monthly or as the person’s needs changed and this makes sure that people are receiving the care they need. Care reviews are held by the proprietor with the resident and their family and social worker a few weeks after a person is admitted, to make sure people are happy with the care and services they are receiving. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 12 People are addressed by their preferred name. People spoken with said staff treated them with respect. Specialist equipment is available to make sure that people’s individual and special health care needs can be met. This includes hoists and pressure cushions. Health care professionals visit the home as required and people are escorted to hospital appointments to ensure their health needs are met. Medication systems in operation were inspected. They have been vastly improved since the last inspection. A new chemist now supplies the home. Staff take time to make sure they are protecting people’s safety by giving medications as prescribed and making sure the medication administration records are signed immediately after medication is taken by each person. Medication requiring to be stored in a fridge is now stored correctly. People who would like to be able to take their own medication are assessed by the staff to make sure they are safe to do so. Medication is stored in a lockable drawer in their bedroom. This makes sure that people’s independence and choice is respected. Staff involved in the administration of medication have had training this makes sure means that staff understand how to handle and administer medicines safely. A medication audit occurs monthly in house and the pharmacist also visits each month to carry out an independent audit, this helps to protect people. The medication administration policy is being updated to make sure it reflects all the positive changes that have been made to the medication systems in operation within the home that now protect people. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use this service experience good quality outcomes in this area. People’s social needs are known and are met. People receive a nutritious diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People’s preferred social activities are recorded at the pre admission assessment so that people’s social needs are known and can be provided. This information is built upon during the person’s stay at the home and information about the person’s family history and lifestyle is gained with some help from people’s family. This makes sure that staff can help people to reminisce if they would like to. One of the proprietors plans the activities which take place; this includes bingo, dominoes, indoor skittles and netball. Once a month Tai Chi and chair exercises are provided for people who wish to take part. Televisions are provided in the communal lounges for people to use. Staff and the proprietors know each individual well and put themselves out to ensure outings and trips to the shops occur. The proprietors regularly go shopping on people’s personal request and spend a great deal of time to ensure people have exactly what Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 14 they want to buy. Outings occur, five people enjoyed a trip Burnby Hall Gardens recently, which they said they enjoyed. Children from a local school visit at Christmas time to sing to people in the home and they come at other times to talk with people living there. A Christmas party is held for people living in the home with entertainment and a buffet provided for all relatives and staff. Christmas presents are given to people who live at the home. On the day of the visit people were playing dominos and had a sing along to old time music. Staff were also seen manicuring ladies nails whilst they were watching television. A hairdresser visits once a week and a chiropodist as required for people’s convenience. Visitors are welcome and people can go out with their relatives whenever they wish. People’s religious preferences are known. Holy Communion is provided once a month and some residents go out to a local church club. A visitor said “The staff at Broadway Lodge are very pleasant and welcoming to me and I am always offered a cup of tea or coffee during my visits”. Resident’s meetings are held regularly to make sure people who live in the home have their views heard. Any issues are addressed to make sure people are happy with the service they are receiving. People’s dietary needs are known, special diets can be provided. The menu for the day is written on a board in the dining room so that people know what is on offer to them. Staff sit down by the side of people who need some help to eat or drink and assist them in an unhurried manner. One relative spoken with said she had been invited with her sister to come to the home to have lunch and tea with her mum to celebrate their mum’s birthday. This was a surprise and she thought this was very nice indeed. The kitchen was inspected and items of food prepared and stored in the fridge were dated and food decanted into storage containers in the dry store had the “ Best by” dates recorded, to make sure food is fresh for people to eat. The cleaning undertaken, daily, weekly and monthly was recorded and this was audited monthly by management to make sure that people were being protected by the food handling and hygiene systems in place in the home. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use this service experience good quality outcomes in this area. People have their views listened to and acted upon, and procedures are in place to help protect people from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure is available to people. Complaints are investigated and documented, and the person informed of the outcome. The proprietors have an open door policy anyone one can see them to make their views known at any time. People spoken with said they felt comfortable to raise any issues with the staff or proprietors and felt issues raised would be dealt with. A safeguarding policy is in place with a clear large notice displayed in the office with all the phone numbers needed to report any allegation of abuse. The proprietor and staff knew what to do if an allegation of abuse occurred. Staff receive training in this subject, which is also discussed at interview. This helps to protect people from abuse. Checks are undertaken to ensure staff are suitable to work in the care industry. Staff do not start at the home before the result of police checks are known. This helps to ensure that staff who are not suitable to work in the care industry are not employed at the home. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26. People who use this service experience good quality outcomes in this area. People live in a home that is maintained, and infection control measures are in place to help protect people. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The entrance to the home is secure and window restrictors have been fitted to the ground floor bedroom windows to make sure unauthorised people cannot gain access to the home. There are two lounges on the ground floor and tables for dining in two areas of the home so that people can choose where to sit and where they would like to eat their meals. A programme of maintenance is undertaken to make sure that the home remains pleasant for people who live there. There is a passenger lift available to allow people who are not mobile enough to negotiate the stairs access to all areas of the home. There is a garden with furniture and ramps provided for Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 17 people in wheelchairs and those who require walking aids to help them to get into the garden where garden furniture is provided so people can sit out if they want to. The home is clean and there is no malodour. Hand wash facilities are available in all areas of the home to help prevent the spread of infection. The laundry facilities inspected are adequate for the home. Soiled linen is handled correctly to help protect people’s health and prevent the spread of infection. Easy chairs and dining chairs have protective covers on them. People are being asked individually if they would like to have a cover on the chairs they use. Each individual is having their views documented and everyone at the home will decide if they want a cover on their chair or not to make sure it is the person’s own individual choice that is being respected. A part time cleaner is employed. Care staff assist with some domestic duties, especially laundry. The laundry was inspected and infection control measures are in place and hand washing facilities are provided which helps prevent the spread of infection. There are two double bedrooms, which have screens between the beds to protect the sharing occupants privacy and dignity. All bedrooms have a lockable door and a lockable drawer so people can have secure space if they wish. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 18 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): Standards 27,28,29 and 30. People who use this service experience good quality outcomes in this area. People receive care from staff who are well-trained so that they can meet people’s needs safely. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff are provided in sufficient numbers to meet people’s needs. A thorough recruitment process is followed which includes recording the outcome and responses from potential staff at interview, as well as undertaking all necessary references and criminal checks. This ensures people are protected from staff that may not be suitable to work in the care industry. People are allocated a “key worker” who helps to support them. Recruitment policies and procedures are thorough to make sure that staff who are recruited are suitable to work in the care industry. An equal opportunities policy is in place. Staff update their training to ensure their health and safety is protected and that of the people living in the home. There is an ongoing training programme in place to keep staff up to date with how care should be delivered. Staff have undertaken a lot of training since the last inspection, this is ongoing and they are about to have further moving and handling training provided. This helps staff keep their knowledge and skills up to date, and help them provide Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 19 good care to people living in the home. A training matrix has been created to help make sure staff are always up to date. Training in relation to fire prevention has been undertaken by all staff and the fire service has been contacted to make sure the training being provided is enough to make sure people are protected. More than 99 of staff hold a National Vocational Qualification in Care, this helps to enhance the care being provided to people living in the home. Staff meetings occur regularly and minutes are recorded. Handovers occur. Supervision and staff appraisal take place and allow staff and the proprietors time to clarify any issues and make sure staff have the skills and support they need to perform their care well. Staff are experienced and people said staff knew them and knew what they had to do to meet people’s needs in an individual way, which they were happy with. One member of staff said, “I am really happy working here, I love the residents they are now my family, the more staff we have the better the quality of care. I feel things are much better now since the last inspection, there has been a lot of improvements”. Another commented “ We provide the best care we can give, to make the service user happy and contented. We respect the service user and their wishes”. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 20 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): Standards 31,33,35 and 38. People who use this service experience good quality outcomes in this area. People live in a home that is well managed, audits are in place to make sure people’s health and safety is being protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The proprietors have worked very closely with the staff and brought in a consultant to make sure the areas of concern in the previous report have been addressed. The proprietors are dedicated and manage the home on a day-to-day basis and cover evenings and weekends on call as well as visiting people living in the home out of hours. They are experienced and undertake training courses to help keep them up to date. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 21 The information about what the home can offer people is now up to date and reflects what the home can provide. This makes sure people can make a decision about what the home has to offer them. Quality assurance procedures are now in place, written audits are undertaken on care profiles and medications and food preparation and kitchen hygiene. Medication systems in operation in the home have been vastly improved. This helps to make sure people’s health and well being is protected. People who use the service are sent a yearly questionnaire to give their views about how the home is meeting their needs and to find out if there are any issues people would like to be addressed. A training matrix is now in place and this helps keep the skills of the staff up to date to make sure people can receive good care. There is a copy of the Key Lines of Regulatory Assessment available in the home and the proprietors and staff are looking at this information to help them to make sure the home is providing services which can be audited, which fall into the “good” quality rating category. Notifications are now being sent to the Commission for Social Care Inspection to keep us informed of any issues that we need to be aware of, this helps us to support the home. Staff meetings and resident and relative meetings are held and people can have access to the minutes of these meetings to make sure they are aware of what is happening in the home. Personal allowance accounts are available for people living in the home if they do not wish to look after their own money. These accounts have been changed to make sure they reflect accurately the balance of money people have available to them and receipts are kept for all transactions. An audit is undertaken each month to make sure this system is correct and continues to protect people from financial abuse. Health and safety checks and regular maintenance is undertaken to make sure the home remains a nice place for people to enjoy. Fire doors are now not held open by inappropriate methods; this helps to protect people if a fire should occur. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 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 3 X X 3 Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard OP9 Good Practice Recommendations An updated medication policy should be available at all times to staff to reflect the improved systems which are in place and to make sure that staff are all working according to the home’s latest requirements and guidance. This will help to protect people. Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Broadway Lodge DS0000015790.V372817.R01.S.doc Version 5.2 Page 25 - 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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