Care Home: Broomgrove Nursing & Convalescent Home

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What the care home does well Broomgrove Nursing home provides sufficient information to people who may wish to use the service so that people were able to make an informed decision about the home. The health and personal care that people receive at the home was based on their individual needs. The principles of respect, dignity and privacy were put into practice by the staff and monitored by the management. The people who live in Broomgrove were able to make choices about their lifestyle, and were supported to maintain their life skills as much as they were able to. People who use the service were able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home were protected from abuse and their rights were protected by the management and the systems in place. The staff working at the home were trained, skilled and employed in sufficient numbers so that they were able to support the people who live at Broomgrove and contribute to the smooth running of the service. The management and administration of the home was based on openness and respect to those who use the service and those who work at the home. What has improved since the last inspection? The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. The ongoing refurbishment is set to improve the residents’ facilities and benefit the people who live at Broomgrove. The programme of renovation and refurbishment is well underway. This has included renovation of bedrooms and the kitchen. The quality audits by the manager have identified some room for improvement and the management were making arrangements to make changes. The identified changes should be actioned in a timely manner so that improvements could be realised by the service users and the staff working at the home.Broomgrove Nursing & Convalescent HomeDS0000021772.V375436.R01.S.docVersion 5.2 What the care home could do better: The service user plans must be updated and need to be comprehensive. They need to reflect the peoples’ current objectives for health and personal care needs. Therefore the documentation at the home needs to outline the actions to be taken by the staff to achieve the expected outcome for individuals. There needs to be documentary evidence that the care has been planned with the help of the individuals and their families. The interests of people living at the home must be recorded in their care plans. Opportunities for stimulation through leisure and recreational activities in and outside the home must be organised, which need to reflect the needs, preferences and the capacity of those who reside at Broomgrove. Up to date information about the activities must be circulated to all people in the appropriate formats. Previous Requirement: 14/08/07 Two staff have been appointed in the last month. However, little progress has been made with regards to promoting social and 1:1 activities since the last Key Inspection. The manager need to ensure that all staff receive formal supervision at least 6 times a year. All staff need to attend mandatory training at the correct intervals and be competent to promote health, safety and wellbeing at the work place. Key inspection report CARE HOMES FOR OLDER PEOPLE Broomgrove Nursing & Convalescent Home 30 Broomgrove Road Sheffield South Yorkshire S10 2LR Lead Inspector Marina Warwicker Key Unannounced Inspection 4th June 2009 11:00 DS0000021772.V375436.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. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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 Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broomgrove Nursing & Convalescent Home Address 30 Broomgrove Road Sheffield South Yorkshire S10 2LR 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) 0114 266 1311 0114 268 4276 enquiries@broomgrove-trust.co.uk The Broomgrove Trust Mrs Jill Marie Wall Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (31) of places Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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 with Nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Physical Disability - Code PD The maximum number of service users who can be accommodated is: 31 12th June 2007 2. Date of last inspection Brief Description of the Service: Broomgrove Trust Nursing and Convalescent Home with Sheltered Housing is a registered charity established in 1964 to meet the needs of older people in Sheffield. Individualised nursing care is provided in a warm and supportive environment, by a well established, skilled and committed team of nurses and care assistants who are particularly experienced in caring for people who need recuperation. The home provides convalescent care for those who have recently been in hospital and respite care for people whilst their family or carers take a holiday; it also offers a number of places for permanent care. Rate of fee reflects the dependency levels and specialist needs of the individuals. It ranges from £700 to £850. People pay for hairdressing, chiropody, toiletries magazines and news papers. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. An inspection of Broomgrove Nursing Home was carried out on Thursday 4th June 2009 between 11:00 am and 4:30 pm. The staff, the management and the people using the service were not informed of our visit and therefore it was unexpected. Ten people were consulted and some others were observed. Four relatives and five staff were spoken with. We sent out surveys to staff and multidisciplinary professionals seeking their views of the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and chatting with people using the service, the staff, the management and the visitors. We gave feedback throughout the day to the manager and the staff who participated in the inspection process so that they were able to take action or verify identified issues. The premise was inspected, which included bedrooms of the people using the service, the communal areas and the service areas such as the kitchen and the laundry. The outside areas surrounding the building were also checked. Thirty one people were using the service on the day of the site visit. Samples of individuals’ care plans, daily records; staff recruitment and training files were some of the records that we checked. We would like to thank the people who live at Broomgrove, their relatives, the staff and the management for their contribution towards this process. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 6 What the service does well: Broomgrove Nursing home provides sufficient information to people who may wish to use the service so that people were able to make an informed decision about the home. The health and personal care that people receive at the home was based on their individual needs. The principles of respect, dignity and privacy were put into practice by the staff and monitored by the management. The people who live in Broomgrove were able to make choices about their lifestyle, and were supported to maintain their life skills as much as they were able to. People who use the service were able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home were protected from abuse and their rights were protected by the management and the systems in place. The staff working at the home were trained, skilled and employed in sufficient numbers so that they were able to support the people who live at Broomgrove and contribute to the smooth running of the service. The management and administration of the home was based on openness and respect to those who use the service and those who work at the home. What has improved since the last inspection? The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. The ongoing refurbishment is set to improve the residents’ facilities and benefit the people who live at Broomgrove. The programme of renovation and refurbishment is well underway. This has included renovation of bedrooms and the kitchen. The quality audits by the manager have identified some room for improvement and the management were making arrangements to make changes. The identified changes should be actioned in a timely manner so that improvements could be realised by the service users and the staff working at the home. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 7 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. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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 Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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): 1,3&5 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. People who may wish to use the service have the information needed to make an informed decision about the home. EVIDENCE: We spoke with eight residents, two relatives, three staff and checked records relating to this outcome area. An updated brochure of the home was available for people. The manager informed us that the service user guide was to be updated as a result of the changes at the home. We checked five service user files to see whether people have had their needs assessed prior to being admitted to the home. All five people had assessments. They were by the placing authorities, or the residents who were self funding had assessments by the senior staff at the home. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 10 These were some of the comments we received. “I used to come here for respite and I know the staff so I chose to move in here.” “The needs were assessed by X health authority and we are very please Y was able to move to this home. Staff are very caring.” “I have recently moved in, since my family say that I am not safe at my home. The family visit me and its early days and if I like it here I will consider staying here permanently.” Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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&11 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 health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff and monitored by the management of the home. EVIDENCE: Five service users were consulted and their care plans were checked. Three staff were interviewed and three relatives were spoken with when checking this outcome area. The documentation needs to be updated to reflect the changing needs of the people living at the home. The peoples’ current objectives for health and personal care need to be clearly identified and the necessary action to be taken by the staff to achieve the expected outcome for individuals needs to be planned with the help of the individual and their families. These plans need to be documented on individuals’ files. The manager informed us that Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 12 they were looking into introducing Person Centred Care Pathway Programme to improve documentation and also to deal with the gaps in the current system. The nurse in charge of shifts with the help of the care staff promoted the health and social care for the people living at the home. During our visit we observed the staff and spoke with the people using the service about their views. These are some of our findings. The staff informed us that they had an adequate number of aids to help them deliver the care. They said that the people attended out patients appointments from the home and that they helped to organise transport and sometimes escort arrangements. We asked how many people had problems relating to tissue viability and infection control within the home. The manager said that two people had leg ulcers, one person had pressure sore and another had MRSA. We noted that these people were managed according to the national guidance on Tissue viability and Infection control. The staff had taken appropriate measures when treating these people and they seemed comfortable during our visit. A discussion took place with regards to the privacy and dignity of those who had aprons and gloves outside their bedrooms. We can confirm that staff must take universal precaution when delivering personal care and therefore protective clothing such as aprons and gloves must be kept in peoples’ own rooms. However if there was to be an outbreak of diseases e.g. Diarrhoea & Vomiting then the people and their visitors need to be informed and protective clothing and cleaning materials must be made available in the affected area of the home. Most people did not wish to self medicate and wanted the nurses to administer medication. The pharmacy audits had taken place and the nurses said that they follow-up improvements recommended by the pharmacist. The manager had identified further training for the staff at the home with regards to the management of medication and has organised this. Those who wished to manage their medication were monitored by staff to ensure the individual’s ability to manage their medicines safely. All five people we spoke with said that the staff were very polite and helpful. These were some comments. “The care staff are wonderful, they can’t do enough.” “I have seen other places but here the care is of a high standard and the carers make it possible.” “Sometime carers take a little while before returning to finish what they had started. They get called away and perhaps forget to get back and I have to buzz. Mostly carers are good I have no complaints.” “I see for some staff this is a vocation and they put their heart and soul into it. I sometimes see them get upset when the others don’t pull their weight. I get on with all the staff and they are always polite. I have no complaints.” Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 13 Care staff said that they have had training on End of Life Care and that the training had been useful. One person said that it was very upsetting when someone dies and more upsetting telling the residents. We noted that this had been raised at one of the staff meetings and the management were aware of this issue. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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. People who live in Broomgrove are able to make choices about their lifestyle, and are supported to maintain their life skills as much as they are able to. The arrangements for social, cultural and recreational activities needs to improve to enable people occupy their time usefully. EVIDENCE: The routines of daily living were flexible. Two people said that they could go to bed and get up when they like. We received the following comments in relation to activities organised at the home. “I choose when I want to take part in activities. I am very cautious and like to take my time joining in.” “It’s my choice that I like to read and I like my company. If I want, I suppose I can ask to join in activities.” Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 15 “It would be good if a variety of activities are made available. The activities should include what we individuals want and like; then more of us will join in.” An activities co-ordinator whose background in occupational therapy and a complementary therapist have been recruited in the last month to organise a varied range of activities and outings for the people. It is hoped that the people living at Broomgrove would benefit by their appointments. We witnessed visitors arriving at the home and spending time with their relatives/friends. We also noted the staff welcoming the visitors and helping them locate the service users if they were not in their rooms. We were informed by two service users that they handled their finances and their families helped them. The administrator informed us that the home was not appointee to any service user and that they helped some service users keep a small amount of money in the safe so that the people were able to pay for the day to day expense such as hair dressing, purchasing of magazines and news papers. On the day of our site visit the kitchen was shut down for refurbishment and a makeshift area to prepare breakfast, supper and snacks had been made available. The manager informed us that these arrangements had been agreed by the Environmental Health (EH) and Health & Safety (H&S) officers. The main meal of the day was prepared and transported from another service and the manager assured us that all arrangements were in compliance with the Food safety, EH and H& S standards. We noticed the kitchen staff checking the meals on delivery which included temperature checking. People said that they enjoyed their meals and they were aware of the temporary arrangements. The following are some of the comments we received. “Good food and plenty of it.” “We now seem to have a good variety. I enjoy the food here.” “We could do with fruit being available between meals. They can bring the bowl of fruit with biscuits when they bring drinks around.” “I am looking forward to the kitchen opening then I will be going to the dining room. I enjoy meeting the others at mealtime.” The people who needed special diets due to their conditions received appropriate diets. We witnessed the staff serving and helping people at mealtime. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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): 16,17&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. People who use the service are able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home are protected from abuse and their rights are protected by the management and the systems in place. EVIDENCE: We asked some service users and the staff whether they knew how to make their concerns known to the manager. All the people we spoke with knew that there was a procedure they could follow but told us that they preferred to speak to the staff on duty or speak to the manager if they had any issues. We witnessed some people sharing some issues with the manager and the senior staff. The manager had a record of formal complaints received by the home, the records of the investigation and action taken by the home as a result of the findings. The staff we spoke with have had training on Protection of Vulnerable Adults. Two staff were able to tell us the action they would take if they witness abuse of a resident. The management have been prompt in reporting any allegations of abuse to the appropriate authorities and have worked in partnership when Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 17 investigating the incidents. However there had not been any incidents of allegations of abuse reported in the last twelve months. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. The ongoing refurbishment is set to improve the residents’ facilities and benefit the people who live at Broomgrove. EVIDENCE: A programme of maintenance and refurbishment has been ongoing during the last year where some areas have been upgraded to offer better facilities for people. The kitchen is undergoing refurbishment. The garden area was kept safe, attractive and accessible to all the people living at Broomgrove. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 19 During our tour of the premise we noticed it was clean and free from offensive odours. We noted systems in place to control the spread of infection. Two staff were questioned how they promoted the control of infection within the home. These were their comments. That a) they had attended training and that they followed the policies. b) they washed hands between caring for residents. One person said, “This is very important. Hand washing.” c) they wore gloves and apron when they needed to and removed them as soon as they had completed the job, and disposed of them in the bins provided in the rooms. d) they made sure different colour coded bags were used for soiled, infected and dirty linen. All rooms had en-suit facilities and there was also a sluicing facility if it was needed. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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. The staff working at the home are trained, skilled and employed in sufficient numbers so that they are able to support the people who live at Broomgrove and contribute to the smooth running of the service. EVIDENCE: The staffing rotas were checked against the staff on duty. There was plenty of staff on duty on the day of our site visit. Due to the increased dependency levels of the people occupying the home the manager has increased the staff ratio and was also making arrangements to increase the number of nurses on duty during each shift. Three care staff were interviewed and they said that they had completed NVQ level 2 in care and one had completed NVQ level 3. Four staff files were checked and the home was fully compliant with the recruitment process. The manager checked the NMC PIN status of the nurses and kept records. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36&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 management and administration of the home is based on openness and respect to those who use the service and those who work at the home. The management have developed quality assurance systems and the staff are informed of the findings at the staff meeting so that they are made aware of the positive feedback as well as the areas for improvement. EVIDENCE: Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 22 The manager has clear lines of accountability within the home and with the Trust membership. Records were kept of the training and development events the registered manager and her senior staff had attended. The quality assurance system has been developed and the manager said that the following methods were used to check the quality of service in the last year. 1) Feedback from the annua,l service users and the staff surveys, 2) Issues raised in the minutes at the three monthly meetings of the service users and their relatives 3) Matters brought to the attention at the two monthly staff meetings. We had access to some of these documents. They were comprehensive and issues raised have been addressed in an objective manner. The manager outlined the following changes planned by them as a result of the feedback. These were some. • The staffing structure and their responsibilities were to be reviewed to promote efficiency. • The launch of the Named nurse & Key worker system was to give specific responsibilities so that the people would be informed of the nurse who was to be in charge of the individuals’ care and the care workers who would be allocated to them during their stay at the home. • Once Named Nurse system and team nursing is established staff supervision is to be organised within each team. • The building is to be divided into units to reflect the layout. There is thought to be two units, up and down stairs. • Each unit would be supported by a staff team. This is to improve team work, promote better communication between the staff and the people using the service. • Numbering of the rooms to be reorganised to make it user friendly and in compliance with the fire safety arrangements. The present arrangement is confusing. • Plans to introduce Care Pathways approach with Person centred care. This is to improve the present documentation and to develop a systematic approach to care planning and enable service users and their relatives’ involvement. We asked four staff whether they had regular supervision approximately 6 time a year with their line managers. They said that the nurses supervised them on a daily basis but were not aware of any other supervision. We were informed that all staff attended two day mandatory training and the records were kept of those who had attended and those who needed updates. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 23 We had access to recent regulation 26 provider monthly audit reports. The report was informative and focussed on all aspects of the service. Broomgrove Nursing & Convalescent Home DS0000021772.V375436.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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 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 X X x 2 x 2 Broomgrove Nursing & Convalescent Home DS0000021772.V375436.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15,13 Requirement Timescale for action 16/11/09 2. OP12 16(2)(m) &(n), 16(3) The service user plan must be comprehensive. It needs to reflect the peoples’ current objectives for health and personal care needs. There must be documentation outlining the actions to be taken by the staff to achieve the expected outcome for individuals. There needs to be documentary evidence that the care had been planned with the help of the individual and their families. The interests of people living at 16/11/09 the home must be recorded in their care plans. Opportunities for stimulation through leisure and recreational activities in and outside the home must be organised, which must reflect the needs, preferences and the capacity of those who reside at Broomgrove. Up to date information about the activities must be circulated to all people in the appropriate formats. Previous Requirement: 14/08/07 Two staff have been appointed in DS0000021772.V375436.R01.S.doc Version 5.2 Broomgrove Nursing & Convalescent Home Page 26 the last month. Little progress since the last Key Inspection. 3. OP19 16 The programme of renovation 14/08/09 and refurbishment must be followed through as planned which must include the renovation of the kitchen. Previous Requirement: 06/11/07 Work commenced end of May and expected to be completed by end of July 2009. The manager must continue the quality audits and draw up an action plan. The matters for change must be prioritised and addressed in a timely manner. The manager must ensure that all staff receive formal supervision at least 6 times a year. All staff must attend mandatory training at the correct intervals and be competent to promote health, safety and wellbeing at the work place. 29/09/09 4. OP33 26 5. OP36 18 29/09/09 6. OP38 12 &13 14/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. OP8 2. OP11 Refer to Standard Good Practice Recommendations To ensure that the privacy and dignity of those who need to be barrier nursed, the staff should keep the aprons and gloves inside the bedrooms near the sink and avoid using the corridor. The staff should have clear guidance on who should be letting other residents or the staff know about the death of service users. DS0000021772.V375436.R01.S.doc Version 5.2 Page 27 Broomgrove Nursing & Convalescent Home Care Quality Commission St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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