Inspection on 18/05/05 for Bracken Lodge

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bracken Lodge 03/09/07

Bracken Lodge 01/08/06

Bracken Lodge 07/10/05

Bracken Lodge 20/09/04

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Southfields

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bracken Lodge 155/157 Foxon Lane Caterham Surrey CR3 5SH Lead Inspector Joe Croft Unnnounced 18 May 2005, 10:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bracken Lodge Address 155/157 Foxon Lane Caterham Surrey CR3 5SH 01883 348961 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) A N J Coowar Ltd Abdulha Aziz Coowar Care Home 10 Category(ies) of LD Learning Disability, 18-65 years - 10 registration, with number of places Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of those to be accommodated will be 18-65 years. Date implemented: 11 March 2003 That the manager undertakes training leading to NVQ Level IV in management and care or equivalent. Date implemented: 11 March 2003 Date of last inspection 20 September 2004 Brief Description of the Service: Bracken Lodge is situated in a quiet residential area of Caterham, a short distance from the local shops and amenities. Care and accommodation is provided for up to 10 younger adults with learning disabilities. The bedroom accommodation is provided on the ground floor and first floor levels, and consists of one shared and eight single bedrooms. Bathroom and toilet facilities are provided on both floors. There is a medium size communal lounge and a smaller quiet lounge on the ground floor for the residents to use. The home has a large conservatory, which is used as a dining room and activities area. The property is two semi-detached houses that have been joined together. There is a large garden to the rear of the property. Car parking spaces are available to the front of the home. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours with one inspector. A tour of the premises was undertaken and staff and care records were sampled during the day. The registered manager was interviewed, and other staff were spoken with during the course of their duties. Six of the nine residents were spoken to during the day. Residents said they were happy living in the home, and that they liked the activities they do. All residents spoken to said that they attend day centres where they take part in lots of different activities, one resident proudly displays items of pottery he has made whilst attending the day centre. They said that they do different activities in the home, they help to prepare and cook the meals, do puzzles, art and craft, as well as going shopping, going to the cinema, and visiting clubs and restaurants. Residents stated bedrooms had their personal belongings such as televisions, stereos, pictures and family photographs. One resident stated that he was pleased with his bedroom because it had just been redecorated. Residents stated that they knew the staff, and liked them, that the food is good at meal times, and if you do not like a particular meal, you and/or the staff will always cook you a different meal. Residents said that they make choices regarding activities they want to do, places to visit and choose their own clothes. The home was subject to a complaints visit in January 2005. Copies of the report are available at the Commission For Social Care Inspection Surrey Local Office and at the home on request. What the service does well: What has improved since the last inspection? Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 6 More variety is offered in the menus. The kitchen floor has been replaced with a laminated floor. A survey had been used to elicit the views of the care the residents receive. These were also sent to the residents’ families and care managers. The registered manager submits Regulation 37 Notifications to the Commission For Social Care Inspection Surrey Local Office. 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. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 and 5 The home has an appropriate admission procedure in place that includes a needs assessment of potential residents, and offers the opportunity for visits to the home. Contracts were in place for residents whose files were inspected. EVIDENCE: The residents guide is currently being re-written using the Makaton signing symbols, this will make the document easier for residents to comprehend. The home has not had any new admissions since 1991. The home currently has one vacancy, and the admissions policy would be followed should a prospective resident be identified. The manager stated that care managers undertake pre-admission assessments, these were evidenced during the inspection. Prospective residents would be invited to visit the home and offered an overnight stay prior to moving into the home. The manager stated that a place would not be offered to a resident whose needs could not be met. Residents’ files sampled contained contracts between the home and the residents, which were signed by the care managers and the resident. However, the fees had recently been increased. The contracts must be reviewed to reflect this, and, contain the information as stated in National Minimum Standard 5.2. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 Systems for service user consultation were in place that indicated residents’ views are sought in relation to their needs and aspects of their lives in the home. Care plans and risk assessments require updating. EVIDENCE: All residents had a care plan in place and contained the necessary information on how the individual needs of the resident are to be met. The care plans are not reviewed every 6 months as required. Risk assessments are in the process of being updated and reviewed. The care files were in disarray, and must be better organised with an accurate index as to the contents. Residents spoken to did not understand the concept of the “Care Plan”. When asked about certain activities they choose to do, their response reflected the recordings in their care plans. Residents stated that they make choices about themselves, the activities they like to do and the food they would like to eat. One resident stated that he chose the colour for his bedroom. Staff stated that residents are involved in making decisions about their lives. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,14 and 17 Residents have access to the local community with staff support and attend day centres. The home offers appropriate leisure activities. Menus offer variety, and take into account the preferences and dietary needs of residents. EVIDENCE: Residents stated that they choose the activities they like to take part in, which include art, craft, cooking, puzzles, shopping and trips into the local community. On return from their day centres, residents were observed taking part in activities they had chosen. Staff stated that they support the residents to visit the local community and amenities. They go shopping, bowling, visit cinemas, restaurants and the local football club, which provides residents with opportunities to meet other people Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 11 from outside of the home. Residents spoken to stated that they liked to go shopping, bowling and to the club. Staff stated that residents are consulted about the menus. Residents confirmed that they help to choose the menus, and that they could have a different meal if they did not like that day’s meal. Residents were observed taking part in the cooking process. Residents stated that they have jobs in the home that they like to do. Menus were viewed and found to offer balanced and appetising meals. Inspection of the kitchen areas found food to be appropriately stored in cupboards, freezers and fridges. The home provides plenty of fresh fruit and vegetables. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 The home offered individual care to the residents. Resident’s views are taken into account when personal support is offered. No residents self medicate. The home had a system in place for the recording and administration of medicines. EVIDENCE: Staff stated that personal support is offered to residents who request it, and by staff of the same sex. Staff stated this is undertaken in a private and sensitive way to protect the dignity of the resident. Residents stated that they choose the clothes they want to wear each day. None of the residents self medicate. The home uses the blister packs and MAR sheets for the recording of medication. There was a book for recording medicines that was brought into the home, and another book that recorded unused or expired drugs that had been returned to the Pharmacy. Training records evidenced that members of staff responsible for administering medication had received the appropriate training. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home had a Complaints Policy and Procedure, and a leaflet for residents explaining what to do if they were unhappy. Residents are protected from abuse, neglect and self-harm by the home’s Protection of Vulnerable Adults Policy and Procedure. EVIDENCE: Staff stated that they had read the Complaints Policy and Procedure, and would take their complaints to the manager. If they were dissatisfied with the way a complaint was dealt with, or the complaint was about the manager or deputy manager, they would contact the Commission For Social Care Inspection. The Complaints Procedure and leaflet were evidenced during the inspection. These must be reviewed and updated to include the Commission For Social Care Inspection Surrey Local Office contact details. The home must produce a complaints leaflet in a format that the residents can easily read and understand. Residents stated that they would talk to the manager if they were unhappy. This was observed during the inspection, when one resident had upset another. This was handled and resolved in a sensitive manner. Staff stated that they were aware of protecting adults from abuse and had read the Protection of Vulnerable Adults Policy and Procedure. This policy was viewed during the inspection, and a requirement has been made for this to be reviewed in line with the Surrey Multi – Agency Protection of Vulnerable Adults guidelines. The last recorded training on the Protection of Vulnerable Adults Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 14 was May 2004. The acting manager must attend the Surrey Multi-Agency training on the Protection of Vulnerable Adults. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The general standard of the environment within this home is good, providing residents with an attractive and homely place to live. Bedrooms are personalised and privacy is maintained. EVIDENCE: Residents stated that they liked the home and they were able to have their own belongings in their bedroom. The redecoration programme of all bedrooms had commenced with the ground floor bedrooms. The manager stated that the decoration of the upstairs bedrooms would commence within the next month. The ground floor accommodation was nicely decorated and clutter free. It was pleasing to note that the kitchen floor had been replaced with a laminated floor since the last inspection. The home has sufficient toilets and bathrooms on each floor. Work is required on sealing some floors and bath edges. One bath has a bath lift, but none of the current residents need to use it. Residents are able to use the baths and toilets on their own and in private. One resident stated that he likes to have showers. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 16 The residents have unrestricted access to the lounges, dining room and garden. Residents were observed using all of the communal areas during the inspection. The home was clean, tidy and free from offensive odours. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34 and 36 The staff team in place offer consistency of care and support to residents within the home. Staff are clear about their roles. The home has a recruitment policy and procedure. EVIDENCE: Staff spoken to stated that they were clear about their roles and responsibilities, and enjoyed working in the home. Staff key work residents. The manager stated that key workers are currently being reviewed. The staff team consists of five full time and five part time staff. Recent training has included Protection of Vulnerable Adults, Health and Safety, Hygiene Awareness, Emergency Aid in the work place, working with Epilepsy, Pressure Care and the Control of Infection. However, mandatory training for all staff must be updated. The home has appointed a new manager who has many years experience of working in care homes, and is currently undergoing the NQV level 4 in care and the Registered Managers Award. The acting manager stated that the application for registration had been forwarded to the Commission For Social Care Inspection. One member of staff had almost completed the NVQ level 2 training, and one staff has the NVQ level 3 award. The certificate was Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 18 evidenced at the time of the inspection. The manager stated that five members of staff had commenced the NVQ level 2 training. The staff files sampled, with the exception of one, contained the necessary information as required, and in line with the homes’ recruitment policy. Of the five staff files sampled, one member of staff had no references. An immediate requirement was made. This member of staff must not be left unsupervised until all references have been received and authenticated. Care staff had not been receiving regular formal, recorded supervision. A requirement has been made. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Residents views are sought about the home. The health, safety and welfare of residents is promoted. EVIDENCE: Staff stated that residents have meetings where views about the home and their lives are sought. However, records of residents meetings were not available during the Inspection. The manager must ensure that records of residents meetings are maintained. Quality assurance questionnaires had been used for residents, their family members and other professionals. These were evidenced during the inspection. Water temperature records evidenced that they are tested twice a week. Records of all other appliance testing were evidenced during the inspection, with the exception of the boiler. The proprietor must arrange for this inspection to be carried out and a copy of the report to be sent to the Commission For Social Care Inspection Surrey Local Office. Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 2 2 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bracken Lodge Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? 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. 2. Standard 5 6 Regulation 5 (1) (b) (c) 15 (b) (c) Requirement Contracts must be reviewed and include all as stated in Standard 5.2 Residents Care Plans must be updated and reviewed every six months. This was a requirement from the previous inspection and must now be complied with. Risk assessments must be reviewed and regularly reviewed The Complaints Policy and Procedure must be reviewed and include the Commission For Social Care Inspection Surrey Local Office details. The home must produce the complaints leaflet in a format that residents can easily read and understand. The Protection of Vulnerable Adults Policy must be amended to bring it in line with local multi - agency procedures. The manager must attend the Surrey Multi-Agency training on the Protection of Vulnerable Adults. Mandatory training must be updated for all staff. Two written references must be obtained for all staff before Timescale for action 18/6/05 18/5/05 Immediate 3. 4. 9 22 13 (4) (a) (b) (c) 22 (7) (a) (b) 18/5/05 18/5/05 Immediate 5. 22 22 (2) 18/5/05 Immediate 18/5/05 Immediate 18/7/05 6. 23 13 (6) 7. 23 13 (6) 8. 9. 32 34 18 (1) 19 18/7/05 18/5/05 Immediate Page 22 Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 employment commences. 10. 11. 12. 36 39 42 18 (2) Formal supervision for care staff must take place 6 times a year 24 (10 (3) Residents meetings must be recorded 23 (2) (c ) The boiler must be serviced and the report submitted to the Commissioin For Social Care Inspection Surrey Local Office 18/5/05 Immediate 18/5/05 18/7/05 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 Good Practice Recommendations Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Eashing Surey GU7 2QN National Enquiry Line: 0845 015 0120 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 Bracken Lodge h58 h09 s13572 Bracken Lodge v 227465 180505 Stage 4.doc Version 1.30 Page 24 - 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. 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