Inspection on 07/10/05 for Bracken Lodge

This inspection was carried out on 7th October 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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bracken Lodge 03/09/07

Bracken Lodge 01/08/06

Bracken Lodge 18/05/05

Bracken Lodge 20/09/04

Similar services:

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Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

Dovedale Court

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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 Bracken Lodge 155/157 Foxon Lane Caterham Surrey CR3 5SH Lead Inspector Joseph Croft Unannounced Inspection 7th October 2005 10:00 Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 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 Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 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 Adults 18-65. 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. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bracken Lodge Address Bracken Lodge 155/157 Foxon Lane Caterham Surrey CR3 5SH 01883 348961 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) A N J Coowar Limited Mr Abdulha Aziz Coowar Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of those to be accommodated will be 18 - 65 years. That the manager undertakes training leading to NVQ level IV in management and care or equivalent. 18 May 2005 Date of last inspection 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 ten 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 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 facilities are available to the front of the home. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year 2005 – 2006. It will be necessary to view both inspection reports for 2005 – 2006 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adults. One inspector undertook this unannounced inspection on the 7th October 2005. The duration of the inspection was four hours. As part of the inspection process in depth discussion took place with the registered person and two members of staff were formally interviewed. At the time of the inspection there were only four residents present in the home. The understanding and communication level of residents at this home is very low, and only one resident, on this occasion, was able to communicate with the inspector. The inspection included sampling of policies, procedures, records, care plans, health care records, statutory records, duty rota and training records. Staff were observed to be interacting with the residents in a positive manner and supporting residents with the choice of activity they wished to do. The resident spoken to stated he was happy living at the home, liked his bedroom and that his friend, who is a policeman, can visit him. The resident showed the inspector his bedroom, which had photographs of his friends, and his collection of radios. During discussion the resident stated he likes the food, and he can choose to eat his meals in his bedroom. This resident also stated that he chose not to attend his day centre today, a decision that was respected by staff. Staff were open and honest during discussions, and are aware of the residents care plans and their health needs. Four immediate requirements and eight requirements were made during this inspection. What the service does well: The home continues to be clean, tidy and free from offensive odours. Residents are supported to maintain contact with family, relatives and significant others. Staff promote the rights of residents and respect their privacy. Residents’ health care is monitored and visits by health care professionals are clearly recorded. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 9 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 the following standard(s): EVIDENCE: These key Standards were assessed at the previous inspection. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 10 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 the following standard(s): EVIDENCE: These key Standards were assessed at the previous inspection. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 15 and 16 Residents maintain contact with family, relatives and significant others, and their rights, privacy and responsibilities are taken into account in their daily lives. EVIDENCE: The registered person stated that residents’ family and friends are encouraged to visit the home. The registered person stated that the majority of residents’ parents are now elderly, and therefore not able to visit as often and they used to. When appropriate, staff working at the home use the home’s transport to take residents to visit their parents. This was confirmed during discussions with staff. Four residents have no family contact. The registered provider stated that staff are working with care managers to establish contact with an advocate agency. Residents are able to meet in private with their family and friends in their bedrooms. Family and friends are allowed to join residents for meals if they and the residents agree. The registered person stated that family and friends are invited to barbeques, birthday parties and seasonal activities held in the home. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 12 The registered person stated that residents have opportunities to meet other people and make friends outside of the home through attending day centres and a local football social club. This was confirmed during discussions with staff. One resident spoken to stated that he enjoys attending the social club, but does not always attend the day centre. This resident has made friends with a police officer from the Surrey Constabulary who regularly visits. The resident proudly displays photographs of his friend on his bedroom wall. Staff stated that residents are encouraged to make friends, and would support residents who develop relationships with other people. The registered person stated that matters in regard to sexual awareness are covered in topics at the day centres, and in the home as and when they arise. Residents were observed to have unrestricted access to the communal parts of the home, including the garden. The resident spoken to stated that residents are not allowed to wander into other people’s bedrooms without their permission. He also stated that staff knock on bedroom doors and wait to be invited in. The registered person stated that residents help with daily tasks around the home, which include cooking, laying and clearing tables, and cleaning their bedrooms. During discussions staff stated that residents are encouraged to help each other, clean their bedrooms and help with daily living tasks around the home. The registered person stated that residents do not have keys to their bedrooms through their own choice. A requirement has been made that it must be recorded in care plans that residents choose not to have a key for their bedrooms. Staff and the residents spoken to state they address each other by their first names. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19 The home has regard for ensuring that residents’ health care is monitored and visits by health care professionals are recorded. EVIDENCE: Residents’ care plans sampled evidenced that the home maintains clear records of health care needs, and clearly records appointments with the GP, dentist, chiropodist, optician and other health care professionals. Refusals to see a health care professional are recorded in residents’ care plans. The registered person stated that the GP, dentist, district nurse and chiropodist visit the home and see residents in the privacy of their bedrooms. Any treatment required is conducted at the appropriate surgeries. Each resident has a medical profile and written risk assessments relating to health care needs. These were sampled and evidence of regular reviewing was being undertaken. It was noted that one resident takes medication to a day centre. There was not a written risk assessment in place for this. Discussions took place with the registered person in regard to this. A requirement has been made that the registered person must write a risk assessment for this. Residents’ weights were recorded each month in care plans. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 14 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 the following standard(s): EVIDENCE: These key Standards were assessed at the previous inspection. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These key Standards were assessed at the previous inspection. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 16 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 The home must address certain staffing issues in order to meet the residents’ needs effectively. EVIDENCE: Staffing at the home includes the registered person, four full time care staff and four students. At the time of the inspection it was evidenced that the registered person had overseas students working more than twenty hours per week. An immediate requirement was made that students must not work more than twenty hours a week, and the registered person must forward a copy of the staffing arrangements for the home to the Commission For Social Care Inspection Surrey Local Office. Three staff have the NVQ level 2, and one staff member is due to commence the NVQ level 3 in January 2006. Training records sampled evidenced that only one member of staff has recently attended training on the Protection of Vulnerable Adults. A requirement has been made that all staff must receive training on the Protection of Vulnerable Adults. The home does not have a training and development plan. A requirement has been made in regard this. The registered person stated that new staff undergo a one-month inductiontraining period. Evidence of the induction-training programme was observed by the inspector, and was found to include a tour of the buildings, information Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 17 and training on policies and procedures, confidentiality, supervision and care plans. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 and 43 The home has regard for the health, safety and welfare of residents; however, staff must receive updated mandatory training. The home does not have a registered manager and is therefore operating illegally. EVIDENCE: Staff training files evidenced that mandatory training was in need of updating for all staff. This was a requirement from the previous inspection and must be complied with. The registered person stated that he had been trying to arrange dates for the mandatory training with the National Consortium of Colleges. This was evidenced during a telephone conversation with a representative from the College. A requirement has been made that the registered person must submit dates for this training to the Commission For Social Care Inspection Surrey Local Office. The registered person ensures that the health and safety of residents and staff are maintained through the annual servicing of appliances in the home. The fire alarm system and fire extinguishers were serviced on the 6th July 2005; Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 19 Fire risk assessments were evidenced, and dated 24th January 2005. The Surrey Fire and Rescue inspection was conducted on the 24th January 2005, but the registered person could not locate the report. A requirement has been made that a copy of this report must be submitted to the Commission For Social Care Inspection Surrey Local Office. Evidence of weekly fire tests was observed; the last fire drill took place on the 16th July 2005. The registered person stated that the boiler had been serviced, but could not locate the report. A requirement has been made that a copy of the certificate is submitted to the Commission For Social Care Inspection Surrey Local Office. The portable electrical appliances were tested on the 6th September 2005 and the gas installations on the 1st July 2005. Evidence of weekly recordings of the water temperatures was viewed. It was noted that the last test for Legionella was on the 16th December 2003, and the home does not have a written risk assessment regarding the prevention of Legionella. It is important that this area is addressed. A requirement regarding this has been made. Fridge/freezer temperatures are recorded on a daily basis. The home submits Regulation 37 notices within the given timescales. The home’s acting manager has left the home since the previous inspection, and therefore the registered person has resumed his role as the registered manager. The registered person stated that he does not want to manage the home, and that he is in the process of recruiting a manager. A requirement has been made that an action plan with timescales for recruiting a manager must be forwarded to the Commission For Social Care Inspection Surrey Local Office. Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bracken Lodge Score X 2 X x Standard No 37 38 39 40 41 42 43 Score X X X X X 2 2 DS0000013572.V250355.R01.S.doc Version 5.0 Page 21 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 Standard YA16 Regulation 12 (4) (a) Requirement Timescale for action 07/11/05 2 YA19 12 (1) 13 (4) (c) 18 3 YA33 4 YA33 18 (1) (a) The reason why residents do not have keys for their bedrooms must be recorded in their care plans. The registered person must write 14/10/05 a risk assessment for the resident who takes his medication to the day centre. The registered person must 07/10/05 ensure that students do not work more than twenty hours per week. The registered person must 07/10/05 submit a copy of the staffing arrangements for the home to the Commission For Social Care Inspection Surrey Local Office. The registered person must ensure staff receive updated training on the Protection of Vulnerable Adults. The registered person must produce a training and development plan for staff. The registered person must forward a copy of the Surrey Fire and Rescue Inspection report to the Commission For Social Care Inspection Surrey Local Office. DS0000013572.V250355.R01.S.doc 5 YA35 13 (6) 07/11/05 6 7 YA35 YA42 18 (1) (C) 23 (4) 07/11/05 07/11/05 Bracken Lodge Version 5.0 Page 22 8 9 10 YA42 YA42 YA42 18 (1) (c) 13 (4) (C) 13 (3) 11 YA42 25 (2) (e) 12 YA43 8 (1) (a) The registered person must provide staff with up to date mandatory training. The registered person must arrange to have the water system tested for Legionella. The registered person must forward a copy of the service certificate for the boiler to the Commission For Social Care Inspection Surrey Local Office. The registered person must forward a copy of the Employers Liability insurance to the Commission For Social Inspection Surrey Local Office. The registered person must submit an action plan with timescales for the recruitment of a manager, to the Commission For Social Care Inspection Surrey Local Office, in accordance with Section 11 of The Care Standards Act 2000. 07/11/05 07/11/05 14/10/05 07/10/05 07/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bracken Lodge DS0000013572.V250355.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey 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. 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