Inspection on 11/04/07 for Braemar Court

This inspection was carried out on 11th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Braemar Court 24/10/05

Braemar Court 07/06/05

Braemar Court 20/10/04

Braemar Court 05/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Braemar Court Braemar Court 16 Sydney Road Guildford Surrey GU1 3LJ Lead Inspector Unannounced Inspection 11th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braemar Court Address Braemar Court 16 Sydney Road Guildford Surrey GU1 3LJ 01483 502828 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) Dr Mazin Al-Nakeeb Mrs Hazel Al-Nakeeb, Mrs Susan Al-Nasrawi, Mr Zaid Al-Nasrawi Mrs Hazel Al-Nakeeb Care Home 23 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (23) of places Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 23 (twenty three) older people accommodated, 6 (Six) may suffer from dementia. 24th October 2005 Date of last inspection Brief Description of the Service: Braemar Court provides residential care for up to twenty-three (23) older people. It is situated in a residential area close to Guildford town centre. Part of the house has been extended including the addition of conservatory to the rear. Accommodation is arranged over three floors that are accessible by stair lifts. Access to some bedrooms requires residents to be physically able to manage the stairs. The home has a large garden. Some parking is available to the rear of the house and restricted parking on the road. The fees for this service range from £375 to £540 per week. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 0945 and was in the service for four hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner and manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. What the service does well: The home has a stable staff team which and the manager stated that she has no need to use any agency staff. Service users were very complimentary about the quality of the food they received. On the day of the site visit one service user told us that curry was her favourite meal but another said she would not choose that but there was an alternative which she said she enjoyed. Comment cards returned to CSCI were also complimentary on service user saying ‘you never get the same thing two days running. It is always lovely and tasty’. From the evidence seen by us and comments received, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 7 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 Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment that is undertaken ensures that service users can be confident that their health care needs will be met. The home does not provide intermediate care. EVIDENCE: The registered manager stated that she carries out all pre-admission assessments prior to the service users moving into the home to ensure that their care needs can be met. We observed the assessments that had been completed which were all kept together in one folder. The manager said that care plans are generated from this assessment. The home does not provide intermediate care beds. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual plans, which reflect the care, and support they require and their health care needs are fully met. The medication policies and procedures that are in place and implemented by staff protects service users during this procedure and the privacy and dignity of the service users is respected. EVIDENCE: We looked at two individual plans of care and found that care plans, risk assessments, pre-admission assessments, daily notes and weights and nutritional screening are all kept together in different folders. The plans are not individual and when reviewing with service users and relatives it was difficult to gather all the information together. It is a recommendation at the end of the report that plans are made individual so there is one file per service user and when care plans are generated the home uses one problem per page to allow staff to update them easily. There was evidence that the plans had been reviewed every month and service users and their representatives had Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 10 been consulted. A comment card returned to us said ‘ I am impressed by the quality of care my father receives and the staff respect the individuals and their preferences’. The manager told us that she had good support from her local general practitioner (G.P.) who provided good healthcare for the service users. A comment returned to us from the G.P said ‘There is always excellent care of my patients. This is a place I would happily book myself into – a rare accolade I accord to very few’. The manager stated that the G.P. will visit whenever called. The home is supported by other health care professionals who visit the service users regularly and they are the district nurse, chiropodist, opticians, and dentist. Records sampled indicated that these visits were recorded and outcomes were noted and the manager said that this is then passed on to all staff verbally. Another comment card returned by a health care professional stated ‘ I have no hesitation in recommending this home’. The home has all of their medications delivered from a local pharmacy and that they use the monitored dose system for dispensing. Medication administration charts sampled showed no gaps or errors. The manager stated that all staff that administers the medicines has had training and we observed their certificate of attendance. The manager stated that the privacy and dignity of service users is maintained at all times. All the rooms are large en-suite for single occupancy except for a married couple that choose to share. Care is delivered in their own room or ensuite facility. The preferred name that service users wishes to be addressed by is documented in their notes. Staff were observed to knock on bedroom doors prior to entering. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities take place in the home and visitors are welcomed to the home to maintain contact with their family members. Service users can exercise control and choice over their lives. The food at the home was of a good standard and there was equipment available to service users to promote their independence and choice. EVIDENCE: The atmosphere at the home was calm and quiet with some service users sitting in the lounge and some remaining in their bedroom. The manager stated that the home does not have an activities organiser but she will arrange for activities to take place and the programme of events be displayed in the reception. The manager told us that this week there had been a slide show and one service user said ‘I really enjoyed that slide show it was better than the last one and I am looking forward to the man with the music this afternoon’. There is also an exercise class every week and Communion is held once a month and other religious denominations can be catered for. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 12 The manager stated access to the community is limited, as the service users prefer not to out on trips. Every year the home organises a day on the canal and the manager stated that feedback from this was positive. Visitors are welcomed to the home at any time with no restrictions and on the day of the site visit relatives were in and out of the home and all stopped to talk to the manager. Personal choice is encouraged at the home and during a tour of the building the inspector observed many bedrooms and they had all been personalised. One service user told us that she had recently purchased new furniture prior to coming to the home and was pleased that she could bring it with her. The managers said that one service user had now got their own advocate arranged through an external agency. The home employs a full time and weekend chef who cooks all the food. The comment cards received prior to the site visit were all complimentary about the quality of food provided. One service user stated ‘fresh produce is used and is of a good quality, nicely presented and good sized portions’ another said ‘good mother’s cooking’. On the day of the site visit curry was being served and one service user said ‘this is my favourite meal I love the curry here’. Another said ‘I don’t like curry but there is always a choice so it doesn’t matter’. Service users had access to a dining room and adapted cutlery was available to the service users that needed it which promoted their independence. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are protected by the homes complaints policies but the safeguarding procedures needs updating and training to take place to protect the service users from abuse. EVIDENCE: All service users and their representatives have a copy of the homes complaint policy and the manager said that she had not received any complaints since the last inspection. She keeps a complaints log and it was recommended that all complaints including verbal concerns are logged and outcomes clearly identified. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home has the local authorities safeguarding policy, which the manager stated the staff understand and follow these procedures. The copy that the home had was 2001 and this needs to update to the current policy for 2005. Following the visit to the service the manager has confirmed in writing that the updated version has been obtained. The manager stated that she has not had recent training in safeguarding procedures and her staff had not completed any mandatory training in these procedures and therefore this will be a requirement at the end of the report. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained environment, which was clean and hygienic. EVIDENCE: The service users all have large rooms and all but two have en-suite facilities. We observed that all bedrooms had been personalised and one service user told us ‘I had only just bought my three piece suite prior to moving in here but the manager said I could put it in my room’. The upper floors of the home can be accessed by a lift or a stair lift. Service users have access to the outside and the garden is kept safe and tidy by the owner, who is also responsible for the maintenance of the home. Communal space is available including a lounge, dining room and conservatory and on the day of the site visit all areas were being used. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 15 The laundry was large but very cluttered and it was recommended that this area be tidied as outside of the laundry door one service user sits to have a cigarette and the laundry was also used for the storage of all cleaning materials. This will be referred to under the outcome group for management. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff generally meets the needs of service users but an assessment needs to be made for the night shift to ensure the health and safety of service users at all times. Recruitment folders need to be checked to ensure all documentation is in place for staff to ensure that service users are adequately protected. EVIDENCE: The manager showed us the duty rota and stated that the home has adequate staff numbers with good skill mix to cover the home. There are waking night staff but due to the lay out of the home and number of service users it is a requirement at the end of the report for the manager to assess the night rota and the suitability of one member of staff for the shift supported by a sleeping member of staff. The manager stated that most of her staff has been employed for a long time and she has not needed to use agency staff for a number of years. The manager stated that the majority of staff has the national vocational qualification (NVQ) at level 2 and 3 and all are enrolled on a nationally recognised training programme. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 17 We sampled two recruitment folders but found that they were disorganised and it was therefore difficult to find all the documentation required. One criminal record bureau (CRB) could not be found for one member of staff during the site visit but the manager stated that this had been applied for and one of the owners confirmed this. Following the site visit to the service the manager has confirmed in writing that the CRB has been located. The manager stated that all staff receives regular training and some mandatory training takes place, which includes fire awareness and manual handling. There has been no recent training in safeguarding adults and this was mentioned earlier in the report and a requirement has been made. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a manager fit to do so and is operated in the best interests of the service users. The financial interests of service users are protected but some health and safety procedures need to be strengthened to protect service users from harm. EVIDENCE: The manager is the co-owner with her husband who was also at the home on the day of the site visit. The manager stated that she has her registered managers award and undertakes periodic training. The manager told us that the home has a quality assurance programme that seeks the views of the service users regularly. Survey forms are sent out and Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 19 the responses are acted upon. The manager also stated that regular service user meeting are held and these are documented which was shown to us. Again the manager stated that the opinions of the service users are acted upon. The home does not seek the opinion of any other stakeholder for example the G.P. or other visiting professionals to ensure that the some is achieving the goals for service users and this is recommended at the end of the report. The managers stated that no service user manages their own finances but the home provides a personal allowance account. All transactions are documented and individual records kept and all receipts are kept. All necessary health and safety checks have taken place and we looked at the records provided on the pre-inspections questionnaire and also spoke to one of the owners who are also responsible for the maintenance of the home. During a tour of the building we observed that all cleaning materials that could cause serious hazard to health (COSHH) was stored on an open shelf in the laundry. These chemicals should be in a locked cupboard and this is a requirement at the end of the report. It was stated by the manager that any service user wishing to smoke must do so outside of the laundry area. A risk assessment should be in place for any service user to ensure their health and safety and to ensure that the activity is free from avoidable risks to their health and other service users and staff. This is a requirement at the end of the report. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 16(6) Timescale for action All staff at the home must access 11/05/07 training in safeguarding adults to ensure that service users are protected from abuse. The manager is to look at the 11/05/07 staff night rota and ensure that the home has adequate numbers of staff on duty at night for the health and welfare of service users. All chemicals should be placed in 11/05/07 a locked cupboard to ensure that all parts of the home which service users may have access are free from avoidable risks. Robust risk assessments must be 11/05/07 in place for any service user that uses the laundry area to smoke. The practice of smoking in the area outside the laundry must be subject to a risk assessment to ensure that the risk to the individual and others are reduced as far as possible. Requirement 2 OP27 18(1)(a) 3 OP38 13(4)(a) 4 OP38 13(4)(b) Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 22 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 2 3 4 5 Refer to Standard OP7 OP7 OP16 OP19 OP33 Good Practice Recommendations It is recommended that each service user have their own individual plans of care instead of the information for service users kept in different folders. It is recommended that all care plans generated for service users has one problem per care plan to make sure that it can be read and updated easily. It is recommended that verbal complaints are logged and outcomes clearly identified. It is recommended that all recruitment folders should be organised to ensure they contain all the information that is required. It is recommended that the home seek the views of other stakeholders including visiting professionals to ensure the home is achieving goals for service users. Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Burgner House, 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Braemar Court DS0000013574.V333116.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!