Inspection on 24/10/05 for Braemar Court

This inspection was carried out on 24th October 2005.

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 11/04/07

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 Susan McBriarty Unannounced Inspection 24th October 2005 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.V261123.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 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.V261123.R01.S.doc Version 5.0 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.V261123.R01.S.doc Version 5.0 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, 1 (one) may suffer from dementia. 7th June 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 require 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. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005-2006. During the inspection the manager and two residents were spoken with. A number of documents were sampled including risk assessments, care plans, contracts and pre-admission documents. What the service does well: 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. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 6 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.V261123.R01.S.doc Version 5.0 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The information provided by the home would enable a prospective resident and their family or representative to make a decision about moving in. EVIDENCE: Standard six (6) does not apply. The statement of purpose met the standard including identifying the level of dementia need the home is able to provide for. The residents of the home were all privately funded at the time of the inspection. The contracts provided offered clear information regarding the fee levels and the service the resident could expect from the home. The manager undertakes a basic assessment of need of all prospective residents and should they decide to move in a more detailed assessment begins and is documented and recorded in full. The home was able to evidence appropriate contact with specialist health professionals including the District Nursing services and the community mental health team. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 8 The Inspector spoke to residents who had recently moved to the home regarding their experience of the process. The Inspector was informed that although they did not access a trial visit prior to the move; the move went very well and they were very positive about how the home helped. In discussion with the manager, the information in the statement of purpose and the contracts the home does offer the opportunity for prospective residents to have a trial visit. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9 The home have a good regard for the health needs of the residents. A recommendation was made for the home to consider the use of photographs within the medication administration records. Standards 7,10 and 11 were assessed during the inspection of the 7th June 2005. EVIDENCE: As noted previously the Inspector was able to evidence the home’s contact with specialist health professionals to assist and or assess the specialist needs of specified residents. The Inspector sampled entries within a specified care plan that offered good detail regarding health provision to the specified resident. The home has a policy and procedure for the administration of medication including homey remedies. A copy of the homely remedies procedure had been forwarded to the General Practitioner services used by the home and had been signed as agreed by those doctors. The home has a stable staff team and they know the residents well, no errors were found by the inspector within the medication administration record. However it was recommended that the home consider the use of photographs of each resident within the medication records to further reduce the possibility of error. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 10 The home had made an application for variation and a certificate of registration had been completed at the time of the inspection. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of the 7th June 2005. EVIDENCE: Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of the 7th June 2005. EVIDENCE: The home had updated the policy and procedure regarding the protection of vulnerable adults as required at the inspection on the 7th June 2005. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of the 7th June 2005. EVIDENCE: The requirements made at the inspection of the 7th June had been met. The patio entrance now has a handrail and mobile step to assist residents to access the patio area. The garden had been risk assessed a bright blue rope with attachments hanging down has been placed across the area risk assessed. The thermostatic valves had been adjusted to ensure a more even temperature was provided for resident and staff use. The staff toilet had been provided with paper towels to reduce the risk of cross infection. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of the 7th June 2005. EVIDENCE: Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,38 The home has an appropriate business plan. Standards 31,32,33,35,36,37 and 38 were assessed during the inspection of the 7th June 2005. EVIDENCE: This is a small home that do not have a formal business plan, however the Inspector was able to sample the homes plans regarding repairs, refurbishments and other changes for the coming year. The insurance cover was up to date and a copy placed in the office area. The home had undertaken a quality assurance audit since the inspection on the 7th June 2005. The Inspector sampled the return questionnaires and found a number of very positive comments had been made regarding the service provided by the home. No complaints were noted within the samples. Although Standard 38 was not assessed during this inspection it was noted by the Inspector that a number of the homes policies and procedures had not Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 16 been updated to reflect the change for The National Care Standards Commission to the Commission for Social Care Inspection. A requirement was made that those policies and procedures be updated. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 17 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X X X 2 Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 18 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 38 Regulation 4,5 Requirement The registered person must ensure that the homes policies and procedures are updated to reflect the change from The National Care Standards Commission to the Commission for Social Care Inspection. Timescale for action 12/12/05 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 9 Good Practice Recommendations It is recommended that the home provide photographs of the residents for use with the medication administration records. Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Braemar Court DS0000013574.V261123.R01.S.doc Version 5.0 Page 20 - 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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