Inspection on 07/06/05 for Braemar Court

This inspection was carried out on 7th June 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 24/10/05

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 16 Sydney Court Guildford Surrey GU1 3LJ Lead Inspector Mrs Sue McBriarty Announced 7th June 2005 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 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 H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Braemar Court Address 16 Sydney Road Guildford Surrey GU1 3LJ 01483 502828 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) Dr Mazin Al-Nakeeb Mrs Hazel Al-Nakeeb Care Home 23 Category(ies) of DE(E) - Dementia over 65 (1) registration, with number of places OP - Old Age (23) Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 3. The age/age range of the persons to be accomodated will be : OVER 65 YEARS OF AGE 4. Of the 23 (twenty three) older people accomodated, 1 (one) may suffer from dementia Date of last inspection 20th October 2004 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 H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the first for 2005 – 2006. During this inspection eleven (11) residents, 2 staff members, one visiting professional and the manager were spoken to. A pre-inspection report had been provided by the manager and fourteen (14) comment cards had been received by the CSCI from residents and their families. A full tour of the building took place including the garden. The focus of this inspection was the experience of the residents. Documents were sampled during the inspection including kitchen records, policies and procedures and the most recent staff personnel file. 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 H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 8 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 standard(s) 7,10,11 The residents were treated with respect and dignity. A policy is in place for residents at the time of their death. EVIDENCE: All of the residents spoken to during this inspection spoke highly of the staff and how they were supported by them. All the comment cards received by the CSCI supported this. Both residents and family members felt that they could visit and be visited in private. All the rooms except two have en-suite bathrooms where residents who required assistance could be supported to wash and or bathe. A policy was in place to assist residents at the time of their death. Although the care plans of residents were not sampled discussion with the manager noted that a number of the residents needs are changing. It has been required that the home re-assess the current residents needs and consider whether they need to vary the current registration to increase the numbers of residents diagnosed with dementia. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 9 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 standard(s) 12, 13, 14, 15 Residents are able to exercise choice wherever possible and family members and friends can visit the home throughout the day. EVIDENCE: The service users spoken to during this inspection talked about the activities they took part in. These ranged from going into the local town centre, meeting family and friends or taking part in activities provided by the home. The home has a pet cat and most of the residents talked about the cat and how good it was to have a pet. Many were reminded of their own pets and enjoyed being able to pet and groom the cat. The home was able to take advantage of information provided by a local charity that provided boat trips. The boat was able to take people who were wheelchair users. Those residents who took part thoroughly enjoyed the day and were hopeful that another opportunity would be available. Many of those spoken to were from the local area and had maintained contact with family and friends and felt able to choose when they visited them or were visited. The manager stated that a neighbour had offered the use of their bench for residents to use on their way into town; a number of residents now Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 10 enjoy this facility on their was into Guildford town centre. The neighbours will be invited to the next party at the home as a thank you. Regular residents meetings were held to enable everyone to voice their views if they so wished. The pre-inspection report and the inspection evidenced a four-week rotating menu. The home uses fresh produce and much of the food is prepared on the premises. Lunch was sampled and was found to be hot, fresh and nutritious. A variety of fresh vegetables were seen during the inspection. Residents are able to choose where they eat within either in the dining area or in their own rooms. All the residents spoken regarding food stated that it was ‘very good’. One said that with so many people living in the home one person cannot always like everything and very occasionally found something they were not so pleased by. However a choice is available if the food on the menu is something a resident does not like. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 11 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 standard(s) 16, 17, 18 The home has a complaints procedure. Resident’s legal rights are protected. Some work is required regarding the home’s protection of vulnerable adults policy. EVIDENCE: The home had a complaints policy in place, the comment cards noted that a few people were unaware of the policy. However friends and family members also noted that they would discuss any concerns they had with the manager. No complaints had been received by the home or the CSCI during the last twelve months. During this inspection the manager stated that all of the residents electoral register cards are completed each year and that all of the residents had chosen to vote during this election year. The majority used postal voting. The home had a detailed policy to protect vulnerable adults from abuse. However the policy noted that on receipt of any allegation the home was to contact the CSCI. The local authority protection of adults from abuse policy states that any allegation must be discussed with the local social services or the police in the first instance. It was required that the home made this amendment to their current policy. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 12 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 standard(s) 19, 20 21, 22, 23, 24, 25, 26 The home provided adequate communal space for the residents. The bathing and toileting facilities were adequate. Some work is required within the staff toilet. EVIDENCE: The lounge area was comfortable and in use by a number of residents during this inspection. Suitable seating had been provided. Some of the furniture was ageing, however it remained serviceable. Throughout the home the areas were clean and fresh. One resident’s room had caused the manager some concern and this was discussed during the inspection. The manager had already considered ways of managing the concern and the CSCI will monitor progress. All but two of the resident’s rooms had an en-suite bathroom. Specialist equipment was in place following assessment for all those who needed it. Two Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 13 rooms within the home share a bathroom but do have en-suite toilet facilities. Where required raised toilet seats were in place. The majority of rooms were large some allowing space for a sofa. All the rooms had been personalised by the residents. Re-decoration of the rooms takes place when a resident moves out of the home. The communal areas were clean and airy. The lower ground staff toilet had liquid soap available. However a communal towel was in use. In order to reduce the possibility of cross infection it is required that paper towels be provided. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Qualifying training levels have been met and the home had training records available. Staff rosters were recorded and available to staff. The home has a recruitment procedure that meets the Care Homes Regulations (as amended) 2001. EVIDENCE: The pre-inspection report provided four (4) weeks roster as evidence of staffing levels provided. The home had three staff on duty each morning and afternoon and one staff member on duty overnight. The home had thirteen (13) care staff, seven of who had qualified to NVQ Level 2 or above. Three (3) ancillary staff are employed by the home to provide the cooking and or cleaning services. The personnel files seen and the pre-inspection report evidenced a range of training provided by the home to staff members. The staff file held a record of the training undertaken, the date and whether a certificate of training was held. The manager was fully aware of the amended recruitment requirements within The Care Homes Regulations (as amended) 2001 and supporting policies and procedures were in place and adhered to by the home. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 38 The manager is nurse qualified and has the Registered Managers Award. Further work is required in some areas and these are reflected in the requirements made. EVIDENCE: The manager is nurse qualified and in February 2005 completed the Registered Managers Award. Information given by the residents spoken to during this inspection evidenced that they felt able to discuss their views and needs with the manager. The relationships between staff and the manager were observed and were felt to be appropriate to the various roles, warm and open. The manager stated that previous inspections had asked the home to consider providing quality assurance audits regarding the home and that occasionally these had been completed. It is further required from this inspection that the home provide a regular format for assessing quality assurance. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 16 The home does not deal with resident’s money, however the manager was aware of particular issues and concerns and ensured that information was exchanged where necessary. Evidence of staff supervision was seen within the staff personnel file and the policies and procedures provided by the home. A format for supervision is provided for use and covered the areas noted within Standard 36.3. Some work is required to maintain safe working practices. The provision of paper towels in the staff toilets as noted previously. In addition it is required that further risk assessments be completed by the home. The home has a conservatory that leads out onto a patio area where residents may sit quietly in a shaded area of the garden. There was a step into the patio area and no handrails were evident. It is recommended that a risk assessment be completed to ensure safe access to any resident who wishes to use that area. As part of this inspection a tour of the garden took place. At the rear of the garden is a building that does not belong to the home. The boundary of the home was the walls of this building. In addition the shed belonging to the home is sited next to the same building. There was no fencing between the lawn area and either building. It is required that a risk assessment takes place to consider whether fencing is required to safeguard residents. The inspector was concerned that the hot water in one room was above the recommended limit. The manager stated that thermostatic valves had been fitted and temperatures were checked regularly. It is required that adjustment is made to ensure the recommended level of temperature. Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 3 3 x 3 3 3 2 Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 18 No 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 7 Regulation 15(1) Requirement The registered person must ensure that the current service users are re-assessed and if appropriate make application for a variation of registration to include additional service users diagnosed with dementia. The registered person must ensure that the policy regarding the protection of vulnerable adults from abuse is amended in line with the local authority protection of vulnerable adults policy. The registered person must ensure that the step into the patio area is risk assessed and any action required taken to ensure safe access for service users. The registered person must ensure that the garden area is risk assessed to ensure safe access by service users. The registered person must ensure that the thermostatic valves are adjusted as required and sample each hot tap regularly. The registered person must ensure that the communal towel Timescale for action 31st July 2005 2. 18 13(4)(c ) 30th June 2005 3. 19 23(2)(a) (n) 31st July 2005 4. 19 23(2)(a) (n) 13 (4)(a) 30th June 2005 30th June 2005 5. 25 6. 38 13(4)(c ) 30th June 2005 Page 19 Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 7. 33 24(1)(a) (b)(2)(3), 35 in the staff toilet is replaced by paper towels with an appropriate dispenser. It is required that the registered 31st person undertake regular quality August assurance audits with the service 2005 users and others as appropriate 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 Braemar Court H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 H58_s13574_Braemar Court_v224321_070605_stage4.doc Version 1.30 Page 21 - 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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