Inspection on 29/02/08 for Braemar Lodge Residential Home

This inspection was carried out on 29th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Braemar Lodge Residential Home 06/01/09

Braemar Lodge Residential Home 04/10/06

Braemar Lodge Residential Home 07/12/05

Braemar Lodge Residential Home 26/04/05

Braemar Lodge Residential Home 31/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Braemar Lodge Residential Home 481 Victoria Avenue Southend On Sea Essex SS2 6NL Lead Inspector Pauline Marshall Unannounced Inspection 29th February 2008 08:40 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 Lodge Residential Home DS0000059881.V358986.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 Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braemar Lodge Residential Home Address 481 Victoria Avenue Southend On Sea Essex SS2 6NL 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) 01702 339728 Mrs Saima Munir Raja Mrs Saima Munir Raja Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (12) of places Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To review and ensure that appropriate levels of all staff in sufficient numbers are employed within the home day and night for the care, safety and wellbeing of service users. This includes senior care staff, care staff and support staff. Timescale = within 28 days of registration To ensure that the surrounding areas are made secure to ensure the safety and wellbeing of service users Timescale = within 28 days of registration Timescale = within 28 days of registration Date of last inspection 4th October 2006 2. Brief Description of the Service: Braemar Lodge is registered to provide care and accommodation for twelve persons over 65 years of whom some may have dementia. The home currently offers day care services for up to four people from Monday to Friday. The premises provide homely, comfortable and adequate space. There is a choice of communal areas including lounge, dining room and conservatory. There are six single and three shared rooms on the ground and first floor. Access to the first floor is via a passenger lift. The second floor is for staff use only. There is a pleasant and secure garden and off road parking. Braemar Lodge is in keeping with houses in the vicinity. It is situated in close proximity to the Priory Park and is close to local community facilities and services. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £1687.00 to £1950.00 per calendar month and there are additional charges for hairdressing, chiropodist, taxis, toiletries and newspapers. There is a flat rate charge of £42.50 per day for day care services. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection that lasted for eight hours and ten minutes. The process included discussions with the owner, acting manager, staff, people who live at the home and one of their relatives. A random sample of policies, procedures, safety records, staff and residents’ files were examined and a tour of the premises took place. The manager completed and returned the homes annual quality assurance assessment (AQAA) and this has been used throughout the report. Surveys were sent to people living in the home, their relatives, health and social care professionals associated with the home and staff that work there to obtain their views on the service the home provides. The response was positive and comments from these surveys have been used throughout the report. All of the key standards were inspected. What the service does well: What has improved since the last inspection? The acting manager has developed the care plans to include more detailed information on the level of help that people need, the development is ongoing and further improvements are being made to ensure that staff know exactly what help to give to people. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 6 The owner is the registered manager; there is a new acting manager who intends to apply for registration. The new acting manager has ten years experience working in Braemar Lodge. People living in the home and their relatives say that the level of activities provided by the home has improved and that they are happy with this. What they could do better: Care plans could be developed further to ensure that any health needs are current. There must be clear guidelines to staff for the use of as and when prescribed (PRN) medications. The outcomes of any complaints must be fully recorded and the abuse policy must include the actions staff has to take if they suspect abuse. Repairs to the home must be carried out without delay; one toilet door would not shut and another had no lock on it. The second assisted bath must be repaired or replaced so that there are adequate bathing facilities for people to use. People must be assessed for the use of aids and adaptions that are used in the home; the toilet raiser and rail in the downstairs toilet may not be suitable for everyone using them. To minimise the risk of infection paper towels and liquid soap must be used in all communal areas of the home. Additional staffing could be employed throughout the weekdays when there are up to four people in the home for day care. The four staff on duty includes the person in charge and care staff are responsible for the cleaning and the cooking throughout the weekdays and this leaves minimal staff on the morning shift to assist people living in the home and attending for day care. The owner and acting manager must make sure that they have a full employment history for all the staff they employ and they must take up two written references and carry out criminal records bureau checks (including POVA 1st if starting work before the CRB is received). There must also be evidence of staffs’ fitness to work on each of their files. Supervision should be carried out at least six times a year. Regular fire drills must take place and the outcomes recorded to ensure that staff and residents know what actions to take in the event of a fire. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 7 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 Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 8 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 Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 9 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): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to receive up to date accurate information about the home and they will be provided with a thorough assessment of their needs prior to moving in. EVIDENCE: The owner last updated the homes Statement of Purpose and Service User Guide in September 2007. There have been some changes to the management structure since then and both documents require updating to include the recent changes. The owner said that all prospective residents are provided with a welcome pack that includes copies of the homes Statement of Purpose and Service User Guide. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 10 Either the owner or the acting manager carries out a full assessment prior to admission and each of the three care files that were examined contained a full pre-admission assessment. The acting manager said that the initial assessment informs the care plan and that people are admitted on a month’s trial before a permanent residency is offered or taken up. People who use the service were spoken with and they confirmed that they were able to visit the home and decide if they liked it before moving in. Relatives of people living in the home said that assessment took place and that their relative had ample opportunity to test out the services offered by Braemar Lodge. Braemar Lodge does not provide intermediate care. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst people can generally expect their care plans to meet their assessed needs, there are some shortfalls with regard to the level of assistance required. People can be confident that they will be treated with dignity and respect. The lack of guidance on the administration of as and when required medication does not fully protect people; the medication is generally well managed in all other aspects. EVIDENCE: Three care files were examined and each contained copies of each person’s personal details, their initial assessment, their current medication and any possible side effects, risk assessments, weight, fluid and bath charts, records of health appointments and the daily notes. Each of the care files examined had been reviewed on a monthly basis. The acting manager has recently reviewed the homes care plan documentation and they now contain much Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 12 more detail of the level of care people need, however the three care files examined varied in the amount of detail provided. The care plan documentation has provision for the resident and their relative or advocate to sign to confirm their agreement of the plan, however the three care files examined were unsigned. Relatives said in their surveys “care and medical plans are drawn up regularly, discussed and signed off”. These issues were discussed with the acting manager and she said that she intends to amend the care files that have shortfalls. The owner said in her annual quality assurance assessment (AQAA) that residents and relatives approve care plans and that they are now more in depth and improved. Each of the three care files examined contained some details of health appointments including optical and chiropody. One entry for chiropody did not provide any details of the care provided and the care plan stated that this person should see the chiropodist every six weeks, however they had two visits recorded in the last year. The acting manager said that the person had not required chiropody care as frequently as was first thought. All other health care appointments were recorded and the daily care notes contained details of any further actions needed. Residents and their relatives spoken with said, “we get good health care and the doctor is called when needed”. Three medication administration sheets (MARS) were examined and the medication count agreed with the amounts on the medication sheets. There was as and when prescribed medication (PRN) entered on the medication administration sheets but there were no protocols for its use. People living at the home said that they felt well treated and that staff were always respectful and courteous when helping them. Relatives spoken with said, “I am always made welcome and am offered a cup of tea and my relative is always treated with respect and dignity”. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 13 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. People can expect to be offered a range of activities both in the home and out in the local community. People can expect to receive a good wholesome diet. EVIDENCE: The acting manager said that people attend the local church social club and that the home offers people indoor activities in the winter and more outside opportunities in the warmer weather. Staff was observed interacting with residents throughout the inspection and people were singing, laughing and talking with each other throughout the day. People living in the home spoken with said “we get on with each other and its good to see our friends that live outside the home” and “ there is plenty to do, we have quizzes, play bingo, watch TV, have a cinema night and if I want more I can ask and I will get it”. The owner said that she takes residents out to the seafront in the summer. Relatives surveyed said “the staff organise a birthday party every year and we as a family are always welcome”. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 14 Relatives spoken with said that they are involved in their relatives care and that they are invited to attend residents meetings if they wanted to. People living in the home said “we have meetings to decide what we want to do and eat” and “I choose things every day and make up my own mind”. Relatives said in their surveys that “the home tries to make it as near to the residents home as possible and my relative is looked after 100 and is always well dressed”. The atmosphere in the home was very relaxed and homely and people spoken with said they enjoyed their mealtimes and had a good choice of food. The home operates a four-week rolling menu that offers a range of breakfast options and a daily choice of two main meals. People said that in addition to their meals there was plenty of home made cakes, biscuits and fruit on offer should they get peckish in between meals. Relatives said in their surveys that “the food appears to be very good home cooking and not much goes to waste”. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 15 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. People can be confident that their complaints will be dealt with effectively. Whilst staff are aware of abuse procedures the homes policy does not include enough detail to ensure that people are fully protected from abuse. EVIDENCE: The complaints policy was last reviewed in March 2007 and requires amendment to reflect the new CSCI details. People living in the home and their relatives were spoken with and said that they knew how to complain or to raise any concerns and that “the home always listens and act immediately when concerns are raised”. The homes complaints book had a copy of one complaint and the owners response stapled to it but there was no details of any outcome or if the complainant was satisfied that the complaint had been dealt with appropriately. The acting manager said that this had been followed up by a telephone call and that the complainant was satisfied. There has been one safeguarding issue since the last inspection and it was dealt with appropriately. The homes adult safeguarding (POVA) procedure covers the signs of abuse and the different ways in which vulnerable people can be at risk of abuse but does not provide staff with adequate information of the correct actions to take. Staff spoken with was aware of the need to stop Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 16 any abuse and report to their manager but were not aware of what further actions were to be taken. The owner said that all staff have received adult safeguarding training and that they were due to be updated in March 2008 and that the policy and procedure would be amended to include the need to report any suspected abuse to the Local Authority. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 17 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, 21, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home was clean and fresh the need to carry out essential repairs and the replacement of bathing facilities impacts on peoples safety and comfort. Inadequate hand washing materials potentially places people at risk of infection. EVIDENCE: There are two assisted baths in the home but the downstairs bathroom and toilet had an out of order notice pinned on the door; the acting manager said that this has been out of use for some time due to the chemical toilet being broken. There was a fold up bed stored in this bathroom. The acting manager said that this bathroom was due to be replaced in 2008 and that a walk in shower room was planned. The downstairs toilet door would not shut properly; the acting manager said that a handyman is in the process of being Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 18 employed and that repairs to the door will be made as soon as he starts work. One of the toilets had no lock on the door. All bedrooms were personalised and included many small items of peoples own furniture; people spoken with said that they were able to bring small personal items of furniture with them when they moved in. There was screening in place in all of the shared rooms and each room contained emergency call buttons. One room had a pull cord attached to the call system and this was laid near to the residents’ bed; no other rooms had pull cords attached to the call bell system. The acting manager said that this was because all other residents were able to reach the call buttons with no difficulty. All residents currently use the upstairs assisted bath due to the downstairs bathroom being out of use; people spoken with said that they were quite happy using the upstairs bath. One of the upstairs toilets contained a terry towel and there was no liquid soap provided for hand washing. The acting manager said that staff mainly used this toilet; the door was stiff and unable to be fully closed. Some of the homes radiator covers were left off by the workman whilst they were in the process of repairing the gas central heating system; one radiator cover was damaged and found hanging away from the wall and is in need of repair or replacement. The owner said in her annual quality assurance assessment (AQAA) that “we observe the environment and complete a weekly checklist” and rooms are cleaned and redecorated when they become vacant”. The furniture is of a reasonable quality and the home is well decorated and people living in the home said that they liked the decoration and its homely feel. Relatives surveyed said “we are extremely pleased and Braemar Lodge staff ensure it is a happy and safe environment for all residents”. The home employs a cleaner every Saturday morning and care staff maintains cleanliness at all other times. There was a lack of paper towels and liquid soap in all of the communal bathrooms and toilets and each of the rooms contained a cotton towel for hand drying. The downstairs toilet had a toilet raiser and handrail in it that has been there for some time. The owner said that none of the current residents have been assessed for these and that she had removed them once and residents had requested their return. The home was generally clean and fresh. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. Although adequate staffing levels are being maintained for the people living in the home there is not sufficient staff to meet the needs of the additional four people attending the home for day care. The recruitment practices have major shortfalls and put people at risk. Staff training is appropriate. EVIDENCE: There were four staff on duty in the morning and three in the afternoon; one of the morning staff works in the kitchen preparing lunch. The acting manager said that a cleaner is employed to work on a Saturday morning and that care staff cleans the home at all other times. The acting manager said that there were four people in the home for day care on the day of the inspection; there was no additional staff rotered to accommodate the extra care needs. Staff were observed interacting with residents throughout the inspection and people spoken with said they were happy with the levels of staffing and that “there is always someone there when you need them”. Relatives’ surveys said, “staff are very good with the residents and have the right skills and give good care”. The owner said in her annual quality assurance assessment (AQAA) that all staff have induction and understand their duties and that the staff dynamics works well. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 20 Of the thirteen staff employed at Braemar Lodge six have achieved NVQ level 2 or above and a further four are working towards it. The acting manager said that she holds an NVQ level 3 qualification and plans to undertake the registered managers award in 2008. The owner has completed her NVQ 4 in care and the registered managers award and is currently the registered manager for Braemar Lodge. Three staff files were examined and one contained all the relevant documentation with the exception of a photograph. One staff file contained an application form that did not have a full employment history, one written reference, no evidence of a POVA 1st check and a criminal records bureau check dated two months after the employee started work. The third staff file examined did not contain an application form; any written references and no evidence of a POVA 1st check being carried out. None of the staff files examined contained a photograph of the staff member or evidence of staff fitness to work. The acting manager said that the results of the POVA 1st checks are given to the home over the telephone and that she had not recorded the time and date of the calls but would do so in future. The owner states in her annual quality assurance assessment (AQAA) that all people who have worked at the home in the last 12 months have had satisfactory preemployment checks. There was some evidence of staff training on all of the staff files examined; the acting manager said that staff generally kept their certificates of attendance at training and would normally provide the office with a copy for the staff file. The owner states in her annual quality assurance assessment (AQAA) that all staff are trained and that the home has internal training sessions. The owner said that internal training in all of the mandatory subjects takes place annually and updates are due in March 2008 and she would forward the CSCI a copy of the matrix that covered the subjects and the names of staff that attended the training that had taken place in 2007. The owner said that more specialised training is organised for staff with outside trainers such as the Local Authority. Staff spoken with said they were happy with the level of training and that the NVQ had helped them in their role. Relatives surveyed commented on staff skills and experience and said that they felt staff was well trained. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 21 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, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people can expect to live in a safe well managed home that is run in their best interests; the managements’ recruitment practice and lack of staff supervision could potentially put people at risk. EVIDENCE: The registered manager is also the owner of Braemar Lodge and has more than eight years experience within the private care sector and is qualified to NVQ level 4 in care and holds the registered managers award. The acting manager has worked at Braemar Lodge for ten years and has held the acting manager post for the last three months and has an NVQ level 3 in care qualification. The acting manager said that she intends to apply to the CSCI Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 22 for registration as manager in the next few weeks and that she is “picking up from the previous acting manager”. The recruitment practice detailed in the previous section of this report is of concern as it was a requirement made at the last key inspection. Staff and residents spoken with were confident in the acting managers ability to manage the home appropriately. The owner completed the homes annual quality assurance assessment (AQAA) and provided the information that was required. The owner said that regular questionnaires are sent to residents and their relatives and that residents and staff meetings are held regularly to obtain peoples views and that actions are taken to address any identified issues. Three residents cash transaction records and the monies held by the home were checked and were all found correct. People living at the home and their relatives that were spoken with said that the home holds small amounts of cash for them and they are aware of the way it is held and the transactions are recorded. Three staff files were examined; two did not contain any evidence of supervision having taken place, the third contained one supervision that had been carried out in a six-month period. There was evidence on one of the staff files examined that appraisal had taken place. Staff spoken with confirmed that informal supervision takes place regularly but formal supervision is infrequent. The homes gas, electric, water, bath lifts, passenger lift and employers liability certificates were in place and up to date. There was evidence that all equipment has been regularly serviced. A new fire escape has been fitted and the fire inspector visited the home to carry out a fire inspection on 18/02/08. The acting manager said that regular fire drills are carried out but she could not locate the records and that the fire inspector had inspected them. The acting manager said that she would forward a copy of the fire inspectors report to the CSCI when she receives it. Staff spoken with said that they had received training in health and safety matters and that it was included in the induction process. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X 2 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 (1) Requirement The care plan must include any relevant up to date health care needs and must contain enough detail for staff to provide residents with the appropriate level of assistance. There must be clear written guidelines for staff for administering as and when prescribed (PRN) medications to prevent the risk of incorrect administration. The abuse policy must include clear details of the actions staff are to take if they suspect abuse has taken place. All repairs must be carried out in a timely manner, this includes the need for toilet doors to shut and have locks fitted on them to provide residents with privacy. There must be sufficient numbers of bathing facilities in good working order to ensure that the needs of residents are met. There must be paper towels and liquid soap in all communal areas to minimise the risk of the DS0000059881.V358986.R01.S.doc Timescale for action 01/05/08 2. OP9 13 (2) 01/05/08 3. OP18 13 (6) 01/05/08 4. OP19 23 (2) (b) 01/05/08 5. OP21 23 (2) (j) 01/06/08 6. OP26 13 (3) 01/05/08 Braemar Lodge Residential Home Version 5.2 Page 25 7. OP29 8. 9. OP36 OP38 spread of infection. A robust recruitment practice must be in place and application forms must include a full employment history, two written references, a photograph of the employee and evidence of their fitness to work. 18 (2) All staff working at the care home must receive appropriate supervision. 23 (4) ( c) Regular fire drills must take (iii) (d) place to ensure that staff and residents know what actions to take in the event of a fire. All staff must have suitable training in fire prevention. 19 (1) (i) Schedule 2 01/05/08 01/05/08 01/05/08 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. Refer to Standard OP16 OP27 Good Practice Recommendations It is recommended that the final outcomes of any complaints made be recorded in the complaints records. It is recommended that additional staff be employed to carry out domestic and cooking tasks particularly on week days when there are day care residents in the building. Braemar Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Lodge Residential Home DS0000059881.V358986.R01.S.doc Version 5.2 Page 27 - 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. 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