CARE HOMES FOR OLDER PEOPLE
Braemar Lodge Residential Home 481 Victoria Avenue Southend On Sea Essex SS2 6NL Lead Inspector
Valerie Buckle Unannounced Inspection 11:00 7 December 2005
th 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.V268989.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 Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 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.V268989.R01.S.doc Version 5.0 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 w 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 26th April 2005 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 also offers day care for a maximum of two service users 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. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two hours in the home. There was a tour of the premises, an inspection of a sample of records, policies and procedures. Two members of staff were spoken with and five residents spoke about their life at the home. The manager assisted with the process of the inspection, the four requirements and three good practice recommendations from the last inspection had been met. What the service does well: What has improved since the last inspection? What they could do better:
There is a rolling programme of maintenance for the home, the home must ensure that the replacement carpet is fitted in the residents bedroom as planned. A copy of the report of the findings of the quality assurance questionnaires should be forwarded to the CSCI. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 6 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 Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 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 Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,6 All residents have a contract with the home. EVIDENCE: Resident’s contracts were seen, these were included in their files and had been signed by the resident and their family. The home does not offer intermediate care. Braemar Lodge Residential Home DS0000059881.V268989.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): 7,11 Resident’s personal care and health needs are being met by the home. Improvements have been made to the care planning procedure. EVIDENCE: Residents and their families are involved in setting up the initial plan of care and risk assessments. Care plans inspected were comprehensive and covered all areas of resident need. The information kept on the files was accessible to staff and gave clear instructions on how to meet residents needs. Care plans were seen to be reviewed monthly and kept up to date. A policy and procedure on death and dying is in place at the home. Residents last wishes were seen to be included on their files. The manager said that the practice of the home is to care and nurse sick residents at the home for as long as possible, unless the resident requires medical care. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 10 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): 15 The food provided at the home was of a good standard, and meals were well presented. EVIDENCE: Residents spoken to gave positive comments about the quality of food provided. During the course of the inspection, residents were seen in the dining area eating a wholesome lunch of roast chicken. Residents talked amongst themselves as they ate their meal and the atmosphere was very relaxed and friendly. Comments from residents included “the food is excellent” “the staff are very friendly and caring”, “its like being at home”. Residents can eat their meals in the dining room or the lounge, and mealtimes are flexible. The menu was seen to be varied and provided a choice, nutritional records were kept and showed details of each residents choices and intake of food throughout the day. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were not inspected at the inspection as they were fully met at the last inspection. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 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 the following standard(s): 20,21,23 Braemar Lodge provides care and accommodation to residents in a homely, safe, comfortable environment. The home is well maintained and accessible to the residents. EVIDENCE: The home continues to provide a well-furnished, homely environment for the residents. The home was seen to be clean and fresh. Residents bedrooms seen were well furnished, personalised and decorated to individual taste. The manager said that the resident’s carpet which was soiled was to be replaced within the next two days. The bathrooms and toilets were fresh and adequate to met the needs of the residents living at the home. There was ample communal space, with two comfortable lounges, a dining area and conservatory, which led out to a well maintained accessible garden. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 13 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): 30 The staff group have worked together for a number of years, they are experienced and knowledgeable of residents needs. They are trained and competent to do their jobs. EVIDENCE: Staff training records examined were included in staff files with copies of supervision, appraisals and training needs. At least 50 of the staff group have completed NVQ training and the manager is currently completing the Registered Managers Award. Two staff members spoken to during the course of the inspection said “the manager is approachable and supportive, training is available and supervision takes place. Both staff members were satisfied with their working conditions. Residents spoken to expressed contentment at living in the home and said “the staff are very friendly here, and care for us very well”. Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 14 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): 33,36,37 The home is run in the best interests of the residents. Staff supervision takes place regularly, policies and procedures are in place to protect residents. EVIDENCE: Residents and staff spoken to expressed confidence in the way the home is managed. Minutes were seen of regular staff and residents meetings, and there was evidence of staff supervision/appraisals and training. An annual quality monitoring system has been implemented and questionnaires about the quality of care provided have been completed by residents, their families and professionals involved in their care. A report of the findings has been written and the manager is sending a copy of this report to the CSCI.
Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 15 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 3 X 2 X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X 3 3 X Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 16 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 OP24 Regulation Requirement Timescale for action 30/12/05 Reg 16 (c) Replace soiled carpet in resident’s bedroom. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Braemar Lodge Residential Home DS0000059881.V268989.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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