Inspection on 11/07/05 for Braeside (30)

This inspection was carried out on 11th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Braeside (30) 16/05/07

Braeside (30) 02/05/06

Braeside (30) 05/12/05

Braeside (30) 31/01/05

Braeside (30) 17/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOMES FOR OLDER PEOPLE Braeside (30) 30 Kendall Avenue Sanderstead South Croydon, Surrey, CR2 0NH Lead Inspector James OHara Unannounced 11 July 2005 08:50 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. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Braeside (30) Address 30 Kendall Avenue Sanderstead South Croydon Surrey CR2 0NH 020 8407 0640 020 8407 0640 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) Mr Runjeetsingh Sowambur Mr Runjeetsingh Sowambur Care Home 3 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0) of places Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: For persons with a mental disorder who are over the age of 65. Date of last inspection 31/01/05 Brief Description of the Service: Braeside is a care home for older people who have a mental health problem. The home is registered with the Commission for Social Care Inspection (CSCI). The home has provisions to accommodate up to three older people. At present one service user lives at Braeside. The home is situated in a pleasant residential area of Sanderstead. Both Sanderstead and Purley Oaks railway stations are within easy walking distance. The home is owned and managed by the Registered Provider who lives in the top floor of the property. There are a number of staff members working in the home at present, all are relatives of the Registered Provider. The home consists of three good-sized bedrooms, all on the first floor, a comfortable lounge, dining room and kitchen. There is one toilet, and one bathroom on the first floor. There is a large garden to the rear of the home. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards. This unannounced inspection took place in the morning. Only one service user lives at the home. The registered provider supported the inspection process. Methods of inspection included, previous inspection experience of the home, a tour of the premises observation of contact between staff and the service user and discussion with the registered provider. Records examined included Staff Criminal Records Bureau Checks, care plans, medication records, staff rotas and training records. Twelve requirements and five recommendations from the last inspection were discussed with the registered provider. What the service does well: What has improved since the last inspection? What they could do better: Much of the evidence to support the requirements set at the last inspection was not on the premises for inspection so these requirements remain outstanding. As a result of this inspection there are ten requirements and three recommendations. The home should ensure that the Statement of Purpose contains information so that new service users can make an informed choice about the home. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 6 The service user should have a contract that would inform him of the terms and conditions of occupancy and his and the registered providers rights and obligations. The home needs to develop written procedures for staff to follow to support the service user should there be a problem with his catheter. The registered provider should ensure that staff employed at the home has Criminal Records Bureau Checks. The homes general administration system requires some organising. The inspector would like to thank the service user, the staff and registered provider for their support in the inspection process. 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. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 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 standard(s) 1, 2, 3 and 4. The home has yet to provide evidence that the Statement of Purpose contains information so that prospective service users can make an informed choice about the home. The home has yet offer the service user a contract that would inform him of the terms and conditions of occupancy and his and the registered providers rights and obligations. EVIDENCE: A requirement was set at the last inspection that the Statement of Purpose must be updated and amended to include all details as required in Schedule 1 National Minimum Standards Care Homes for Older People. The registered manager said that this had been completed but was unable to produce this information as it was with his wife on the day of the inspection. The registered manager must send a copy of the updated Statement of Purpose to the Commission for Social Care Inspection. A requirement was set at the last inspection that the registered provider ensure that the service user who lives at the home has a contract as detailed Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 9 in Regulation 5 (1) c and Standard 2 of the National Minimum Standards. This requirement has yet to be addressed. The registered provider said that no service user would be admitted to the home unless a full needs assessment has been carried out by placing care managers with involvement of the prospective service user, and his/her representatives (if any) and relevant professionals including occupational therapist. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 10 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, 8, 9 and 11. The home has failed to develop written procedures for staff to follow to support the service user should there be a problem with his catheter. Limited progress has been made on improving procedures for dealing with medicines in the home. These shortfalls have the potential to place the service user at risk. EVIDENCE: A requirement was set at the last inspection that the registered provider must ensure that the service user has a full needs assessment carried out by the placing authority and that this assessment is kept under review. The needs of the service user in relation to mobility and adaptations should be included in this assessment. The registered provider said that he contacted the service users care manager who has in turn reviewed the service users care plan 08/12/05. The registered provider has also completed his own assessment for the service user living at the home and sent this to the care manager for approval. The registered provider must ensure that the service users mobility is addressed and included in the next care plan review. A requirement was set at the last inspection that the registered provider sought advice from the Catheter Care Nurse in order to develop written Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 11 procedures for staff to support the service user should there be a problem with the catheter. The registered provider said that he had contacted the District Nurse for advice and is awaiting this information. On the day of the inspection the registered provider called the District Nurse who agreed that she would send this information this week. The registered manager must send a copy of the written procedures for staff to support the service user should there be a problem with the catheter to the Commission for Social Care Inspection. A requirement was set at the last inspection that the registered provider ensures that when medication is returned to the pharmacist that the pharmacist signs or stamps the receipt and returns book. The registered provider said that no medication has been returned to the pharmacist since the last inspection. It is therefore recommended that when medication is returned to the pharmacist that the pharmacist signs or stamps the receipt and returns book. A requirement was set at the last inspection that the registered provider must keep a separate daily record book detailing amounts of controlled medication stored in the home. This requirement has yet to be addressed. The registered provider has obtained information in writing from the service users brother regarding the wishes of the service user upon illness and death. This information is kept in the service users file as required at the last inspection. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 12 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) 14. The home has one service user living at the home he chooses not to go out. Appropriate arrangements are made so that the service user has regular contact with his family. EVIDENCE: The only service user living at the home is agoraphobic and thus chooses not to go out. The registered provider said that the service user likes to do things that he likes around the house such as listen to music, watch television, DVDs, talk to staff and play cards and dominoes. The service user also likes to make his bed and keep his room tidy. The service user said that he likes living at the home and that the staff treat him well. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The home employs Croydon Councils Protection of Vulnerable Adults Procedure. The registered provider is due to attend training provided by Croydon Council on their Vulnerable Adults Procedure on the 07/11/05. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 23, 24 and 26. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. EVIDENCE: Only one service user lives at the home, his bedroom is large and seating and a table is available for use, he had his own personal items and his room was clean and comfortable, he uses the rest of the home as he chooses. On the day of the inspection the service user who is 81 years old stayed in his room. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 15 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) 29. The registered provider is failing in his responsibility to undertake appropriate Criminal Records Bureau Checks for staff and this lack of diligence may put residents at risk from employees who are unsuitable to work with vulnerable adults. EVIDENCE: At the last inspection the homes staffing rota indicated that the either the registered provider or his wife cover from 8am to 5pm each day and that other staff work a.m. shift 8am to 3pm or p.m. shift 2pm to 8.30pm the registered provider said that he is always available in the home and that staff work morning and evening shifts. Only two members of staff work at the home, these members of staff are family members and one also lives at the home. The home now employ’s a template format to record staff rotas as recommended at the last inspection, however the registered provider could not provide a copy of the rota on the day of the inspection. The registered provider must send a copy of the homes rota to the Commission for Social Care Inspection. At the previous inspection a Criminal Records Bureau Check for the registered providers niece had been completed in August last year for employment at another establishment. The other member of staff the registered providers sister in law also has a Criminal Records Bureau Check completed for employment at another establishment. The registered provider must ensure that both members of staff obtain Criminal Records Bureau Checks. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 16 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, 33 and 35. The registered provider has had problems accessing support from other professionals in order to ensure that the health, safety and welfare of the service user is promoted, for example the support guidelines for staff to follow in catheter care and Criminal Records Bureau Checks are still outstanding. The homes general administration system requires some organising. EVIDENCE: The registered provider is a qualified nurse RNMH who has managed this home for fourteen years his wife is a registered manager at another care home and supports him. Much of the evidence to support the requirements set at the last inspection was not on the premises for inspection so these requirements remain outstanding. A requirement was set at the last inspection that the registered provider undertakes training to update his knowledge of working with people who have mental health problems and with older people. The registered provider applied Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 17 for training on dementia however the course was over booked so the registered provider has applied again. A requirement was set at the last inspection that the registered provider ensures that copies of the service users bank statements are available in the home for inspection. The registered provider said that the service user has an annual statement from the bank each December. The service user destroyed the previous statement. The registered provider said that he has however employed a formatted financial recording system; this was not available on the day of the inspection. The registered provider must send a copy of the service users formatted financial recording system to the Commission for Social Care Inspection. The recommendation that the registered provider employ the homes formatted supervision recording system was not discussed at this inspection. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 18 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 2 2 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x 3 3 x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x 3 x 3 x x x Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 19 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 1 Regulation 4(1) Requirement The registered manager must send a copy of the updated Statement of Purpose to the Commission for Social Care Inspection. The registered provider must ensure that the service user who lives at the home has a contract as detailed in Regulation 5 (1) c and Standard 2 of the National Minimum Standards. The registered provider must ensure that the service users mobility is addressed and included in the next care plan review. The registered manager must send a copy of the written procedures for staff to support the service user should there be a problem with the catheter to the Commission for Social Care Inspection. The registered provider must keep a separate daily record book detailing amounts of controlled medication stored in the home. The registered provider must ensure that both members of staff obtain Criminal Records Timescale for action 31/08/05 2. 2 5(1)b 31/08/05 3. 7 14(1)a 31/12/05 4. 8 18(1)c 31/08/05 5. 9 17(1) 30/09/05 6. 29 19(1) Immediatel y. Page 20 Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Bureau Checks. 7. 35. 17(2) The registered provider must send a copy of the service users formatted financial recording system to the Commission for Social Care Inspection. The registered provider must keep a separate daily record book detailing amounts of controlled medication stored in the home. The registered provider must undertake training to update his knowledge of working with people who have mental health problems and with older people. 31/08/05 8. 9 17(1) 30/09/05 9. 31 9(2)i 30/09/05 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. 2. 3. 4. Refer to Standard 9 33. 34 Good Practice Recommendations It is recommended that when medication is returned to the pharmacist that the pharmacist signs or stamps the receipt and returns book. The inspector recommends that the registered provider develop a service user relative questionnaire in order to seek the views of service users family and friends. The inspector recommends that the registered provider develop an annual business plan for the home. Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 Braeside (30) G53-G53 S25757 Braeside(30) unann V228806 110705 Stage 0.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!