Inspection on 05/12/05 for Braeside (30)

This inspection was carried out on 5th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Braeside (30) 16/05/07

Braeside (30) 02/05/06

Braeside (30) 11/07/05

Braeside (30) 31/01/05

Braeside (30) 17/05/04

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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 O`Hara Unannounced Inspection 5th December 2005 10:30 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 Braeside (30) DS0000025757.V269267.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. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 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) 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) DS0000025757.V269267.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. For persons with a mental disorder who are over the age of 65 Date of last inspection 11th July 2005 Brief Description of the Service: Braeside is a care home for older people who have a mental health problem. 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. 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) DS0000025757.V269267.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection at the home this year the first took place in July. The inspection began at 10.30 am and finished at 12.45 pm on a Monday morning/afternoon. Methods of inspection included observation of contact between the registered manager and service user and discussion with the registered manager and his wife. Records examined included Criminal Records Bureau Checks; training records, care plans, relative’s questionnaires, medication record, menus, and service users finance records. Previous requirements and recommendations were discussed the registered manager. What the service does well: What has improved since the last inspection? What they could do better: There were a total of nine requirements and three recommendations set at the previous inspection. Some of the requirements have been met however some need more work to complete. As a result of this inspection there are six requirements and six recommendations. Although the home developed a Statement of Purpose it needs to be reviewed and amended to accurately reflect the services offered by the home. The service users contract also needs to be updated. The home also needs to complete a staffing rota. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 6 So that service users can be confident that their finances are appropriately managed the home should pay particular attention to developing a robust and transparent system for administration of the service users personal finances. The registered manager still needs to undertake training to update his knowledge of working with people who have mental health problems and with older people. The inspector would like to thank the service user, the registered manager and his wife their support on the day of the inspection. 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) DS0000025757.V269267.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 Braeside (30) DS0000025757.V269267.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): 1, 2 and 6. Standards 3 and 4 were assessed as met at the last inspection. Information included in the homes Statement of Purpose is out of date and inaccurate. This could result in an inappropriate placement being made to the home. Equally it could result in service users not receiving the service they expected when they first moved to the home. EVIDENCE: As required at the last inspection the home has developed a Statement of Purpose however since this has been completed there has been changes to the staffing situation at the home. The Statement of Purpose must be reviewed and amended and should accurately reflect the services offered by the home. The registered manager provided a copy of a contract between the home and the service user. The contract was completed in 1995. The registered manager must review and update the service user contract on an annual basis. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 9 The registered manager said that he was not sure if he would carry on running the home as he has had only one service user for some time. He has contacted the Croydon Adult Placement Scheme to see if the home can join the Scheme. It is recommended that the registered manager keep the Commission informed of any future developments as regards joining the Croydon Adult Placement Scheme. Standard 6 does not apply at the home. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Standard 11 was assessed as met at the last inspection. The home has developed written procedures for staff to follow to support the service user should there be a problem with his catheter and progress has been made on improving procedures for dealing with medicines in the home. EVIDENCE: The registered manager stated that the service users mobility was assessed by the service users care manager at the last care plan review as required at the last inspection however evidence of this information was not included in the review record. The registered manager stated that he would record this information in the care plan review and send it to the service users care manager to agree and sign. It is recommended that the registered manager send a copy of the service users care plan to the Commission when it has been amended. The registered manager produced hand written procedures for staff to support the service user should there be a problem with the catheter as required at the last inspection. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 11 It is recommended that the registered manager types up the procedures for staff to support the service user should there be a problem with the catheter. As recommended at the last inspection the registered manager now keeps a record of all medication in the home, this record also includes medication returned to the pharmacist and the pharmacist’s signature for returned medication. The registered manager also keeps a separate daily record book detailing amounts of controlled medication stored in the home as required at the last inspection. On the day of the inspection the registered manager was observed to support the service user in a dignified and respectful manner. The service user did not wish to speak to the inspector however at the previous inspection he said that he likes living at the home and that the staff treats him well. A questionnaire sent by the home to the service uses relative had been returned. The service users brother had been very complimentary about the registered manager and the level of care and support his brother receives. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 15. Standard 14 was assessed as met at the last inspection. 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 except for occasional visits to the local shop. 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 registered manager stated that the service user has regular contact by telephone with his brother. A questionnaire sent by the home to the service uses relative had been returned and the service users brother indicated that communication is good between him, the home and his brother. The home employs a four weekly rotating menu system. The registered manager stated that this record includes all of the food the service user likes. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. Arrangements for complaints and protection from abuse are in place to ensure that service users feel listened to and safe. EVIDENCE: The home employs Croydon Councils Protection of Vulnerable Adults Procedure. The registered manager attended training provided by Croydon Council on their Vulnerable Adults Procedure on the 07/11/05. The home has an appropriate complaints procedure that is included in the new Statement of Purpose. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 the following standard(s): Standards 19, 23, 24 and 26 assessed as met at the last inspection. None of the above standards were assessed at this inspection. EVIDENCE: Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 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 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): 27, 28, 29 and 30. The registered manager does not employ staff in the home, the registered manager or occasionally a family member or an agency staff will be on duty in the home. Given the registered manager and his wife’s qualifications and that there is only one service user living at the home this arrangement is currently acceptable. EVIDENCE: The registered manager is a Registered Nurse Mental Handicap (RNMH). His wife is a Registered Mental Nurse (RMN) and is also a registered manager at another care home. The registered manager lives at the home, does not employ staff in the home, the registered manager, his wife and daughter carry out the majority of the care duties in the home, and occasionally an agency staff will be on duty in the home. Given the registered manager and his wife’s qualifications and that there is only one service user living at the home this arrangement is currently acceptable. The registered manager stated that one member of staff no longer works at the home. The registered manager had obtained a Criminal Records Bureau Check for his daughter who sometimes works at the home. The registered manager and his wife’s Criminal Records Bureau Checks were also examined on the day of the inspection. The registered manager stated that he and his family are going on a short holiday. He has contacted the service users care manager and relatives and a respite placement has been found for the service user during this time. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 16 As previously stated the registered manager has contacted the Croydon Adult Placement Scheme to see if the home can join the Scheme. The registered manager must complete a rota indicating when his family or agency staff work in the home. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33, 34, 35, 37 and 38. So that service users can be confident that their finances are appropriately managed the home should pay particular attention to developing a robust and transparent system for administration of the service users personal finances. EVIDENCE: The registered manager is a Registered Nurse Mental Handicap (RNMH). His wife is a Registered Mental Nurse (RMN) and is also a registered manager at another care home; she supports the registered manager to run the home. The registered manager is currently completing an NVQ level 4 in Management and Care. It is recommended that the registered manager send a copy of his NVQ 4 certificate to the Commission when this has been obtained. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 18 The registered manager should pay particular attention to a requirement first set at an inspection on the 31st January 2005 that the registered manager undertakes training to update his knowledge of working with people who have mental health problems and with older people. Since the last inspection the registered manager has attended training on adult protection and infection control. As stated during the last inspection the registered manager had applied for training on dementia however the course was over booked so the registered provider has applied again. The registered manager has not yet received a new date to attend. It is recommended that the registered manager contact Age Concern for advice on training for working with older people. The registered manager produced finance records for the service user who lives at the home. This included receipts for expenditure. However the registered manager was not able to accurately explain how the service users finances were managed. So that the registered manager can evidence that the service users personal finances are managed in an open, robust and transparent manner he must ensure that the service users financial records include detailed accounts including expenditure, receipts and balances and quarterly bank account statements. If the service user has a bankbook this must be made available for inspection. The service users money must be kept in a safe place. It is recommend that the home ensures that an annual independent audit of the service users financial accounts is carried out. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 19 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 2 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 2 3 X X 3 Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4.1. Requirement The Statement of Purpose must be reviewed and amended and should accurately reflect the services offered by the home. Outstanding requirement partially met. The registered manager must review and update the service user contract on an annual basis. Outstanding requirement partially met. The registered manager must complete a rota indicating when his family or agency staff work in the home. So that the registered manager can evidence that the service users personal finances are managed in an open, robust and transparent manner he must ensure that records include; detailed accounts including expenditure, receipts and balances and quarterly bank account statements. The registered provider must ensure that the service users mobility is addressed and included in the next care plan DS0000025757.V269267.R01.S.doc Timescale for action 31/03/06 2 OP2 5 (1) b. 31/01/06 3. OP27 18 (1) a. 31/01/06 4. OP34 17 (2). 05/12/05 5. OP7 14 (1) a. 31/12/05 Braeside (30) Version 5.0 Page 21 6. OP31 9 (2) 1. review. Outstanding requirement partially met. The registered provider must undertake training to update his knowledge of working with people who have mental health problems and with older people. Outstanding requirement first set at an inspection on the 31/01/05. 31/05/05 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. 5. 6. Refer to Standard OP4 OP8 OP8 OP31 OP31 OP34 Good Practice Recommendations It is recommended that the registered manager keep the Commission informed of any future developments as regards joining the Croydon Adult Placement Scheme. It is recommended that the registered manager send a copy of the service users care plan to the Commission when it has been amended. It is recommended that the registered manager types up the procedures for staff to support the service user should there be a problem with the catheter. It is recommended that the registered manager send a copy of his NVQ 4 certificate to the Commission when this has been obtained. It is recommended that the registered manager contact Age Concern for advice on training for working with older people. It is recommend that the home ensures that an annual independent audit of the service users financial accounts is carried out. Braeside (30) DS0000025757.V269267.R01.S.doc Version 5.0 Page 22 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) DS0000025757.V269267.R01.S.doc Version 5.0 Page 23 - 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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