Inspection on 20/04/05 for Newbrae Eventide Home

This inspection was carried out on 20th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Newbrae Eventide Home 16/10/08

Newbrae Eventide Home 08/08/06

Newbrae Eventide Home 25/10/05

Newbrae Eventide Home 12/10/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Newbrae 41 Crowstone Road Westcliff on Sea Nr Southend on Sea SS0 8BG Lead Inspector Bernadette Little Unannounced 20 April 2005 11.45 am th 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. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Newbrae Address 41 Crowstone Road Westcliff on Sea Essex SS0 8BG 01702 430431 01702 213414 sallyacca@aol.com Moussajee Assrafally and Mrs Salmah Assrafally 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) Moussajee Assrafally CRH 10 Category(ies) of DE, OP registration, with number of places Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Care Home Old age, not falling within any other category Dementia - over 65 years 10 places in total Date of last inspection 12/10/04 Brief Description of the Service: Newbrae provides accommodation for up to ten older people, including those with dementia, and is situated close to the towns of Southend, Westcliff on Sea, and Leigh on Sea. The home has a lounge/dining area, two bathrooms, one shower room and six single and two shared bedrooms, mostly with ensuite facilities. The home offers a small rear garden. There is no off street parking. The home has a passenger lift that provides access to all floors. Newbrae has easy access to local shops and amenities and there are good bus and train links in the area. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a unannounced inspection that took place on 21st April 2005 and lasted about six hours. It included a tour of the premises and inspection of a sample of records and documents. Time was spent sitting in the lounge areas and with residents in their own bedrooms and five were spoken with. Three staff and three visitors were also spoken with. Time was also spent with the registered person/manager, talking about the findings of this inspection, the actions that need to be taken and guidance was offered. What the service does well: What has improved since the last inspection? What they could do better: The registered person needs to think again about the number of staff on duty each day and the jobs they are to do. The number of staff should be increased to the old, agreed number. The registered manager also needs to work full time in the home. Care plans and staff training need to keep getting better. The registered manager must take more care to get all the information about people before they start work looking after the residents. Residents should be given more information, for example about what is for dinner each day, and in a way that is easy for them to read or understand. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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 Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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) 2, 3, 5 and 6 Each resident had a Statement of Terms and Conditions from the home. This needed some clearer detail. Described and written procedures for assessing people before they come to live at Newbrae were satisfactory. Before moving into Newbrae, prospective residents, or their family/friends, were invited to visit, so that they could see what the home was like before making a decision. EVIDENCE: The new providers had improved the written resident contract, and they gave more information. However, the contract was not clear as to who was responsible for paying the fees. There had been no new residents admitted to the home since the new providers had taken over. The registered manager/provider said that any prospective resident would have a full assessment prior to admission to Newbrae, even if it was an emergency admission. The home’s policy and procedure on emergency admissions needs to be developed. Residents spoken with said they, or their relatives, had been invited to visit the home prior to their coming to live there. Visitors spoken with said they had Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 9 visited the home at that time. The new registered manager/provider said that this opportunity would continue to be made available to all prospective residents/relatives. Newbrae does not offer intermediate care. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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 10: Residents were well looked after at Newbrae. Care plans had improved. They need to have more detailed information on how the person wants, and needs, to be cared for. EVIDENCE: The new providers had introduced a care plan file that was clearer and gave more information. The care plan should include care instructions for all aspects of the person’s welfare and wishes, rather than just for any ‘problems’ they may have. All the residents spoken with said that the care they got at Newbrae was good. Residents said that if they were unwell, the staff would call the doctor for them, and that they saw the chiropodist regularly. Records looked at confirmed that residents accessed a range of healthcare services. None of the residents of Newbrae looked after their own medication. There were no rish assessmentsto show the reason for this. The medication records and storage seen were safe and well managed. Staff knocked on the resident’s bedroom door and waited until they were told to come in. Residents spoken with said this was the usual routine and that staff showed respect for their privacy, for example closing the door if personal care was being given. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Residents at Newbrae had choices and access to a range of activities and foods. More information on the menu and foods provided needed to be available. Visitors were welcomed and involved in their relatives’ care and wellbeing. EVIDENCE: Some residents said they preferred to spend time in their own room and follow their own interests. The more able residents said they could get up and go to bed as they please. They were also free to join in the activities and the religious services. Staff were seen to spend time with residents on one to one activities and group games. Outside entertainers were brought into the home regularly. Visitors said they felt welcome at Newbrae, were offered refreshment and could see their relatives privately. Residents said they chose to eat breakfast in their rooms or in the dining room. None of the residents were aware of what was for lunch that day. The menu was not accurate, was somewhat repetitive and no record of nutrition was maintained. Those residents spoken with said the food was generally good, though the meat that day was tough. A relative visited daily to coax a resident to eat and food supplements were also provided. Choices and specific needs were seen to be offered and met. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Arrangements for respecting residents’ rights, protecting the residents and responding to their concerns are generally satisfactory. Staff training on Protection of Vulnerable Adults needs to be provided. EVIDENCE: Residents and visitors spoken with said they would feel able to talk to the new owner/manager and tell him, or the staff, if they had any worries or concerns. The complaints procedure had been amended to tell people that they could contact the Commission directly with their concerns. Information on how to contact a local Advocacy service was displayed on the residents’ notice board. Neither the home nor the Commission had received any complaints regarding Newbrae since the last inspection. The registered manager/provider had the postal voting cards for all residents for the forthcoming election. He advised that they had just been received and residents would be helped to use their right to vote if they wished to. The registered manager/provider had arranged for some staff to have training on management of behaviour that challenged, as this was a relevant issue at Newbrae. None of the care staff had attended training on Protection of Vulnerable Adults. This needs to be arranged so that staff are equipped to meet the needs of, and best protect, the residents. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 13 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) 26 19, 20, 24, 25 Newbrae Eventide provided a safe and comfortable living environment for the residents. A planned programme to maintain this needed to be put in place. EVIDENCE: The home was generally well maintained, and residents said the décor was to their style. Some areas that needed attention, both in maintenance and furniture, were pointed out to the registered manager. The new owners will need to have a written plan for maintenance and redecoration. Radiator covers had been fitted to all the radiators in the communal rooms to ensure resident safety. Alarms had been fitted to the outside doors to alert staff if doors were opened. The registered manager said that the alarms on bedroom doors were being removed, as he now understood that they could interfere unfairly with residents’ rights to go out of their rooms, and be an irritation to other residents at night. Residents in both single and shared rooms said they were satisfied with their bedrooms. The rooms had personal touches and residents had brought some of Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 14 their own things, like photographs and their own armchair and small table. Odour management was notably improved and this made the home a more pleasant place to spend time in. Infection control standards had also been notably improved. The new owners had installed a washing machine with a sluice and higher temperature facility, and laundry was no longer brought through the residents’ lounge/dining room. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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) 27, 29, 30 The recently reduced staffing levels did not provide safe levels of supervision for service users at all times. In addition to this, the deployment of a new member of staff without at least one supernumerary shift did not produce best outcomes for residents. Recruitment procedures were not as safe as they could be to protect residents. Training is beginning to develop. EVIDENCE: The agreed minimum staffing levels at Newbrae were three staff between 8am and 6pm, two staff between 6pm and 10pm, and one awake and one asleep member of staff between 10pm and 8am. The staffing levels had been reduced at Newbrae during the day, as there were eight residents instead of ten recently. On the morning of this inspection, the manager was on duty with one other staff member, who was on their first day working at the home for some years. There were no support staff employed and as well as giving care, the registered manager was also cooking the main meal. Residents being escorted downstairs to lunch explained to the new staff what needed to happen and what their routine was. The staff member did listen to the residents’ wishes. Residents and visitors spoken with said staff were “very nice” or “lovely”. Staff did spend time with some residents, talking or looking at a magazine. Staff did speak to residents and used their name. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 16 Residents said that they found it ‘hard to get used to it when there were new staff’ members to care for them. The registered manager explained that, sadly, four well-liked staff had recently left employment at Newbrae. This was mostly because he had insisted they comply with the law and produce documents to show they had permission to work in this country. A list of the basic training done by staff was available. Where the training happened before the new owner took over, certificates were not always available to confirm when this took place. The new owner had provided training on medication, challenging behaviour, fire, and dementia for some members of staff. The registered manager said he would arrange updates on basic training for all staff, for example moving and handling or first aid. He will also arrange training about conditions that can affect older people such as diabetes, Parkinson’s disease and pressure sore prevention, so that staff are better able to meet the residents needs. Rosters showed some occasions where staff had been working consecutive long day/double shifts. This was not considered safe practice and may put both staff and the residents at risk. Records for two newer staff were looked at. They did not have all the necessary references or evidence to show who the person was. All required checks had not been done before the person started to work at Newbrae. Additionally, the registered manager said that Criminal Record Bureau checks were not available for outside people who come in to provide services to residents. This is a concern as these people had regular unsupervised access to residents.. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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 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) 38 31, 32, 33, 35, The home presented as well managed, but the registered manager must spend enough time in the home to ensure this continues and to act on the issues raised by this and the previous inspection. EVIDENCE: The registered manager said that he had booked a place on the NVQ4 training in Care and Management. He had also done several courses since taking over the home in September 2004. These included basic food hygiene, fire, protection of vulnerable adults and management of challenging behaviour. Around the time of this inspection, the registered manager was working at the home only two or three days per week. He also worked as a nurse specialist/tutor in a hospital. Residents and visitors spoken with said they found the new manager very caring and approachable. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 18 The new registered manager/provider had given questionnaires to residents to find out what they liked or didn’t like about living at the home. He now needs to show that he has used this information to benefit residents. The registered manager said that Newbrae no longer looked after money for any resident. Records showed that checks of the fire equipment were completed regularly. Fire drills need to be regular and include all staff. Records showed that nine staff recently attended fire training. The registered manager was reminded that fire doors must not be wedged open. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x 3 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 2 COMPLAINTS AND PROTECTION 2 3 3 x x x 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 3 2 x N/A x 3 2 Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 20 Yes 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 2 Regulation 5(1)b & 3 Requirement Each resident must have a Statement of Terms and Conditions or Contract which states the fees to be paid and who is responsible for their payment The person registered must have a procedure to support the homes policy on Emergency Admissions Timescale for action 01 July 2005 2. 3 4(1)(c ) Schedule 1 (8) 01 July 2005 3. 7 15(1) The person registered must set 01 July out in each residents care plan in 2005 detail, the actions that need to be taken by care staff to ensure that all aspects of the persons health, personal and social care needs are met. (Previous timescale of 01.01.05 not met) The person registered must maintain an accurate record of the food served to resident in enough detail to show whether the diet is satisfactory and to include any special diets 01 July 2005 4. 15 17(2) Schedule 4 (13) Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 21 5. 18 13(6) The person registered must provide training for all staff in issues relating to Protection of Vulnerable Adults. (Previous timescale of 0.01.05 not met) The person registered must maintain the home in a good state of repair and reasonably decorated. The person registered must maintain adequate staffing levels and appropriate deployment of staff The person registered must ensure that residents are protected by a robust recruitment procedure and records required by Regulation are available for all staff, including volunteers.(Previous timescale of 12.0.04 not met) The person registered must ensure that staff are provided with appropriate training to undertake their work and to meet the needs of residents. (Previous timescale of 01.03.05 not met) The registered person must appoint a manager if he is not, or does not intend to be, in full time, day to day charge of the home. The person registered must ensure that staff are involved in regular fire drills and practices 01 August 2005 6. 19 23(2)b & d 01 July 2005 7. 27 18 21 April 2005 8. 29 17(2) Schedules 2&4 21 April 2005 9. 30 18(1) 01 August 2005 10. 31 8(1)b(iii) 01 July 2005 11. 38 23(4)e 01 July 2005 Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 22 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 15 19 33 Good Practice Recommendations A risk assessment should demonstrate why residents do not manage their own medication Residents should be informed of the menu and they should be able to serve themselves where they are able. A programme of maintenance and redecoration of the premises to be available. The person registered should continue to develop the homes quality assurance systems and collate and act upon the outcomes of resident and relative survey/questionnaires. Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Kingswood House Baxter Avenue Soouthend on Sea Essex SS2 6BG 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 Newbrae I56 I06 S61527 Newbrae V222042 200405 Stage 4.doc Version 1.20 Page 24 - 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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