Inspection on 25/10/05 for Newbrae Eventide Home

This inspection was carried out on 25th October 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 20/04/05

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 Eventide Home 41 Crowstone Road Westcliff On Sea Essex SS0 8BG Lead Inspector Mrs Bernadette Little Unannounced Inspection 25th October 2005 03:00 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 Newbrae Eventide Home DS0000061527.V262017.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. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Newbrae Eventide Home Address 41 Crowstone Road Westcliff On Sea Essex SS0 8BG 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 430431 01702 213414 Mr Moussajee Assrafally Mrs Salmah Assrafally Mr Moussajee Assrafally Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 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 Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Newbrae provides a cosy and calm environment for the residents to live in. The small number of residents and staff at this home allowed for good relationships to be built up between the staff and residents. The quality of the interaction observed between the staff and the residents was particularly noted as good, and residents were spoken to with kindness and respect. The relatives and the professional visitors to the home had only complimentary comments to make, and spoke of how welcoming, friendly and helpful, the manager and staff were. Individual comments included “the food is lovely” and that the person was “very impressed with the care provided and the home’s approach”. Three questionnaires had been returned all with positive comments on for example the food, the care staff, the laundry etc and one comment noted was that the home is “clean, tidy and very friendly”. What the service does well: What has improved since the last inspection? Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 6 There have been improvements to the premises since the last inspection. This has included general maintenance and decoration, including attention to minor details that has made the home a nicer place to live for the residents. A new bath chair hoist had been fitted to meet the needs of residents and protect the staff. The checks and references to be done on people before they can come to work at Newbrae were all in place for the staff that were employed since the last inspection. What they could do better: 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. Newbrae Eventide Home DS0000061527.V262017.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 Newbrae Eventide Home DS0000061527.V262017.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): 1,2,3,4 Newbrae had a good range of information available for those thinking about using the service. The premises, equipment and staff training supported the home’s ability to meet residents’ needs. Appropriate pre-admission assessment was not well documented. EVIDENCE: Newbrae had a Statement of Purpose and Service User Guide. The home must ensure that these are made available to all residents, including in the case of emergency admission, as soon as possible. The timescale for this should be documented in the home’s emergency admission procedure. A social worker advised that the home had been most helpful and supportive to the resident and the social work team in this emergency situation. Following the advice at the last inspection, the home was able to demonstrate that a detailed statement of terms and conditions was available for residents. This now included information on who was responsible for the fees and also referred to the room to be occupied and additional charges. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 9 Records did not indicate that a thorough pre-admission assessment had been undertaken prior to the resident coming to live at Newbrae. This is an area for development. The registered manager was advised of the requirement for this and that he must confirm in writing to the person, following the assessment, that Newbrae can meet their specific needs. Observation of practice demonstrated that staff had an understanding of residents’ individual needs and the ability to meet them. Newbrae Eventide Home DS0000061527.V262017.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, 11 Care plans contained basic information and need to be developed. The homes policy and procedure for end of life practices was not clearly documented so as to provide reassurance for residents and their family. EVIDENCE: A new format for care plans had been used. This contained information more in the form of an assessment. Advice was provided on areas where it needed to be developed. This would include having clear care aims and objectives, and providing specific and detailed instructions on how the care was to be given, to ensure consistency of approach for residents and staff. The care plan should also show that the resident/relative had been involved in this, especially if the resident is able. Risk assessment tools had been used, including for moving and handling, falls, tissue viability and nutrition. The registered manager agreed for the need to have these translated into specific care plan aims for residents. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 11 The home had a policy and procedure for staff to follow in the event of a resident’s death. The registered manager stated that if Newbrae could continue to meet a resident’s care at the end of their life, they would do so. He will make this information available to residents in the Statement of Purpose and Service User Guide, and produce a procedure on care of the dying. The resident’s wishes in relation to end of life practices needs to be recorded in their care plan. Newbrae Eventide Home DS0000061527.V262017.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, 15 Newbrae offered residents meaningful activities appropriate to their individual needs. Records showed a good variety of nutritional food being offered. EVIDENCE: Some residents at Newbrae have dementia and the range of activities provided took this into account. This included one-to-one activities for those able to manage games, and one-to-one time for conversation and reassurance for other residents. A church service is held in the home once a month. Outside entertainers are also provided on a regular basis. One resident confirmed that they are able to spend time either in the lounge or in her own room following their own interests. Residents spoken with said that the food is very nice. One resident said that they can always ask for, and do have second helpings. A relative said that the food always looks very nice and that the home is supportive of them assisting their relative with encouragement to eat at mealtimes. A nutrition record was maintained which demonstrated any specific dietary needs as well as a range and variety of foods. The registered manager advised Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 13 that he, had been given the format by the commissioning officer from the local authority, with whom he works in partnership. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 14 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): 18 Staff training and knowledge protected residents. EVIDENCE: Newbrae had a copy of the local protection of vulnerable adult guidelines and it’s own policy and procedure. The last inspection report identified a need for additional staff to have training on the protection of vulnerable adults. The registered manager attended training provided by Southend Borough Council as well as training by an outside training company, and provided training for the staff. Some staff had also had training on the management of behaviour that challenges, provided by the registered manager. The gender composition of some shifts was discussed with the manager who is in the process of employing another member of staff, which will assist with ensuring that there is a choice for residents as to the gender of the person who provides personal care. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 15 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): 19, 21, 22, 23 Newbrae provided a safe environment with premises and equipment that met residents’ needs. EVIDENCE: All areas of the premises were inspected and noted to be safe. A record of maintenance had been kept, but there was no plan of maintenance for the premises as recommended at the last inspection. Since the last inspection one bedroom has completely been redecorated and re-carpeted. All bedrooms had an en-suite toilet and wash hand basin. There is a bathroom on the ground and first floors, and a shower room on the second floor. A separate toilet is available close to the lounge. Tiling had been repaired/ replaced in the shower room and bathroom as well as in an en-suite. A new bath chair hoist had been fitted. Additional equipment had been accessed for residents as required, including a raised toilet seat and supporting frame in their en-suite. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 16 Residents spoken with said that they were comfortable in their bedrooms and that they suited their needs. One resident said that they had been able to bring some personal pieces of furniture as well as more personal items such as photographs and pictures. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 17 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, 30 Staffing levels were adequate to meet the current needs of residents. Staff training and recruitment procedures protected residents. EVIDENCE: Discussion with staff and residents, as well as observation of practice, indicated that the current staffing levels allowed staff to meet residents’ needs. The registered manager and the roster confirmed that the home operate with three staff, including one senior from 8.30 am to 5.30 pm, two staff including one senior from 5.30 pm to 9.30 pm and one awake and one sleeping-in staff member at night. Care staff undertook all the cooking and ancillary tasks in the home. The registered manager confirmed that he will discuss any change to staffing levels with the Commission prior to implementation. Two staff had completed NVQ level 2 training. One staff member is currently undertaking NVQ level 3. The registered manager advised that two staff are currently undertaking a health and social care course that, on completion, will be equivalent to NVQ level 3. This will need to be evidenced in due course. The recruitment file for the one member of staff recruited since that last inspection was considered. This indicated that all appropriate references and checks had been obtained prior to the person taking up employment at Newbrae. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 18 Discussion with staff and inspection of a sample of records demonstrated that staff have undertaken a range of mandatory training including food hygiene, moving and handling, medication and fire training. They also show additional training for staff in issues such as diabetes, pressure area care, continence management and dementia care. The registered manager advised that he is preparing training for staff on Parkinson’s disease. Induction programme booklets, stated to be TOPSS standards were available and completed on the two staff files sampled. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 19 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, 34, 35, 36, 37 Newbrae was well organised, safe and efficiently managed. Staff felt well supported by the manager and were enabled to support residents. EVIDENCE: Discussion with the registered manager and inspection of the rosters confirmed that he does work full-time at Newbrae. The registered manager advised that he had not only started NVQ level 4 in care and management but that he had almost completed it. He also confirmed that he had completed training as a moving and handling trainer and so was able to provide this training to all his staff. Staff and residents spoken with said that the manager was approachable and supportive. The registered manager confirmed that Newbrae does not look after money for any resident. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 20 A copy of current liability insurance was displayed. The registered manager/ provider confirmed that he was taking all steps to ensure the financial viability of the business and had just completed his first year as owner/manager of the home. There was nothing to indicate that the business was anything other than financially viable. Files sampled showed a supervision contract in place and that staff had been offered at least one supervision session. Advice was provided to the registered manager that the National Minimum Standard stated that supervision should be provided at least six times per year. The registered manager stated that he would endeavour to meet the standard. Records sampled included accident records, rosters, record of visitors, display of registration certificate and these met requirements. Other records inspected are noted and commented upon in the appropriate sections of this report. The registered manager plans to introduce a staff signing in and out book as a record of the hours that staff actually worked. A photograph of all residents must be available. Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X 3 3 3 X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 3 2 2 X Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14 Requirement The person registered must ensure that the prospective resident has been assessed by a suitably qualified person prior to admission, that the person registered has obtained a copy of this assessment, and has confirmed in writing to the prospective resident that with regard to the assessment the care home can meet their specific needs in respect of their health and welfare. Timescale for action 25/10/05 2. OP7 15(1) 3. 4. OP37 OP38 17(1)a Schedule 3 23(4)e The person registered must set 01/11/05 out in each residents care plan in detail, the actions that need to be taken by care staff to ensure that all aspects of the person’s health, personal and social care needs are met. (Previous timescale of 01/01/05 and 01/07/05 not met) A photograph must be kept in 01/11/05 the care home of each resident. The person registered must ensure that all staff are involved in regular fire drills and DS0000061527.V262017.R01.S.doc 01/07/05 Newbrae Eventide Home Version 5.0 Page 23 practices. (Previous timescale of 01/07/05 not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP9 Good Practice Recommendations The emergency admission procedure should identify timescales by which information, for example the service user guide, is provided to residents. A risk assessment should demonstrate why residents do not manage their own medication. (Not assessed on this occasion, carried forward to the next inspection to be considered when medication is inspected). The home should have a clear policy on it’s view on end of life care and practices, made known to residents in the service user guide along with a clear procedure for staff to follow in relation to care of the dying. A programme of maintenance and redecoration of the premises to be available. At least 50 of care staff should achieve a minimum of NVW level 2. The registered manager should achieve NVQ level 4 in caring management. The person registered should continue to develop the home’s quality assurance systems and collate and act upon the outcomes of resident and relative survey/ questionnaires. (Not assessed on this occasion, carried forward to the next inspection). Staff should be provided with formal supervision at least six times each year. 3. OP11 4. 5. 6. 7. OP19 OP28 OP31 OP33 8. OP36 Newbrae Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 24 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 © 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 Eventide Home DS0000061527.V262017.R01.S.doc Version 5.0 Page 25 - 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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