Inspection on 01/11/05 for Sercha House

This inspection was carried out on 1st November 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

Sercha House 11/09/06

Sercha House 25/07/05

Sercha House 24/03/05

Sercha House 29/06/04

Sercha House 27/02/04

Sercha House 11/11/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sercha House 34 Cranes Park Avenue Surbiton Surrey KT5 8BP Lead Inspector Mohammad Peerbux Unannounced Inspection 1st November 2005 9:30 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 Sercha House DS0000013398.V262500.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. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sercha House Address 34 Cranes Park Avenue Surbiton Surrey KT5 8BP 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) 020 8399 6081 020 8399 0156 Mr Prakash Sankaran Mrs P Sankaran Care Home 10 Category(ies) of Dementia (10) registration, with number of places Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Sercha House is a care home providing care and accommodation to ten older people with various degrees of dementia. The Home is situated in a quiet residential area, yet conveniently located for the high street facilities of Surbiton. In addition to a range of shops, banks, restaurants and pubs, Surbiton provides good access to bus and mainline rail links. The amenities of Kingston-upon-Thames are also within easy reach. Accommodation is provided in four shared rooms, and two single rooms. One shared room is on the ground floor, the other rooms on the first floor. There is no passenger lift. There is a garden to the rear, accessible to service users. The building is a detached house on two floors. The home is in keeping with neighbouring properties. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/06. It was an unannounced inspection and took place over two hours. Some times were spent looking at the policies and procedures, talking to the manager and assistant manager. A tour of the building was also carried out. Requirements and recommendations from the previous inspection were also discussed. Overall the home continues to provide a good standard of care. They are all thanked for their time and assistance. What the service does well: What has improved since the last inspection? A copy of the latest inspection report has now been included in the Service User’s Guide. All medication administration records are being accurately completed and the home has developed a medication profile for each service users. The vulnerable adult protection procedure has been amended to state that any abuse will be investigated by Care Management Team and not by the nurse in charge. Staff supervision sessions have improved. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 6 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. Sercha House DS0000013398.V262500.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 Sercha House DS0000013398.V262500.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 The Statement of Purpose, and Service User Guides’ provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. All service users have a contract between the home and service user so they are aware of the terms and conditions of the home. EVIDENCE: The home has a comprehensive Statement of Purpose, and Service Users’ Guide. Both are extremely well presented and cover all the information required by the Care Homes Regulations (2001), including the aims and objectives of the home and the facilities and services provided. It was previously required that a copy of the latest inspection report is included in the Service User’s Guide. This is now in place. The manager stated that all service users or their recognised representatives have a costed contract/statement of terms and conditions of occupancy that are agreed between each prospective service user and/or representative and the home. Copies were sampled as part of the inspection process. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 9 The home does not offer intermediate care. Sercha House DS0000013398.V262500.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): 9 and 10 Generally service users’ medication is well managed to ensure maximised good health. The arrangements for health and personal care ensure that service user’s privacy and dignity are respected at all times. EVIDENCE: In general, medication records, including medicines received, administered and returned were all being appropriately maintained. In line with a previously made requirement, all medication administration records were accurately completed.The home has also developed a medication profile for each service user as previously recommended with their photographs on them. Service users are always treated with respect and dignity in accordance with the homes statement of purpose. Screens are available in shared bedrooms, which are used when personal care is being given. All new members of staff receive a structured induction that includes specific training in how to treat service users with respect and dignity at all times. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: Standards 12,13,14 and 15 were met at the last inspection and there has been no change; they were not assessed at this inspection. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 the following standard(s): 18 The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. It was previously required that the procedure be amended to state that any abuse will be investigated by Care Management Team and not by the nurse in charge. This has been met. There have not been any adult protection concerns raised since the last inspection. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 the following standard(s): 20,21,23 and 25 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home has a combined lounge and dining area with adequate seating for the current service users. An office area is also placed at one end of this area. Furnishings of communal rooms are domestic in character and of good quality, and suitable for the range of interests and activities preferred by service users. There are sufficient numbers of toilet and bathroom facilities near service users bedrooms and communal areas on each floor of the home. Toilets inspected were all noted to be clean and well maintained. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 14 This standard is met as an “existing” care home, that is, it was in operation before the introduction of the Care Standards Act 2000. The bedroom sizes were not confirmed during this inspection but the home’s statement of purpose makes clear the rooms sizes so prospective service users have an indication of the environmental services and facilities available in this home. The home is appropriately heated, lit and ventilated. Some of the bedrooms were checked and found them to be acceptable. They were clean and tidy. Sercha House DS0000013398.V262500.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, 29 and 30 Staff numbers are of sufficient quantity to meet the service users’ needs and provide consistency and to ensure their safety. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. It was previously required that the manager must ensure that the off duty rotas are completed accurately to reflect which shifts the staff are actually working. This requirement has been met. Staff records were examined and were seen to contain references, criminal record checks, original application forms and copies of identification. However it was noted that one newly employed staff was working without a CRB and/or POVA check. An immediate requirement was issued for the registered manager to ensure that no staff are working unsupervised without having carried out a POVA check first on them and they have applied for a CRB check. The assistant manager stated all staff have attended medication training. Food and hygiene course has also been planned for all staff. The assistant manager also reported that further training is being organised. The registered provider is currently undertaking the NVQ assessor course to facilitate the staff with their NVQ training. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 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 and 36 The service users live in a well run home where their interests are safeguarded and their safety and welfare are protected. The home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. EVIDENCE: Throughout the course of the inspection the manager demonstrated a good competent management skills and appears to have created a skilled, positive and enthusiastic workforce. He has many years experience of working with this client group and displayed an insight into the relevant issues. He has currently doing his NVQ level 4. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 17 The owners and the managers’ approach to running the home appears to create a positive and happy atmosphere within the home. Staff are encouraged to participate in the day-to-day operation of the home. Service users and their families are consulted about the conduct of the home and their views are regularly sought. However the home still has to further developed its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s provider still has to evidence in a Development Plan that it is meeting its aims and objectives and is being run in the best interests of service users. These issues were requirements made at the last inspection and therefore would be repeated. No business and financial plan was available at the time of inspection. The Registered Provider must ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is supplied to the Commission for Social Care Inspection. It was previously required that the registered manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. The assistant manager stated that staff are now having supervision on a regular basis.The manager is reminded that staff should have at least six formal supervision sessions a year. Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X 3 3 X 3 X 3 X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 X 3 X X Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 Page 19 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 OP29 Regulation 19(4)(c) Requirement The registered manager to ensure that no staff are working unsupervised without having carried out a POVA check first on them and they have applied for a CRB check. The home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. (Previous timescale of 31/10/05 not met) The homes provider must evidence in a Development Plan that the home is meeting its aims and objectives and is being run in the best interests of service users. Previous timescale of 31/10/05 not met) Timescale for action 11/11/05 2 OP33 24(1)(a) & (b) 31/01/06 3 OP33 24(2) 31/01/06 4 OP34 25(2)(a)(c The Registered Provider must ) ensure that a business plan, demonstrating that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose, is DS0000013398.V262500.R01.S.doc 31/01/06 Sercha House Version 5.0 Page 20 supplied to the Commission for Social Care Inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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 Sercha House DS0000013398.V262500.R01.S.doc Version 5.0 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. 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