Inspection on 11/09/06 for Sercha House

This inspection was carried out on 11th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sercha House 01/11/05

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 Key Unannounced Inspection 11th September 2006 9:30am 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.V310854.R01.S.doc Version 5.2 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.V310854.R01.S.doc Version 5.2 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 Mr Prakash Sankaran Care Home 10 Category(ies) of Dementia (10) registration, with number of places Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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. The range of weekly fees is between £410 and £490. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It took place over five hours. Some times were spent looking at the policies and procedures, talking to assistant manager and registered manager. Some of the service users were spoken to however due to their cognitive ability it was difficult to seek their views. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. Overall the home continues to provide a good standard of care. What the service does well: What has improved since the last inspection? The home’s provider has produced a Development Plan to evidence that the home is meeting its aims and objectives and is being run in the best interests of service users. A business plan is now in place to demonstrate that the home is financially viable for the purpose of achieving the aims and objectives set out in the Statement of Purpose. No staff are working unsupervised without having carried out a POVA check first on them and they have applied for a CRB check. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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.V310854.R01.S.doc Version 5.2 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.V310854.R01.S.doc Version 5.2 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): 3 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission. EVIDENCE: Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a comprehensive needs assessment. The home does not offer intermediate care. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users are treated with respect and have their privacy respected. The system for administration of medication is poor and potentially place service users at risk. EVIDENCE: A sample of service user care plans was examined and it was evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. There was also evidence from review notes that service users’ care needs are being reviewed on a three monthly basis with amendments being made to the service user plans where needs have changed. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 10 The assistant manager stated that care plans would be reviewed more often if the need of the service user changes. The assistant manager was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners and other health care specialists as required. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. One of the service users is in hospital at present for assessment regarding her falls. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The registered person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. Some items of medication were labelled “use as directed”. No other directions were seen for administration. The registered person must ensure that clear directions for administration are in place for all items of medication. The registered provider must also amend the medication policy/procedures to include storage and disposal of medicines. Failure to comply with the aforementioned requirements represent serious breaches of the Regulations and urgent action must be taken by the registered person to address these to avoid the Commission taking further action to enforce compliance. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Service users are always treated with respect and dignity in accordance with the homes statement of purpose. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Religious services are held at the home on a regular basis. The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. Service users are actively encouraged to maintain links with their families and friends. It was clear from entries made in service users daily diary notes and the visitors book itself, that visitors are always welcome at the home and service users can choose whom they see and when. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 12 Service users are being supported to exercise choice and control over their lives in so far as they wish and are able to do so. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. 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 observe. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. 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. The assistant manager stated that not all staff have had training on abuse. The registered person must make suitable arrangements by training staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. There has been one adult protection concern raised since the last inspection. This is currently being investigated by the care management team in Kingston. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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): 19 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. Furnishings and fittings were of good quality and the home was decorated to a reasonable standard. The garden is well maintained and there is a patio area with furniture for service users to sit and enjoy the garden. The manager stated that the lounge, dining area and the hallway would be decorated that week. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However staff training needs to be addressed as this could have an impact on the standards of care being provided. 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. However the manager must ensure that the off duty rotas are completed accurately to reflect which shifts the staff are actually working. The assistant manager informed that 4 staffs are undertaking NVQ Level 2. The management team are aware that they will have to give consideration as to how this standard will be achieved. The registered provider has successfully completed her NVQ assessor course and is now a qualified assessor. Recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 16 From the staff training records, it was noted that they were not always up to date and there are gaps in mandatory training. It was very difficult to ascertain if the staff were up to date with their training. The registered manager must ensure that all staff are up to date with their mandatory training. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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): 31,33,34,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home management generally provides leadership, guidance and direction to staff to ensure service users receive consistent quality care. However progress must be made with regards to the frequency of staff supervision. 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 service users’ group and displayed an insight into the relevant issues. He has currently doing his NVQ level 4 and undertakes periodic training to maintain and update his knowledge, skills and competence while managing the home. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 18 It was previously required that 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. This is now in place. The registered provider has a business and financial plan in place for the home and this has been reviewed recently in line with a requirement made at the last inspection. The assistant manager stated that the home does not look after any service user’s money. There were no supervision records available at the times of inspection. The registered provider 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 health, safety and welfare of service users and staff are being appropriately protected. There is a risk assessment in place for the building and also a fire risk assessment. The hot water temperature was checked in the bathroom upstairs and it was within the recommended level of 43 degrees centigrade. Fire alarm tests are also being carried out on a regular basis. Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 X 3 Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. The registered person must ensure that clear directions for administration are in place for all items of medication. The registered provider must also amend the medication policy/procedures to include storage and disposal of medicines. The registered person must make suitable arrangements by training staff to prevent service user’s being harmed or suffering abuse or being placed at risk of harm and/or abuse. The manager must ensure that the off duty rotas are completed accurately to reflect which shifts the staff are actually working. DS0000013398.V310854.R01.S.doc Timescale for action 11/09/06 2. OP9 13(2) 11/09/06 3. OP9 13(2) 11/10/06 4. OP18 13(6) 11/11/06 5. OP27 17(2) 11/09/06 Sercha House Version 5.2 Page 21 6. OP30 12(1)(a) (b) The registered manager must ensure that all staff are up to date with their mandatory training. The registered provider 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. 11/12/06 7. OP36 18(2) 11/12/06 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.V310854.R01.S.doc Version 5.2 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 Sercha House DS0000013398.V310854.R01.S.doc Version 5.2 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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