Inspection on 25/07/05 for Sercha House

This inspection was carried out on 25th July 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 01/11/05

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 25 July 2005 10:30am 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. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sercha House Address 34 Cranes Park Lane, Surbiton, Surrey, KT5 8BP 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) 020 8399 6091 020 8339 9107 Mr Prakash Sankaran Mrs P Sankaran Care Home 10 Category(ies) of Dementia (10) registration, with number of places G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 24 March 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 owned and Managed by Mr Prakash Sankaran and Mrs P Sankaran.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. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It was an unannounced inspection and took place over four hours. Some times were spent looking at the policies and procedures, talking to the manager and assistant manager and to some of service users. A tour of the building was also carried out. They are all thanked for their time and assistance. What the service does well: A sample of service user files was examined. The home was evidenced to have appropriate assessments and care plans in place. Service users’ care and support needs had been properly assessed, and the range of health, care and social needs presented were evidenced as being met. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet service users’ needs. Service users were observed to be treated with respect by staff and to have their privacy and dignity respected. Service users were observed to receive a wholesome, appealing and nutritious diet in pleasant surroundings, with service users indicating that they liked the food. The dietary needs of service users are noted and catered for. Health and safety checks, including fire safety, are all in place and the home is maintained to a good standard. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The manager must ensure that a copy of the latest inspection report is included in the Service User’s Guide. All medication administration records must be accurately completed at all times. The vulnerable adult protection procedure must be amended to state that any abuse will be investigated by Care Management Team and not by the nurse in charge. The off duty rotas must be completed accurately to reflect which shifts the staff are doing. The manager must ensure that staff files contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. The home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s 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. 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. It is recommended that the home develops a medication profile for each service users and this should include their photographs. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 7 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. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 8 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 G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 9 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) 1,3,4 and 5 Changes are needed to both the Service User Guide and the Statement of Purpose so that they accurately provide full information about the services. This will provide the correct information to enable people to make informed decision about the home on whether it will meet their needs. The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. The necessary information and opportunity to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home. EVIDENCE: It was previously required that the Registered Provider must ensure that the Statement of Purpose is updated to include contacts and regulatory body under ‘complaints’, and to make clear reviews are held on a monthly basis under ‘Care Plan Review’, and following guidance supplied to the home. This has met however the complaints procedure still needed amending to include the timescale for response to a complaint and the complainant could approach the Commission at any times while waiting for a response from the provider. These amendments were carried out on the same day of the inspection. The Service G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 10 Users’ Guide was also comprehensive however it did not include a copy of the latest inspection report. The manager must ensure that a copy of the latest inspection report is included in the Service User’s Guide. 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. It was clear from care plans sampled at random that service user’s needs are being met. Records revealed that service users are in regular contact with other health and social care professionals. From observation of the interaction between staff and service users it was evident that the staff team had managed to achieve good verbal and non-verbal communication with all the service users and that the home was providing more than adequate care. All prospective service users are offered the opportunity to visit the home before a place is offered. It was previously required that the Registered Provider must ensure that prospective service users are given the opportunity for staff to meet them in their own homes or current situation if different, and that the home establishes and records from this it can meet service users needs before admission. The Assistant manager stated that this is now happening and is part of the assessment process. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 11 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 11 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 home has arrangements for the ordering, storage, recording and disposal of medication and has access to a pharmacist for advice. Omissions in medication administration were found that put service users health and welfare 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 regularly reviewed with amendments being made to the service user plans where needs have changed. This was a requirement from the last inspection. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 12 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 and the homes accident book, which are well maintained. The medication administration records were audited. There were four instances where prescribed medication had been omitted or administered but not signed for. The manager must ensure that medication administration records are accurately completed at all times. It is also recommended that the home develops a medication profile for each service users and this should include their photographs. It was previously required that the Registered Provider must ensure that wishes of service users regarding death and dying, with appropriate support and involvement of other stakeholders, are recorded. It was noted that as part of the pre-admission assessment process service users wishes regarding arrangements after death are now discussed and recorded in individual care plans. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 13 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 and 15 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. Service users are able to exercise choice and control over their lives. 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 spiritual needs. The Assistant manager informed that staff respect service users wishes regarding daily routines, which according to the home’s statement of purpose are flexible. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 14 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. 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. It was previously required that all staff to be adequately trained in basic food hygiene training. The Assistant manager stated that five staff have done the training and the rest of the staff have been booked on the course for next month. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 15 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 and 18 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. Service users’ legal rights are protected. However the home’s policies and procedures on abuse need amending to ensure that service users feel safe and protected. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. However the complaints procedure must be amended to include the timescale for response to a complaint and the complainant could approach the Commission at any times while waiting for a response from the provider. These amendments were carried out on the same day of the inspection. It was previously required that the Registered Provider must ensure that, where service users lack capacity, evidence is provided of the facilitation of access to appropriate advocacy services. The Assistant manager stated that the service users and their next of kin are now aware on how to access advocacy services and information are available in the home. 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. However the procedure must be amended to state that any abuse will be investigated by Care Management Team and not by the G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 16 nurse in charge. The staff team have had in-house training in Abuse Awreness.There have not been any adult protection concerns raised. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 17 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) 19,24 and 26 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 bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. The home is clean, hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. It was previously required that G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 18 appropriate yellow and black clinical waste bags are always used to dispose of continence pads. The Assistant manager assured that continence pads are now disposed of appropriately. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 19 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) 27,28 and 29 The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. However the off duty rotas must be completed accurately to reflect which shifts the staff are doing. One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. 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 2 staffs have NVQ Level 2 and the rest of the team will be starting their NVQ Level 2 next month. The management team are aware that they will have to give consideration as to how this standard will be achieved. Staff records were examined and were seen to contain references, criminal record checks, original application forms and copies of identification. However one of the staff files sampled had only one reference. The manager must ensure that staff files contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 20 G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 21 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) 33,36,37 and 38 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. One-to-one supervision sessions are still not being held with staff on a regular basis, this could affect the staff’s ability to consistently meet the service users’ needs. EVIDENCE: Service users and their families are consulted about the conduct of the home and their views are regularly sought. However the home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s provider must also evidence G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 22 in a Development Plan that the home is meeting its aims and objectives and is being run in the best interests of service users. 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 Assistant manager stated that she is planning to start an annual appraisal for all staff. The home appears to be well organised and record keeping very competently managed. Administration in this home is to a good standard. All statutory record keeping checked was satisfactory; this included service user case files, accidents, incidents, complaints, fire records and so forth. The health, safety and welfare of service users and staff are being appropriately protected. Certificates relating to health and safety were up to date. Gas safety, fire safety and environmental health report were seen. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x 2 x x 2 3 3 G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 24 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 1 Regulation 5(d) Requirement The manager must ensure that a copy of the latest inspection report is included in the Service User’s Guide. The manager must ensure that medication administration records are accurately completed at all times. The vulnerable adult protection procedure must be amended to state that any abuse will be investigated by Care Management Team and not by the nurse in charge. The manager must ensure that the off duty rotas are completed accurately to reflect which shifts the staff are working. The manager must ensure that staff files contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. The home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s provider must evidence in a Development Plan Timescale for action 31/10/05 2. 9 13 (2) 25/07/05 3. 18 13(6) 25/07/05 4. 27 17(2) 25/07/05 5. 29 19(4)(c) Schedule 2(7)(8) 31/10/05 6. 33 24(1)(a) & (b) 31/10/05 7. 33 24(2) 31/10/05 Page 25 G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 that the home is meeting its aims and objectives and is being run in the best interests of service users. 8. 36 18(2) 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. 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that the home develops a medication profile for each service users and this should include their photographs. G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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 G53 S13398 SerchaHouse V193095 250705 stage4.doc Version 1.40 Page 27 - 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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