Latest Inspection
This is the latest available inspection report for this service, carried out on 8th April 2008. 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.
For extracts, read the latest CQC inspection for Braeside (30).
What the care home does well Braeside provides care in a small homely environment. We found that People receive care to a good standard. Each person has a very individualised care plan. Individual needs are catered for and every effort is made to ensure that people`s right to make decisions is maintained. What has improved since the last inspection? The management of the home is focused on a planned outcome to have more people living at Braeside. Care is to a good standard, the record of how care is given has improved, and demonstrates how individual needs are catered for. A comprehensive record of food is now maintained. The environment is looking fresh and the small changes to the furniture in the living room are an improvement. What the care home could do better: The service must record how they safeguard people from harm when using the wheel chair outside. A record of non-verbal statements by people will help staff to understand needs. The presentation of the Statement of Purpose is being considered for review. CARE HOMES FOR OLDER PEOPLE
Braeside (30) 30 Kendall Avenue Sanderstead South Croydon Surrey CR2 0NH Lead Inspector
Jean Stuart Key Unannounced Inspection 8th April 2008 10:00 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 Braeside (30) DS0000025757.V361624.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. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Braeside (30) Address 30 Kendall Avenue Sanderstead South Croydon Surrey CR2 0NH 020 8407 0640 F/P 020 8407 0640 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) Mr Runjeetsingh Sowambur Mr Runjeetsingh Sowambur Care Home 3 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3) of places Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD(E) (of the following age range: 65 years and over) The maximum number of service users who can be accommodated is: 3 16 May 07 2. Date of last inspection Brief Description of the Service: Braeside is a care home for older people who have a mental health problem. The home has provisions to accommodate up to three older people. At present one person lives at Braeside. The home is situated in a pleasant residential area of Sanderstead. Both Sanderstead and Purley Oaks railway stations are within easy walking distance. The home is owned and managed by, Mr. Sowambur the Registered Provider who lives in the top floor of the property. The home consists of three good-sized bedrooms, all on the first floor, a lounge, dining room and kitchen. On the ground there is one toilet, and a toilet and separate bathroom on the first floor. There is a large garden to the rear of the home. The resident is charged £400 per week for the services of the home. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good quality outcomes.
This inspection was unannounced and completed over one day. The site visit lasted four hours. The manager, the person living at the home and one care service professional were spoken with. Records relating to care plans, food, medication, and staff training were seen. Record keeping is to a good standard and reflects the support needed and how this should be given. A tour of the premises was undertaken. Information from the home’s Annual Quality Assurance Assessment has also been included in this report. Braeside provides a small family setting that is very person centred. It is a house on an ordinary street within the local community. The house is comfortable, homely and clean. A care manager reported that “a lot of one to one time” is given. People appeared to be calm and very settled and did not display any anxiety. What the service does well: What has improved since the last inspection? What they could do better:
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 6 The service must record how they safeguard people from harm when using the wheel chair outside. A record of non-verbal statements by people will help staff to understand needs. The presentation of the Statement of Purpose is being considered for review. 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. The summary of this inspection report can be made available in other formats on request. Braeside (30) DS0000025757.V361624.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 Braeside (30) DS0000025757.V361624.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The Local Authority initially assessed the needs of the person. The provider also carries out an assessment of need when people move into the home ensuring that needs can be met. EVIDENCE: Before moving into the home, an assessment of each person is carried out by the placing Local Authority. This enables the provider to judge if the establishment can meet the person’s needs. It provides staff with information to set up an initial individualised plan. A good assessment of need was seen for an individual who lives there.
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 9 No other person has moved into the home since the last inspection. The home offers intermediate care but this has not been given in the last year. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Care planning is in place for individuals ensuring that there is a complete and current record of need. Records show health care needs are attended to. There is an efficient medication policy, medication records are fully completed. The person’s right to make decisions is respected. EVIDENCE: We found that care plans are person centred and written in plain language looking at all areas of a person’s life. People right to live the life they choose is respected. The person chooses not to speak, yet their facial features displays their reaction to a question. A record of
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 11 the non-verbal communications by the individual will help people to understand the persons needs. Wheelchairs are used in the community with the manager. The home must ensure that risk assessments are completed for this activity to protect the person from harm. One person is registered with a local doctor. The CSCI was informed when the person recently had time in hospital. The record shows that an individual’s needs are as evidenced by district nurse visits. Peoples’ health needs are met. Each individual has their own room and are free to come and go around the home. Their right to privacy and autonomy is upheld. When a non-verbal decision regarding an afternoon snack was made, the manager obliged and respected the resident’s decision. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People’s preferred life style is accommodated and they can exercise choice about how they wish to live. The manager assists contact with family. A comprehensive record of the satisfactory food served. EVIDENCE: A record is maintained of daily life, including regular walks, planned holidays, and involvement with professionals such as trips to the G.P. and visits by the District Nurse. This gives an outline of the persons preferred life style. We asked how people spend their day, they could not be encouraged to talk and chose to sit in silence. Braeside (30) DS0000025757.V361624.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Individuals feel safe and confident in the service provided by Braeside. Staff are aware of the issues around abuse, their primary aim being to protect people from harm. EVIDENCE: One person did give a full response when asked if they are happy at Braeside, but did show in other conversations they could respond negatively when required. The manager reported that there have been no complaints in the past year. A previous complaint has been seen on an earlier inspection. The complaint procedure is outlined in the Statement of Purpose and the service user’s guide. We saw evidence that the manager had been on adult protection training in 2005. To protect people, all family working in the home staff have been CRB (Criminal Record Bureau) checked.
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 14 To safeguard residents financial affairs all matters are dealt with through an accountant. The accountants holds all current information, a record of this was seen on a previous occasion. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, clean, well maintained environment, a homely atmosphere has been created. EVIDENCE: We spoke with a person in their large bedroom. This person was at ease in their bedroom. Rooms in the house have been painted and the decor now looks fresh. A change of prints in the lounge and a photograph of a person who lives there add to the homely appearance. Furniture in the room is arranged with care. The environment of the lounge has improved by the room having less furniture.
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 16 The toilet has been painted, and made more cheerful by landscape prints placed on the wall. The manager reported that the bathroom is the next room to be decorated. There is a good level of cleanliness through out the home rooms were free from offensive odours. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet current needs of residents accommodated in the home. A committed family team supports the resident and staff numbers are adequate to meet the needs of people. EVIDENCE: The home has a satisfactory staff roster. One member of staff is available throughout the day. The home currently has one resident. There no turnover of staff (family members), which provides people with stability and consistency. The manager is a qualified nurse and has National Vocational Training Level 4 training. Staff records show that courses have been completed in dementia, moving and handling, fire safety, and food hygiene. Some people providing care have attended training in protection of residents from harm/abuse, and food handling.
Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 18 The home does not have a recruitment and selection policy. All people who work there have done so for many years. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The health safety and welfare of people including fianacial matters are promoted and protected through policies, procedures and informal consultation with the person. The manager is fit to be in charge. EVIDENCE: Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 20 The manager is now providing a clear sense of direction for the home. He is very committed to being able to provide a home for more people without losing sight of the needs of the person who lives there. The manager seeks professional help when necessary to ensure that people’s long term financial issues are protected. The health safety and welfare of people are promoted and protected through policies, procedures and informal consultation with people. It was noted that in line with good practice policies and procedures are reviewed annually. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 13(4)(b) Requirement The home must ensure that risk assessments are completed and any activity is free from avoidable risks. Timescale for action 31/05/08 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 OP7 Good Practice Recommendations Staff must reflect on the care plan how a person speaks using body language. This will ensure a fuller understanding of the person’s needs. Braeside (30) DS0000025757.V361624.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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