Inspection on 21/02/08 for Burgess House

This is the latest available inspection report for this service, carried out on 21st February 2008.

CSCI found this care home to be providing an Good service.

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

Burgess House 21/11/05

Burgess House 15/06/05

Burgess House 22/10/04

Burgess House 30/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Burgess House Burgess House 236 Felixstowe Road Ipswich Suffolk IP3 9AD Lead Inspector Sharon Thomas Unannounced Inspection 21st February 2008 09:00 Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 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 Burgess House DS0000037332.V360123.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 Adults 18-65. 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. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burgess House Address Burgess House 236 Felixstowe Road Ipswich Suffolk IP3 9AD 01473 588500 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) Rob.Illingworth@socserv.suffolkcc.gov.uk Suffolk County Council Mr Robert Illingworth Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2007 Brief Description of the Service: Burgess House is a local authority resource providing respite care and short breaks for younger adults (namely those under 65 years old) with learning disabilities. The house and grounds are owned by Mencap, but managed and supported financially by Suffolk County Councils Social Care Services. Staff are County Council employees. The people who use the service are known as guests. They go to their normal day care service, returning to Burgess House in late afternoon. People come to live at the home mostly for short periods of time, from a day or two to a weekend, seven days to a couple of weeks. Occasionally it is used for what are termed emergency placements because no other accommodation can be found and guests then may stay for a number of weeks or months. Referrals are made for the service through the Community Care Team. A new day resource building has been built at the rear of the property. There is a separate entrance for day attenders. Guests pay a set fee of £9.55 per night for the service. Burgess House DS0000037332.V360123.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 the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. The manager completed an Annual Quality Assurance Assessment with information about the home. Throughout the report this document will be referred to as the ‘AQAA’. We sent surveys out to people living in the home; relatives, health & social care professionals and members of staff. All of the questionnaires returned to us contained positive responses about the home and many were highly complimentary. This inspection visit was unannounced and covered the key standards, which are listed under each Outcome group overleaf. A visit to the home took place on 21 February 2008 and included a tour of the premises, discussion with the manager and members of staff. Observations of how members of staff interact and communicate with people staying there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was busy but relaxed. The home was originally registered for ten places. However, as all bedrooms had now been furnished as single rooms, the home only accepted eight guests at a time. The service is currently providing respite breaks for 95 families. We spoke to staff that work in the home and looked at a number of files and paperwork. We examined information about what services are provided for people using the service. We looked around where people live, the gardens and the grounds. The manager also wrote to the inspector and told them what they thought the home did well and what improvements had been made. The inspector also used other information that they already knew about the home from information regularly sent to the inspectors’ office. If you would like to know how people are cared for and supported you can read the inspectors report. You can ask the person in charge of the home for a copy, or contact the inspector. The person in charge of the home will give you the inspectors’ telephone number and address. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 6 What the service does well: The service is a well run by a knowledgeable, skilled manager and good support staff who recognise and practice Equality and Diversity relating to all people using the service. There is a strong ethos of listening to people and acting on their views. People staying in the home are empowered to make their own choices and decisions; they are helped to understand about rights and responsibilities. Burgess House has a good Quality Assurance system that takes into account the views of people staying in the home, relatives and other interested parties. The atmosphere in the service is relaxed and friendly and there are good interactions between people staying there and members of staff. There is a robust system for the storage and administration of medication to support and protect people living in the home. Burgess House has developed good systems for care planning and that ensure residents needs and aspirations are realised. reviews Staff do the right things to keep people healthy and know what to do if they become ill. The home only allows people to work there once they have gone through the required employment safety checks. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to use the service can be confident that Burgess House will carry out a pre-admission assessment that will decide whether the service can meet the needs of the individual. EVIDENCE: The AQAA states that all referrals to the service come through the Community Team and the individual has an up to date Community Care Assessment and Carers Assessments. One senior member of staff takes the lead on new referrals arranging to meet the person and their carers to discuss our service provision and ensure it is suitable for the individual. Any potential restrictions on choice, freedom or facilities are discussed during the initial assessment and family carer’s views and needs are taken into account with the individual’s agreement. We examined the care files of three people who use the service and found that they contained a full range of assessments that generate a clear guide to staff of what care the person will need and how they wish to receive their care. The care files contained a copy of the most recent social service assessment that overall gave Burgess House the information that they needed. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported to be involved in decisions about their lives and play an active role in planning the care and support they receive. EVIDENCE: At the time of the last inspection care plans were judged to be good and since then, the manager and staff has continued to develop the care plans to further improve them. We looked at the support plans for two people using the service as part of the inspection process. These contained clear detail of the actions that staff needed to take to support individuals to live an independent lifestyle to the maximum of their capabilities while staying at Burgess House. There is evidence to confirm where individuals had been consulted and involved with developing their support plans. For those less able to contribute there was evidence of family involvement. The care plans contained information Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 10 regarding the physical, social and emotional support that people needed and the care that staff needed to provide. These documents are well written and contained accurate and up to date information. Residents’ files contained support plans for all areas of daily life, risk assessments and information relating to instances where residents’ rights were infringed in order to maintain their safety and well being. Risk assessments were present for activities including accessing the community, wheelchair use, social activities, swimming and medication amongst others. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to continue to carry out their normal activities and lifestyles while they stay at Burgess House. EVIDENCE: People staying at Burgess House are supported to continue to attend their usual day resource centres during the week and this was evidenced on the day of the visit when all the guests had left for the day. Some of these are attending the 40 Plus day centre attached to Burgess House. Family contact is a key part of the assessment process and this enables staff to gain a deeper understanding of the needs of people staying with them. Guests staying for a weekend are encouraged to continue to take part in their normal planned activities. People staying in the service could go out to the nearby shops, the cinema, or the local pub. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 12 The guest contract made clear that staffing resources meant that it was not possible to accompany guests to regular clubs or meetings. Parents/carers are asked to make arrangements for this. The manager’s AQAA states that the service supports people to access local amenities and attend social events, however many people enjoy staying in the home during their visits. From written documents and discussion with the staff it is clear that the staff have an in depth knowledge of the people using the service. The staff have a strong commitment to providing a positive experience to people staying in Burgess House. The kitchen was inspected on this visit and we found it to be clean and well organised. The permanent chef is not currently working in the kitchen and other staff have temporarily taken on this role. The stocks of dried, fresh and frozen food are plentiful. The service caters for individual eating plans and evidence of this was found in the kitchen. There is a 5-week menu, which provides for full meals at breakfast and evening. Packed lunches are provided for those going off-site for day care. Staff are aware of the likes and dislikes of the people using Burgess House. One relative commented that …”the cooks are very mindful of giving food my [relative] likes and they go to great lengths to do this”. The manager’s AQAA states that dietary sheets are completed for all people staying in the service and that staff use this information to adapt the menu or offer alternatives. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to stay in Burgess House receive excellent personal and healthcare support that meets their needs and wishes. There are systems in place to ensure the safe administration of medication and the protection of people staying there. EVIDENCE: We found evidence in people’s care plans that indicated showed that guests’ health was closely monitored and professional advice sought as and when required. The care plans recorded contact or visits by health care professionals. Pre-admission and risk assessments identified health care issues to make sure the staff are aware of any action to be taken regarding the health care issues of individuals. People are supported if they are able to to make decisions regarding their health care needs and these decisions are recorded appropriately in the daily records. Medication is brought in by guests to cover the duration of their stay. A letter of authorisation signed by the GP had to accompany all medication and be in Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 14 the original containers clearly marked with the person’s name, the date dispensed and the correct dosage. Details of these are recorded at the beginning and the balance at the end of each stay. Medication Administration Records (MARS) are kept up to date, a sheet recording staff signatures and corresponding initials was to be placed at the front of the MARS folder making it possible to quickly and easily identify who had administered medications. Medication held in the home is stored securely to ensure the protection of people staying there. The manager’s AQAA states that the health cared needs are monitored by staff during their stay in the service. Following a risk assessment guests are encouraged to self-administer their own medication and that all medication issues are recorded and staff are aware of these issues before providing support. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying in Burgess House and their representatives were able to express their concerns and could be sure they were listened to and taken seriously. The service operates appropriate practices and procedures to protect vulnerable adults. EVIDENCE: There had been no complaints received by the home or by the Commission for Social Care Inspection since the previous visit. The home has a clear and informative Complaints Policy and Procedure in use. It is available in a pictographic format in the home. All of the relatives who replied to the preinspection survey said they had never had to make a complaint but they were aware of how to make a complaint. The manager’s AQAA states that the whole staff team have received training or refresher in the Protection of Vulnerable Adults since the previous visit to the service. The policies and procedures relating to recruitment promoted the safety of people living at the home by including obtaining enhanced Criminal Records Bureau disclosures and two written references before a new staff member starts work at the service. Staff training in the protection of vulnerable adults is recorded, and staff are able to describe the action they would take if any allegation of abuse were made. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to use Burgess House benefit from a homely, comfortable environment that is well maintained and clean. There are adaptations and equipment in place that meet the needs of the people staying there. EVIDENCE: Burgess House has eight single bedrooms all with a wash hand basin. The manager’s AQAA states that there is a high demand for ground floor bedrooms and in resonse to this the service has converted an unused lounge into a bedroom and decomissioning another bedroom within theservice, thus not affecting the registration. Although people using the service could not be guaranteed that they would always be given the same bedroom, every effort was made to accommodate individual wishes. Where a guest had special physical needs, his or her stay could well be arranged so that the same bedroom was provided because of the specialist equipment in situ. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 17 We found the laundry area clean and well organised. Some laundry is done for guests such as underwear, but mostly their laundry is bagged and goes home with individuals at the end of their stay. As previous there is a bathroom on each floor, and two shower rooms downstairs, one with a ceiling hoist. The downstairs bathroom has a Malibu bath with a hoisting chair. The room is spacious enough for wheelchair access. The home is well maintained and offers a homely and domestic atmosphere to those wishing to use the service. One bedroom is equipped for guests who needed to be hoisted. Slings with guests’ names on them are kept in storage for their next stay. All guest rooms had been fitted with automatic electronic door closers linked to the fire alarm. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying in Burgess House benefit from a competent, well trained staff team, who are well supported and well managed. The recruitment procedure in the service provides the safeguards that ensure appropriate staff are employed. EVIDENCE: A sample of two staff personnel files was examined on this visit. Records are well maintained and all the necessary documentation is in place, including photographs, references, health declarations, proof of identity and Criminal Records Bureau (CRB) checks. Training for staff continues to be organised for the year. The majority of the training is done on site. The home is closed on training days. The training on those days covered Food Hygiene, COSSH, Sensory Awareness, Unisafe, and the Protection of Vulnerable Adults. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 19 Of the 20 permanent staff team 14 have achieved NVQ Level 3 while 2 are undertaking the NVQ Level 2. This is a great improvement on the number of staff with this level of training at the last inspection. The managers AQAA states that staff receive 6 days a year training that relates to the needs of the people that stay in Burgess House that includes both mandatory and specialist training. The range of training provided in the home enables staff to offer people a more person centred knowledgeable and relevant service. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to stay in the home may be confident that the service is well managed. The ethos of the home ensures that the interests of people staying there are central to the way the home is run. The health and safety of people using and working in the home are promoted and protected. EVIDENCE: There were two people registered as joint managers, since the previous visit one manager has moved on within the organisation. The service is now managed by Robert Illingworth. Management tasks are now Mr Illingworth’s sole responsibility and he is aware of the whole picture of activity in the home. From discussion with the manager it was clear that he is capable, competent and knowledgeable about the service and the people using it and this can only benefit the people staying in the service. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 21 The AQAA states that the manager in the home has the qualification and experience to manage the home. People using the service are asked to express their opinions through the quality assessment programme. Some Health and Safety records were examined on this visit. Service certificates showed that equipment used in the home is regularly checked to ensure the safety of the people using it. There are records of weekly checks on hot water temperatures of baths and showers, and monthly checks of hand wash basins. Fire alarms are tested weekly by staff and quarterly by an outside contractor. Staff spoken with were able to explain their role in keeping people including themselves safe. Evidence was seen of action taken, including the testing of emergency lighting, and the training of staff. Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 © 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 Burgess House DS0000037332.V360123.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!