CARE HOMES FOR OLDER PEOPLE
Burgh Heath Road (33) 33 Burgh Heath Road Epsom Surrey KT17 4LP Lead Inspector
Lisa Johnson Unannounced 16 June 2005 10:00 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. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Burgh Heath Road (33) Address 33 Burgh Heath Road Epsom Surrey KT17 4LP 01372 741025 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) Mrs Mala Jagutpal Mrs Mala Jagutpal Care Home 3 Category(ies) of LD Learning Disability (1) registration, with number MD(E) Mental Disorder - over 65 (2) of places Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 1 resident 20-65 years, 2 residents over 65 years. Date of last inspection 20 July 2004 Brief Description of the Service: 33, Burgh Heath Road is a large semi detached house situated in a residential area close to the town centre of Epsom. The home is presently registered for three service users. The accommodation is on two levels. There are three single bedrooms on the first floor. There is a large lounge and dining area. There is a large kitchen which is accessible for service users to make snacks and drinks. There is a large garden which is well maintained and accessible. There is car parking facilities at the front of the house. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s first inspection for 2005/2006. This was an unannounced inspection carried out by one inspector and took place over three hours. The main focus of the inspection was to review the requirements made at the last inspection. A tour of the premises took place. Care plans, staff files, policies and procedures and other documents were sampled. The inspector spoke to residents and staff and provided comment cards. Due to the various activities that service users were undertaking out side of the home the inspector was only able to obtain minimal feedback from service users. The inspector would like to thank the service users and staff for their assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection?
All of the requirements made at the last inspection have been completed. A comprehensive range of policies have been implemented which relate to records that must be kept in relation to service users. All staff have completed training in first aid ensuring that there is a first aider working on each shift. A business and financial plan is available as well as an annual development plan. A policy has been implemented in respect of the death of a service user and a quality assurance system has been put in place based on receiving feedback from service users, relatives and health professionals. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5 Adequate information was available that would assist prospective service users make an informed choice as to whether the home would be a suitable place to live. Assessments are completed prior to new persons being admitted to the home and trial visits and stays are accommodated. EVIDENCE: The homes Statement of Purpose was sampled and found to be detailed and informative. The document described the services that the home is able to offer. There is a clear admission policy, including an assessment process, which takes place prior to any new person being admitted to the home. There is opportunity for prospective service users and their relatives to visit the home and to stay. Contracts were in place in the form of a statement of terms and conditions. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9,10 &11 The health and personal needs of service users was being met. Risk assessments were completed. Some service users retain and administer their own medication and are protected by the homes policies and procedures. The manager has implemented a plan that adheres to the individuals wishes with regard to illness and death. EVIDENCE: Each service user in the home has a comprehensive care plan in place. It was clear that service users health and personal needs were being met. Dates of care plan meetings were documented and were being implemented in consultation with service users. There was evidence that health screen checks were taking place and one service user who suffers from diabetes was being supported with monitoring. Risk assessments were up-to-date and support service users to maintain an independent lifestyle. Accident records were maintained adequately and medication and records stored appropriately. Two service users self administer their medication and safe storage was observed in service users bedrooms and this was supported by written risk assessments. The home has implemented a policy and procedure in relation to handling death and dying.
Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 10 However photographs of service uses were not available on service users plans and this has been made requirement. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 & 15 Activities provided in the home are flexible and varied to suit service users preferences. Service users are given the opportunity to maintain contact with the community, family and friends and are assisted to exercise choice and control over their lives. EVIDENCE: There was evidence that service users are involved in household activities such as meal preparation, housework and gardening. Evidence was seen that service users have individual tastes and are given opportunities to make choices about meals. They are able to come into the kitchen and make snacks and drinks for themselves, indicating that service users are encouraged to lead as an independent life as possible. One service user uses public transport independently and was initially supported by staff through this process. A confidentiality policy is in place and information maintained in the home was kept appropriately. There is a range of activities in the local community for service users if they so wish. One service user has employment at a garden centre and service users attend classes at college. Individual are able to come in and go out as they please: two service users who were leaving stated that they were going for a fish and chip meal and then going to the pub confirming this. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 12 There are opportunities for service users to attend church, shopping and the hairdresser. Service users have the opportunity to visit friends and family and friends can visit the home. There is access to a telephone for private calls. Although there are service user meetings in the home, these had not been updated and a requirement has been made that service users are kept informed on the pending changes in the home. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 standard(s) 16 & 18 The home has an adequate complaints procedure. The staff team have received training in the protection of vulnerable adults which protects service users from abuse. EVIDENCE: A clear complaint policy is available and is kept in the service user guide. There have been no complaints received since the last inspection. The Local Authority Protection of Vulnerable Adults procedure is in place, however the home is required to obtain an updated copy. Evidence was available that staff have attended Protection of Vulnerable Adult training, The home has implemented feedback forms that have been given to service users, relatives and health professionals to obtain their views about the service and these were sampled. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 23, 24, 25 & 26 Service users live in a comfortable, hygienic and well-maintained environment. Service users bedrooms are maintained and decorated to their choice. EVIDENCE: The sitting room is well presented and provides a homely atmosphere. Toilet, washing and bathroom facilities were sufficient in number to meet the needs of the service users. Bedrooms are spacious and decorated with the personal belongings and interests of the service users. Service users have keys to their room but evidence was seen that one service user does not like to use the key and this has been documented on the care plan. There is a large kitchen, which was cleaned to a high standard. Food was stored appropriately and fridge and freezer temperatures were recorded daily. An application has been received by the Commission for Social Care Inspection in relation to the home increasing the number of service users from three to six living at the home. At the time of the inspection maintenance work was being undertaken. Three bedrooms upstairs were in the process of being
Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 15 decorated. A new office is in place with the existing office to become a dining room. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 16 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, 29 & 30 The staffing levels were adequate to meet the needs of service users. Appropriate training has been carried out to ensure that staff carry out their job role safely and competently. However staff supervision needs to be in place on a regular basis. EVIDENCE: There are three staff on duty in the home, including the manager. The manager has completed the Registered Managers Award and one staff member is completing the National Vocational Award level three. Evidence was seen that staff have been undertaking developmental training, which includes; administration of medicines, first aid, infection control, fire training, health and safety and supervision and practice. As the home will be recruiting three new members of staff a requirement was made that an induction programme is implemented. Personnel files for the three members of staff were sampled. Evidence was available that the required information was available and that police checks have been undertaken. Staff supervision sessions have been implemented however these were found to be out of date and a requirement has been made that all staff receive supervision at least six times a year. Staff meetings were sampled and were not taking place regularly and this has been made a requirement. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 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) 31, 32, 33, 34, 36, 37 & 38 The home is managed in an open and inclusive atmosphere. A quality assurance system has been implemented based on seeking views from service users. Policies and procedures have been implemented. However written records are to be maintained for recording weekly fire alarm checks and water temperatures to ensure that the safety and well being of service users. EVIDENCE: The manager has completed the Registered Managers Award and has several years experience as a manager. The management approach was observed to be open and it was clear that service users are encouraged to take an active role in the home. The manager has made good progress in implementing policies and procedures, which safeguard the rights and interests of service users, such as control of harmful substances, infection control and food hygiene. The manager has implemented a quality assurance system to gain feedback from service users, relatives and health professionals.
Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 18 A business plan is in place and the service is financially viable. Although staff supervision has been implemented records were outdated, therefore this has been made a requirement. Records are stored and maintained appropriately and a confidentiality policy was in place. The home has received an updated report from the fire officer and the manager ensures that fire drills are recorded. A new alarm system has been installed and the manager must record that weekly fire alarm checks are maintained. A record is also to be maintained for recording water temperatures to reduce the risk of accidents. All staff have received updated first aid training, which ensures that a trained staff member is on duty on each shift. Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3
COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 2 3 2 Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 20 NO 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. 2. 3. 4. Standard 7 14 18 16 Regulation 17 (1) (a) 12 (2) 13 (6) 22 Requirement A photograph must be made available on all service users care plans. Service user meetings in the home must be updated. An updated copy of the local authority POVA procedure must be made available. The complaints procedure must be amended to state that CSCI can be contacted at any stage of a complaint. All staff must recieve up to date supervision and a record kept. An induction programme and training plan must be imlemented for all new staff. Staff meetings must be updated and recorded. Written records must be implemented showing evidence that fire alarm points and water temperature are taking place regularly. Timescale for action 1month 16/7/05 2 months 16/8/05 1 month 16/ 7/05 1 month 16/ 7/05 2 months 16/7/ 05 2 months 16/8/05 1 month 16/7/05 1 week 23/6/05 5. 6. 7. 8. 36 30 36 38 18 (2) 18(1)(c) 21 23 Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 21 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 Good Practice Recommendations Burgh Heath Road (33) H58-H09 s13488 33 Burgh Heath Road v221152 160605 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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