CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE
Burgh Heath Road (33) 33 Burgh Heath Road Epsom Surrey KT17 4LP Lead Inspector
Lisa Johnson Announced Inspection 17th November 2005 10:00 X10029.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 Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 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 and 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. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 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 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) www. Burghheathlodge. Co.uk Mrs Mala Jagutpal Mrs Mala Jagutpal Care Home 3 Category(ies) of Learning disability (1), Mental Disorder, registration, with number excluding learning disability or dementia - over of places 65 years of age (2) Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 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 16th June 2005 Date of last inspection 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 are car-parking facilities at the front of the house. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second inspection carried out in 2005/2006.The announced inspection took place over four hours and was carried out by one inspector. A full tour of the premises was undertaken and care plans policies and procedures and other required documentation was sampled. The inspector spoke to three service users, the registered manager and one member of staff in the home. The inspector also spoke to one visiting health care professional. Two comment cards were received from service users, one from relatives and three from health care professionals. These comments are reflected in this report. The inspector would like to thank the service users and staff for their assistance and cooperation during this inspection. What the service does well:
There was a homely and friendly atmosphere in the home. There was evidence to support that service users are encouraged to be as independent as possible and observation confirmed that staff talk to service users and provide support when required. Good relationships were seen between service users and staff. Service users spoken to spoke well of the home and its staff. Comments such as “I like living here, the food is very good”. Another service user said “I can make choices about my meals and I can get up when I want”. It was evident that service users are involved in decision-making and participate in household tasks one service user said “ We have meetings and I like to tidy the garden and help to clean the car, it keeps me active”. Another comment received was, “ I enjoy doing my housework, I like dusting and cleaning my windows”. Another written comment received from a service user stated, “ I am happy everything is so good”. A comment received from a health care professionals were “The home provides the highest care possible”. “The home is always friendly and welcoming”. A relative comment received reflected that care is satisfactory and that they are always made to feel welcome when they visit
Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
All staff must have two references and a photograph available on their personal file and these documents were missing on one staff file sampled. A requirement was made that documents must be made available. This is to ensure that service users are protected by the homes recruitment policy and practices. One person has been helping in the home on an occasional basis assisting with kitchen and cleaning duties but is not officially employed. However there was no evidence provided that this person has been recruited appropriately with no protection of vulnerable adult or police check. An immediate requirement was made that person should not be assisting in the care home until appropriate checks have been applied for and the recruitment policy followed. This is to ensure that service users safety and welfare is protected. A further requirement was made that the home obtains copies of the General Social Code Conduct. As the home is currently recruiting new members of staff a copy must be made available.
Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 7 A recommendation was made that the registered manager should consider implementing a complaints log record and a further recommendation was made that the home should consider implementing a written programme for planned maintenance and fabric and decoration of the home. 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) DS0000013488.V257103.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5 The homes Statement of Purpose and service user guide provide prospective service users with sufficient information to help them make an informed choice about admission to the home. The home is able to demonstrate that service users needs are assessed prior to admission to the home. Service users are provided with the opportunity to test drive the home. EVIDENCE: Since the previous inspection the home has now been registered for six service users. The Statement of Purpose and service user guide have been updated and provide an overview of the homes facilities and services. A service user spoken to confirmed that he is being provided with information about the home. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 10 The home is currently receiving referrals to the home and one new service user has recently been admitted on trial basis. The assessment carried out was detailed and gave a good overview of his needs. Goal plans and risk assessments have been completed. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 The home is able to demonstrate that resident’s health and emotional needs are met. Detailed risk assessments were in place. Service users rights are respected. EVIDENCE: Each resident has a completed care plan, which has been reviewed and based on assessment. Plans were detailed and structured with clear goal plans in place. Plans have been signed by residents where possible and key workers. Detailed risk assessments were in place.
Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 12 Service users have access to a range of health care specialists including access to a local GP. Comments received from two health professionals concluded that they are satisfied with the overall care provided in the home and that effective communication takes place. One health care professional stated, “ The home has been providing the highest care possible”. Staff were observed to be knocking on service users doors before entering. Comments received from two service users confirmed that they have a key to their room and that their privacy is maintained. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home supports service users to maintain independent living skills. Service users take part in fulfilling activities and participate in the local community. Service users engage in a range of leisure activities. Residents are provided with a well-balanced diet. EVIDENCE: Service users spoken to enjoy being independent and visit the local shops, going to the local café and meeting friends in the local pub. One individual spoken to maintains contact with her relative who she visits and telephone access is available. One service user works in a garden centre and is in possession of his own bicycle.
Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 14 One individual said “ I like helping in the home by tidying the garden and cleaning the car”. Another service user said, “ I like dusting and cleaning my windows”. Service users confirmed that meetings are held in the home, which they attend. One service user spoken to said, “I like living here, and I can have a lie in when I want”. Service users are provided with the opportunity to choose their meals on daily basis respecting individual choices and preferences. Service users spoke highly of the meals provided. One service user said, “ The meals are very good and I can choose where I have my breakfast”. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 15 Complaints and Protection
The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The home is able to demonstrate that there is an accessible complaints procedure. Service users legal rights are protected. EVIDENCE: A complaints procedure is in place and no complaints have been received since the previous inspection. Comments received from service users indicate that feel happy and safe living in the home and know whom to approach in the home if they had any concerns. One service user stated, “ I am happy, everything is so good”. A recommendation was made that the home implements a complaints log record book. Service users were provided with information to enable them to participate in voting in the elections Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25 & 26 The home is able to demonstrate that service users live in a comfortable home, which is clean and hygienic. EVIDENCE: A full tour of the premises took place. Since the previous inspection the home is increasing its occupancy from three to six service users. There is now a large separate dining room and three extra bedrooms. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 17 There is a separate toilet and shower downstairs and a further bathroom and toilet upstairs. Stair rails are in place and referrals would be made for an occupational therapist assessment for any specialist aids or equipment should these be required Bedrooms have been redecorated and new armchairs have been obtained. Bedrooms were personalised with individual’s belongings and personal interests. However a recommendation was made that the registered manager should consider implementing a written programme for the renewal of fabric and decoration of the home. The home is in close proximity to Epsom Town centre and externally the home is maintained in good decorative order, which is in keeping with the local community. A superficial crack was observed in the sitting room wall and the manager said that an engineer is currently looking at the cause of this. The home was clean and hygienic. Laundry facilities are separate to the kitchen area. Adequate hand washing facilities were in place with soap and hand drying towels in place. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The home should ensure that all required documents are made available in staff files. This is to ensure that service users are protected by the homes recruitment policies and practices. EVIDENCE: References and photographs were unavailable for one member of staff. A requirement was made that all documents are made available to ensure that service users are protected by the homes recruitment and policies and practices. During the inspection a discussion took place in respect of one person who was seen working in the kitchen. The manager stated that this person visits occasionally and is known by the manager and assists with kitchen duties and cleaning but is not employed by the home. There was no evidence that this individual has received a protection of vulnerable adult and police check. An immediate requirement was made that this person should not be assisting in the home until applications are made for these checks and recruitment policy
Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 19 and practices have be followed. This is to protect the health, safety and welfare of service users. The home has completed a local code of conduct. However a requirement was made that the home acquires copies of the code of conduct set out by the General Social Care Council and should ensure that all staff are issued with a copy. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 37 & 38 The home is able to demonstrate that service users financial interests are supported. Adequate policies and procedures were in place. The health, safety and welfare of service users is protected. EVIDENCE: Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 21 Service users manage their own finances and all have their own bank accounts. A range of policies and procedures were sampled including, nutrition, accident reporting, whistle blowing, access to records and confidentiality. Records were sampled for maintenance testing including electrical testing; gas certificates, and insurance certificates were in place. The home now has adequate records in place for recording weekly fire alarm checks and water temperatures. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 22 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 3 2 X 3 3 4 X 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 ENVIRONMENT Standard No Score 19 3 20 X 21 3 22 3 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 34 35 36 37 38 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X 3 X 3 3 Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 23 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 29 Regulation 19 (1) (b) Requirement a) The registered manager must ensure that two references and photographs are made available for all members of staff employed in the home. This is to ensure that service users are protected by the homes policies and practices. b) The registered manager must ensure that one person who has been providing occasional assistance in the home must not work in the home until a protection of vulnerable adult check has taken place. An application must be made for a police check and recruitment policy and practices are followed. This is to ensure the health, safety and welfare of service users is protected. The registered manager must obtain copies of the code of
DS0000013488.V257103.R01.S.doc Timescale for action 17/12/05 29 19 (1-5) 2. 29 1 (4) 17/12/05
Page 24 Burgh Heath Road (33) Version 5.0 conduct and practice set out by the General Social Care Council and to ensure that all existing and new staff that will be employed in the home are issued with a copy. 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 2 Refer to Standard OP 16 OP 19 Good Practice Recommendations The registered manager should consider implementing a complaints log record. The registered manager should consider implementing a written programme for the renewal of the fabric and decoration of the premises. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Surrey Area Office 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
© 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. Burgh Heath Road (33) DS0000013488.V257103.R01.S.doc Version 5.0 Page 26 - 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!
