Inspection on 15/06/07 for Burcot Grange

This inspection was carried out on 15th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burcot Grange 19/12/05

Burcot Grange 04/11/04

Burcot Grange 11/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Burcot Grange 23 Greenhill Blackwell Bromsgrove Worcestershire B60 1BJ Lead Inspector Nic Andrews Key Unannounced Inspection 15 and 19 June 2007 09:15 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 Burcot Grange DS0000018497.V340764.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. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burcot Grange Address 23 Greenhill Blackwell Bromsgrove Worcestershire B60 1BJ 0121 445 5552 0121 447 8111 staff@burcotgrange.com 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 Stewart Mark Bales Mrs Karen Beverley Bales Mr Stewart Mark Bales Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability (40), Physical disability over 65 years of age (40) Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to two service users, with needs in the above categories and who are aged between 50 and 65 years, for respite care only. 19th December 2005 Date of last inspection Brief Description of the Service: Burcot Grange is a large, detached Victorian building located in a rural setting in the village of Burcot. The premises have been developed and upgraded for their purpose as a residential care home for older people. A number of the rooms provide extensive views of the surrounding countryside. The home has two passenger lifts to enable the service users to access the accommodation above ground floor level more easily. The home has attractive, wellmaintained gardens and external areas where the service users and their visitors can sit in warmer weather. Car parking facilities are provided at the front of the premises. The current owners have operated the home successfully since 1990. The home is registered to provide personal care for a maximum of forty older people who are frail and unable to live independently. The service users may also have a physical disability, sensory disability or mental health needs. The home is also able to accommodate up to three people with low dependency needs in two ground floor suites adjacent to the main building. Extensive roof space in the eaves of the premises has been utilised to provide three large, self-contained units that can accommodate a maximum of five people, who are primarily self-caring, but may also require support from staff. The home provides a respite care service and two rooms are used for this purpose. A day care service for a limited number of people can also be provided on request. The stated aim of the home is to provide high quality care by dedicated professional staff within a friendly, safe and comfortable environment where everyone has the opportunity to enjoy supportive independence with home comforts, freedom of choice and an individual life style. The fees ranged from £620.00 to £900.00 per week. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over the course of two days. The home was inspected against the key National Minimum Standards with the help of the registered manager, the head of care and the head of facilities. Various records and policies and procedures that the home is required to maintain were inspected. Parts of the premises were also inspected. The care of service users was tracked. Individual discussions were held with two service users, two relatives of service users and four members of staff. What the service does well: What has improved since the last inspection? Since the last inspection the home had undertaken some refurbishment work. This had included improvements to the service users’ bathroom/showers, the staff accommodation and the training facilities. A new hairdressing salon had been opened. A yoga group had recently commenced. The home had received recent awards for the garden and external facilities. A ‘residents’ group’ had been formed that met once a month to discuss matters relating to the home and the care they received. The home had received recognition from Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 6 ‘Investors in People’ and had also received an award from an external organisation for excellence in health and safety and personnel administration. 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. Burcot Grange DS0000018497.V340764.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 Burcot Grange DS0000018497.V340764.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): 1, 2, 3 and 5. The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with the opportunity to visit the home prior to admission and are given relevant information about the service to enable them to make an informed choice. The service users’ needs are assessed and they are given a contract that contains the terms and conditions of residence. EVIDENCE: A copy of the home’s statement of purpose was made available for inspection. The information in the statement of purpose was relevant. However, it did not include all of the required information. The statement of purpose needed to include the address and relevant qualifications of the registered provider and manager, the relevant qualifications and experience of the staff working at the home, the age range and sex of the service users, the range of needs that the home is intended to meet and the home’s policy and procedures (if any) for emergency admissions. The reference to the home’s fire precautions should also include a reference to the staff fire safety training and the arrangements made for the care and accommodation of the service users in the event of a temporary closure of the home in the event of fire. The complaints procedure should include a reference to the timescale for dealing with complaints. The Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 9 arrangements made for dealing with reviews should include a clear indication that service users will be consulted and encouraged to take part in the monthly review of their care plans. The statement of purpose must include the number and size of all the rooms and the arrangements made for respecting the privacy and dignity of service users. The service users’ guide also contained relevant information. However, like the statement of purpose, the service users’ guide needed to include additional information including a description of the individual accommodation and communal space, details of the relevant qualifications and experience of the registered providers, manager and staff, any special needs or interests catered for, a statement that a copy of the most recent inspection report is kept at the home and available for perusal on request, the service users’ views of the home, the timescale for dealing with complaints and information about how to contact the local social services and health care authorities. The registered manager confirmed that all of the service users had been issued with a statement of their terms and conditions of residence (contract). The files of the service users included a copy of their contracts. The contracts were signed and dated. The contents of the contracts were satisfactory. However, the out of date reference to the National Care Standards Commission (NCSC) should be deleted and replaced by a reference to the Commission for Social Care Inspection. The registered manager confirmed that all prospective service users were assessed prior to admission. The registered manager and/or the head of care usually carried out the assessments. The assessment form included a reference to most of the aspects of care listed in Standard 3.3. However, the assessment form should also include a reference to communication, history of falls and carer and family involvement and other social contacts/relationships. The assessment form consisted mainly of a score chart. The assessment form should include more space for recording details of the prospective service users’ care needs. The home had a satisfactory admission procedure. The registered manager recognised the importance of ensuring that prospective service users were given an opportunity to visit the home prior to admission. The home had a trial period of eight weeks. A reference to the trial period was included in the statement of terms and conditions of residence. The registered manager stated that the ‘majority of service users were admitted following an introductory period’ and that emergency admissions were ‘very unlikely’. The relatives of two of the service users confirmed that their parents had both visited the home prior to admission and were given information to enable them to make a decision. Burcot Grange DS0000018497.V340764.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 and 10. The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The service users’ health and personal care is based on their individual needs. The arrangements for the storage and handling of medication help to ensure the service users’ wellbeing. The service users are treated with dignity and their right to privacy is respected. However, the care plans need to show that all aspects of the service users’ needs are reviewed and met. EVIDENCE: It was confirmed that all the service users had a care plan that was based on an assessment of their care needs. The care plans included risk assessments on mobility and pressure sores. However, the care plans that were inspected did not include a reference to all of the aspects of care that are listed in Standard 3.3. The column in the care plans that outlined the care required to meet the service users’ needs contained limited information to guide the staff in the delivery of care. Not all of the care plans had been reviewed every month. The recommendation that was made as a result of the previous inspection in regard to care plans had not been fully implemented and is referred to again in this report as a requirement. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 11 All of the service users were registered with one of six local surgeries. The service users were also receiving support from other healthcare professionals including the district nurse, chiropodist, continence adviser and the community psychiatric nurse. The home had provided one of the service users who was at risk of developing a pressure sore with a suitable mattress. The district nurse provided any additional pressure relieving equipment that was required. It was stated that nutritional screening was carried out in respect of each new service user at the point of admission where this was considered necessary. Nutritional screening using a recognised nutritional assessment form should be undertaken in respect of all service users. The home had made suitable arrangements to ensure that the service users’ received appropriate dental and ophthalmic care either in the community or at the home. The service users also underwent hearing tests as and when necessary. Two physical activity sessions were provided each week. The registered manager was intending to use the home as a venue for monthly meetings commencing in September 2007 that would provide support for people with a dementia illness and their carers. The home used the Boots monitored dosage system for the administration of medicines. The home provided secure facilities for the safe storage of medication including a controlled drug cupboard that complied with the Misuse of Drugs (Safe Custody) Regulations 1973. Two members of staff signed the Medication Administration Record (MAR) charts when the medication was written on to the MAR charts by hand. There were no photographs of the service users on the MAR charts. The MAR charts were inspected and it was noted that, in the case of two service users, there were eleven gaps the records of administration during May and June. The dates of opening were recorded on the outside of the medicine packets. Access to the medication cupboards was restricted to senior members of staff. A dedicated fridge was provided for medicines that required cold storage. A record of the fridge temperatures was maintained. The home’s policy and procedure for the administration of medication that included homely remedies had been reviewed on 18 December 2006. The registered manager confirmed that the home had a copy of the guidelines ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ produced by the Royal Pharmaceutical Society of Great Britain dated June 2003. The registered manager also confirmed that a risk assessment had been carried out in respect of nine service users that self-medicated. The list of the names and signatures of the staff that were involved in the administration of medication was updated during the inspection. The local pharmacist carried out an audit of the home’s medication procedures every six months. The home provided ‘in-house’ training on the administration of medication. In addition, the local pharmacist also provided training on the use of the monitored dosage system. The registered manager stated that all the staff that were involved in the administration of medication had received the Boots advanced training in the care of medicines. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 12 The staff with whom discussions were held understood the importance of upholding the service users’ privacy and dignity. The responses that were given by the staff to the questions that they were asked reflected good practice. The privacy of the service users was enhanced by the high standard of accommodation provided. All of the service users’ bedrooms had en suite facilities. The service users confirmed that they were treated with respect by the staff and that their privacy was maintained. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home promotes the service users’ quality of life by seeking their views, offering choice, encouraging them to remain as independent as possible and providing a balanced and nutritious diet. EVIDENCE: The service users were provided with a wide and varied range of social and leisure activities. These included activities that took place at the home and also excursions to various places of interest. A ‘Social Diary for Burcot Grange’ was produced each month for the service users in the form of a leaflet. The social activities for June included a shopping trip, visits to a garden centre and a restaurant and a garden party. In addition, the home held a number of weekly activities. These included an art class, discussion groups, exercise groups, a bridge club and a computer club. The service users received visits from ministers of religion and a Communion service was held once a month. A part-time member of staff was employed specifically to coordinate activities. The registered manager intended to develop the new tranquillity suite so that head massage and aromatherapy were provided. The service users spoke positively about the arrangements that were made by the home to provide for their social, recreational and religious needs and interests. One service user said, ‘There’s too much. There are computer lessons and visits to Symphony Hall. You needn’t sit and stare into space’. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 14 No unnecessary or unreasonable restrictions were placed on visiting. The service users and the relatives of service users with whom discussions were held confirmed that visitors were ‘always made welcome and offered a cup of tea’. The registered manager and staff were aware of the importance of service users being able to maintain contact with their families and their contact with the wider community. Opportunities for the service users to retain and enhance their contact with their relatives and friends were provided and encouraged. The home supported the service users’ right to exercise personal autonomy and choice. There was evidence to show that the service users were able to bring personal possessions with them when they were admitted. The service users spoke positively about their accommodation and expressed their pleasure at being able to personalise their bedrooms. The service users confirmed that they were enabled to make choices in regard to their daily routines and matters affecting their care including the food provided, where they ate their meals, their participation in activities and when they got up and went to bed. Details of the local advocacy service were included in the service users’ guide. The service users’ guide should also include a clear statement that the service users have the right to access the personal records held about them by the home. The menu was planned one week in advance. A choice of food was available for each meal and the service users were asked each morning to indicate their choice of food for the day. The food provided was balanced, varied and nutritious. The service users confirmed that they enjoyed the food and described it as ‘very good and well presented’. It was stated that there was always a choice. The food that was observed being served during the inspection was wholesome and attractively presented. Six service users that required help with eating were served their meals in the conservatory and were given staff assistance. Meals were served at appropriate and flexible times and drinks and snacks were available throughout the day. The dining room was clean, pleasantly decorated and provided a congenial setting in which to eat. Service users with special dietary needs were catered for including vegetarian, diabetic and gluten-free diets. Special occasions such as birthdays, St Patrick’s Day, Burns’ Night and other similar events were also celebrated. The kitchen manager consulted the service users individually each month about the food. The service users also discussed the standard of food at the ‘resident’s meetings’ and their views were relayed back to the registered manager. The kitchen was well staffed. The home had been the recipients of the Heartbeat Award for several years in succession. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and other relevant policies and procedures to help ensure that the service users are protected from abuse. The service users feel confident about making complaints. However, some of the documentation needed to be amended to ensure the safety of the service users. EVIDENCE: The home had a clear, simple complaints procedure. Details of the procedure were included in the statement of purpose and service users’ guide. The registered manager stated that the home responded quickly to all concerns and complaints. However, the procedure did not include an assurance that complaints would be responded to by the home within a maximum of 28 days. The registered manager stated that individual issues were dealt with and recorded on the service users’ files. The registered manager was advised to introduce a register in which any complaint that was made against the home could be recorded with details of the investigation and any action taken. A suitable complaints record for this purpose was introduced during the inspection. No complaints had been made to the CSCI against the home since the previous inspection. The service users said that all the staff were approachable. They also confirmed that they felt confident about making a complaint, if necessary, and that it would be dealt with quickly and appropriately. The home had various documents that helped to ensure the protection of the service users. These included a whistle blowing procedure and a copy of the Department of Health publication ‘Protection of Vulnerable Adults Scheme - A Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 16 Practical Guide in Care Homes and Domiciliary Care Agencies’ dated 26 July 2004. The home’s rules governing gross misconduct by staff were referred to in the Employees Handbook. The Handbook also contained some information about adult protection and making a protected disclosure i.e. whistle blowing. It was also confirmed that staff were given copies of leaflets on abuse. The registered manager stated that, in cases of suspected or alleged abuse, the home had use of a helpline to an external agency. The home’s policy on ‘Dealing with Aggression Towards Staff’ should include a clear statement that the use of any form of restraint must only be used in highly exceptional circumstances and that the amount of force used should be the least necessary to protect the service users or other people from harm. The registered manager said that he had begun to address this matter. A poster was displayed on the staff notice board of the Worcestershire policy and procedure for the protection of vulnerable adults. A policy and procedure on the protection of vulnerable adults from abuse should be developed to include a reference to reporting, without delay, any suspected or alleged incidents of abuse to the police, the Adult Protection Coordinator and the CSCI in accordance with Regulation 37. The policy should also be developed in accordance with the Department of Health publication ‘No Secrets’ and include, for example, categories of abuse, recognition of abuse, indicators of abuse and procedures and practice guidelines for responding to abuse. The registered manager confirmed that, since the previous inspection, no incidents of suspected or alleged abuse had occurred within the home and that the home had not had to refer the name of any member or former member of staff for consideration for inclusion on the POVA register. The registered manager stated that the staff had been made aware of issues relating to abuse through the home’s staff induction training programme. In-house training had also been provided during March 2007 that had included POVA, adult protection, whistle blowing, equality and diversity, complaints procedure and risk assessments. The training had involved all of the staff working in sub-groups led by a senior member of staff. However, further training on abuse awareness must be provided for all the staff. The registered manager stated that home’s policy in regard to service users’ money and financial affairs was ‘non-involvement’ wherever possible. It was stated that the staff were aware that they should not become involved in assisting in the making of or benefiting from service users’ wills and that instructions on this issue were included in the Employees Handbook. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. . The service users live in clean, comfortable and well-maintained surroundings. EVIDENCE: The location and layout of the home was suitable for its stated purpose. The home was a large, detached Victorian property that stood in its own grounds at the end of a long driveway. The home was well furnished and decorated to a high standard. The premises had been adapted for their present use as a residential care home and had operated successfully since 1990. The main communal areas included a morning lounge, an afternoon lounge, a conservatory and a dining room. The premises were accessible to people in wheelchairs and were well maintained. The home had two passenger lifts to enable the service users to access the accommodation on the first floor more easily. The grounds were attractive and well maintained and provided pleasant sitting areas to enable the service users to enjoy views of the garden and the surrounding area. The gardens were accessible to people in wheelchairs. The use of CCTV cameras was restricted to the front door and side entrances. The registered manager confirmed that the cameras were used for security Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 18 purposes only. It was noted that there were no handrails in any of the corridors. The registered manager said that a risk assessment had been carried out and handrails were not considered necessary. The registered manager produced a brief written programme of routine maintenance. This needed to be developed to include all of the significant items of maintenance and renewal. The home’s response to the recommendation that was made in regard to Standard 19 as a result of the previous inspection was assessed. It was recommended that the recommendations of the Fire Safety Officer should be implemented without delay. The registered manager confirmed that the recommendation had been fully implemented. The premises were clean, tidy and free from unpleasant odours. The laundry was appropriately sited and equipped. The laundry contained a wash hand basin and paper towel and liquid soap dispensers. The laundry also contained three washing machines and one tumble dryer. A recommendation was made as a result of the previous inspection that ongoing consideration should be given to the provision of a sluice. It was confirmed that two of the washing machines had a sluice facility. The registered manager also stated that a risk assessment had been carried out and that it was not considered necessary to provide a separate sluice. The recommendation is regarded as having been implemented. The laundry provided a ‘same day’ service. The ‘red bag’ system for the disposal of soiled linen was used. A supply of protective aprons and gloves were available for use by staff. The laundry floor finishes were impermeable and these and the wall finishes were readily cleanable. The cupboard in which cleaning fluids were stored was not lockable. The registered manager stated that a risk assessment had been carried out and that it was not considered necessary to provide a lock on the cupboard door. The service users expressed their satisfaction with the standard of cleanliness of their bedrooms and the standard of laundering of their own clothes. The home had an infection control policy that had been reviewed on 1 February 2007. The home’s infection control policy should be reviewed in accordance with the ‘Guidelines for Infection Control in Care Homes’ dated 2003 produced by the Herefordshire and Worcestershire Health Protection Unit. The staff cleaned manually the commode pots that are used. The home did not have appropriate facilities to carry out this task and manual cleaning is not the recommended method of decontamination. Disposable commode pots should be used. The registered manager stated that the home used separate flannels for the service users’ personal care needs and separate toilets were provided for kitchen and care staff. The home had a policy for dealing with the outbreak of infectious diseases that included a programme for keeping relatives informed. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The staff are experienced and trained to fulfil the aims of the home and to meet the needs of the service users. The staff recruitment procedures help to ensure that the service users are protected from abuse. EVIDENCE: A copy of the staff duty rota and details of the staffing arrangements were made available for inspection. These indicated that the staffing levels and deployment of staff were sufficient to meet the needs of the service users. The registered manager stated that, normally, there were five or six members of care staff on duty in the mornings, four care staff on duty in the afternoons and three care staff on duty in the evenings. In addition to the care staff, the staffing establishment included activities staff, clerical and domestic support, catering and maintenance staff. A head of department was responsible for each main area of work. At night, two members of staff were on waking duty and one member of staff was on call or sleeping-in. The staffing levels at night should continue to be kept under review in order to ensure that they are sufficient to meet the needs of the service users and their levels of dependency. The service users spoke positively about the staff. One service user described the staff as ‘wonderful’ and said that they had ‘the patience of angels’. Another service user said, ‘The staff are very helpful. They’re all very good. If you ever wanted anything they would never say ‘No’. The staff are very sensitive to what you want. They do the right thing’. Another service user said, ‘I think I’m very spoilt. I’m in sheer luxury here. I’m so lucky to be here’. The relatives of the service users also expressed their satisfaction with Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 20 the standard of care provided and the attitude of the staff. One relative said, ‘They treat my mother so well and it’s a lovely place. Any concerns are sorted out. The home attempts to keep relatives informed. You know they’ll work with you. Sensitive issues are handled appropriately. All the staff are deeply committed’. Another relative said, ‘The care is first class. We’re kept informed of changes. My mother is content’. The home employed a sufficient number of care staff who had completed the NVQ level 2 training that slightly exceeded the minimum ratio of 50 trained members of staff required by the National Minimum Standards. It was pleasing to note that the NVQ training was ongoing and that three members of staff had also undertaken NVQ level 3 training. It was confirmed that agency staff were not used. The staff files that were inspected contained evidence to show that the staff had completed an application form and had undergone a CRB disclosure check. It was noted that the staff had commenced working at the home before the results of their CRB disclosure applications had been received. However, the registered manager confirmed that a POVAfirst check was always undertaken prior to the commencement of employment. It was stated the staff were kept under close supervision and that care staff were not allowed to carry out any personal care tasks until after the results of the CRB applications had been received. Two written references had been obtained in respect of each member of staff and they had been issued with a statement of their terms and conditions of employment (contract). The staff files included a photograph. The staff were issued with a copy of the code of conduct and practice set by the General Social Care Council. During the inspection this item was included on a checklist of issues to be addressed following the appointment of new members of staff. A member of staff with whom a discussion was held confirmed that she had been issued with a contract, a job description and a copy of the code of conduct and practice. The home provided a staff induction programme for new staff. The induction was adapted from a checklist based on the TOPSS (Skills for Care) standards. The registered manager stated that the home’s policies and procedures were used to reinforce the staff induction programme. Evidence should be provided to show that the staff have read and understood the main aspects of the home’s policies and procedures. Details of the training undertaken by the staff were being recorded. However, it was not possible to assess very easily the training that had been undertaken by the staff. The individual training and development assessments and profiles in regard to all the staff needed to be further developed. The recommendation that was made in regard to this issue as a result of the previous inspection still stands. The provision of training in person centred care will enable the staff to develop a more holistic approach to their work and the development of the care plans. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and there is a positive and open approach to the management of the service. The systems that are in place for monitoring the quality of the service help to ensure that the home continues to develop in response to the service users’ needs. EVIDENCE: The registered manager had considerable relevant experience and was competent to run the home. He had completed the NVQ level 4 and Registered Managers’ Award training and had also achieved the D32 and D33 Assessors’ Award. He had undertaken a leadership course in 2005 and had recently completed training that was aimed at the continuing development of the service. The registered manager received support from senior staff who had relevant experience and who had undergone appropriate training. The service users spoke highly of the registered providers. One service user said, ‘They’re really wonderful’. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 22 The quality assurance system consists of a number of internal measures used by the home to assess the quality of the service. This included the use of questionnaires that are issued to all of the service users and/or their relatives once a year. Questionnaires were also issued to the service users admitted for respite care at the conclusion of their stay. Service users were asked to comment on any additional facilities they were seeking, what they felt the home did well and what they or their relatives felt the home could do better. The registered manager stated that the results of the questionnaires were analysed and any significant matters raised were acted upon immediately. Other information is placed on a ‘wish list’ and is fed back to the service users at the residents’ meetings so that they can discuss the issues as a group. The registered manager said that the information is also relayed to the service users’ relatives both verbally and in writing and to the heads of departments for information and/or action as appropriate. Information is also given to staff about the outcome of the service users’ questionnaires. Questionnaires to obtain the views of other stakeholders e.g. GPs, district nurses and other visiting professionals had not been used recently. A questionnaire was also used to obtain feedback from members of staff. However, one member of staff said that there had been no staff meeting for at least six months. The home had a one-year development plan that had been arranged in conjunction with Investors in People. Weekly, monthly and annual audits were carried out in regard to care, management and administration, marketing of the home, activities, staff training and housekeeping. The home was intending to introduce family support groups. The registered manager confirmed that no one connected with the running of the home acted as an agent or an appointee on behalf of any of the service users. The service users retained responsibility for their own finances wherever possible or they received assistance from their relatives or solicitors acting on their behalf. The home did not hold any money or personal allowances in safekeeping on behalf of any of the service users. The registered manager said that the home had a strict policy of not dealing with any of the service users’ money. This practice is to be commended. The service users were invoiced for any items that were purchased by the home on their behalf at the end of each month. The registered manager confirmed that the home did not hold any personal possessions in safekeeping on behalf of any of the service users. Standard 36 was not fully assessed on this occasion. However, the home’s response to the recommendation that was made in regard to staff supervision as a result of the previous inspection was assessed. It was confirmed that new supervision forms had been introduced and that supervision meetings were being recorded in greater detail. The recommendation was regarded as having been implemented. This Standard will be assessed more fully at the next planned inspection. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 23 The home had policies and procedures on a range of relevant issues to ensure the safety of the service users and the maintenance of the building and equipment. There was evidence to show that equipment such as hoists, lifts, fire safety precautions, boilers and the central heating system had been serviced and were in safe working order. The registered manager confirmed that thermostatically controlled mixer valves had been fitted to all of the hot water outlets used by service users. Quarterly checks on the water temperatures were carried out in each bedroom. The home had a health and safety policy and relevant information relating to COSHH and RIDDOR. A record of accident was maintained. The fire safety records were satisfactory. The registered manager stated that the home’s fire alarm system had a direct link to an external agency that would automatically contact the fire service in the event of a fire. The Environmental Health Officer had visited the home on 15 February 2007. The registered manager confirmed that the one recommendation arising from the visit had been addressed. Risk assessments had been carried out on various topics and areas of the home. However, the risk assessments did not include all of the safe working practice topics covered in Standards 38.2 and 38.3. Risk assessments had also been carried out in regard to the safe storage of hazardous substances in the laundry, the provision of handrails in the corridors and the provision of a barrier at the top of the steps leading to the cellar. However, the inspector was of the view that the control measures may not be sufficiently robust to safeguard the service users from the potential hazards. A requirement was made as a result of the previous inspection that notifications must be made to the Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. Since the previous inspection, accidents had occurred that had resulted in service users being taken to hospital for treatment that had not been notified to the Commission. The inspector agreed to send relevant guidance to the registered manager on this issue. The registered manager gave an assurance that the home took a robust approach to the health and safety concerns of the service users. Policies and procedures were in place to support this view. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 24 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 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X N/A X X 3 Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 15 Requirement The care plans must set out in detail the action that needs to be taken and be reviewed at least once a month to ensure that all aspects of the service users’ needs are met. Medication must be administered to the service users at the correct time and MAR charts signed at the same time that the medication is administered, to ensure that service users receive their medication safely and as prescribed. All the staff must receive formal training on the protection of vulnerable adults to ensure that service users are fully safeguarded from the risk of abuse or neglect. Risk assessments must be carried out and recorded for all the safe working practice topics covered in Standards 38.2 and 38.3 in order to ensure that service users are fully safeguarded from risk of harm. Action must be taken to ensure that notification is made to the DS0000018497.V340764.R01.S.doc Timescale for action 30/09/07 2 OP9 13 31/07/07 3 OP18 13 30/09/07 4 OP38 13 21/08/07 5 OP38 37 21/08/07 Burcot Grange Version 5.2 Page 26 Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. This is to ensure that service users can experience the safeguards provided by regulation. (Previous timescale 31/01/06 not met). 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 3 4 5 6 Refer to Standard OP1 OP2 OP3 OP8 OP9 OP14 Good Practice Recommendations The statement of purpose and service users’ guide should be amended in accordance with the guidance given in this report. The statement of terms and conditions of residence (contract) should be amended in accordance with the guidance given in this report. The form that is used for assessing the care needs of prospective service users should be amended in accordance with the guidance given in this report. Nutritional screening should be undertaken on all service users on admission using a recognised assessment form and kept under review. The MAR charts should contain an up to date photograph of the service users in order to assist identification. The service users’ guide should state that the service users have a right under the Data Protection Act 1998 to access their personal records held about them by the home and how this will be facilitated for them. The complaints procedure should be amended to include an assurance that all complaints will be responded to within a maximum of 28 days. The home’s policies and procedures on the protection of vulnerable adults from abuse should be amended in accordance with the guidance given in this report. The programme of routine maintenance and renewal of the fabric and decoration of the premises should be developed DS0000018497.V340764.R01.S.doc Version 5.2 Page 27 7 8 9 OP16 OP18 OP19 Burcot Grange 10 OP26 11 12 OP26 OP30 13 14 15 OP30 OP33 OP38 and implemented. The home’s infection control policy and procedure should be reviewed and, where necessary, amended in accordance with the ‘Guidelines for Infection Control in Care Homes’ dated 2003 produced by Herefordshire and Worcestershire Local Health Protection Unit. Disposable commode pots should be used. The home should have an individual training and development assessment and profile in respect of each member of staff that records all of the relevant training that has been undertaken, the identified training needs and how these will be met. The profile should include evidence to show that the staff have read and understood all of the relevant policies. A staff-training matrix should be re-introduced and kept up to date. All the care staff should undertake training in person centred care. The views of GPs, district nurses, chiropodists and other visiting professionals should be sought on how the home is achieving goals for service users. The risk assessments regarding the safe storage of hazardous substances, the provision of handrails in the corridors and the provision of a suitable barrier at the top of the steps leading to the cellar should be reviewed. Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Burcot Grange DS0000018497.V340764.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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