Inspection on 19/12/05 for Burcot Grange

This inspection was carried out on 19th December 2005.

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

The inspector 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 15/06/07

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 R McGorman Unannounced Inspection 19th December 2005 14:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burcot Grange DS0000018497.V267501.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. 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.V267501.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burcot Grange Address 23 Greenhill Blackwell Bromsgrove Worcestershire B60 1BJ 0121 445 5552 0121 445 8111 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.V267501.R01.S.doc Version 5.0 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. 4th May 2005 Date of last inspection Brief Description of the Service: Burcot Grange is registered to provide residential care for up to 40 older people, who are frail and unable to live independently, who may have a physical or sensory disability or who may have mental health problems. The home is also able to accommodate up to 3 people with low dependency needs in two ground floor suites adjacent to the main building. Extensive roof space in the eaves of the house has been utilised to provide 3 large self-contained units that can accommodate up to 5 people, who are primarily self-caring, although may occasionally request support from staff. Respite care is available when required and 2 rooms are regularly used for this purpose. Day care can be provided on request. Burcot Grange is located on the Lickey Hills with extensive views across the Worcestershire countryside from many of the rooms. The home is owned and managed by Mr and Mrs Bales who purchased the property in 1990 and have sensitively developed and upgraded it over the past few years. 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. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to follow up on previous recommendations and to monitor the care provision at the home in relation to the stated aims and objectives. The inspection took approximately 3 hours, about half of which time was spent with residents, staff, and visitors, to ascertain their views on living or working, or having some involvement at Burcot Grange. The care records of some residents were seen, and also the files of recently appointed staff were checked. Conversations with several service users, members of staff and relatives confirmed their satisfaction with life at ‘The Grange’. The records kept in respect of the maintenance of equipment and safe working practices, including the fire log book, were also checked during the course of the inspection, and copies of other documentation which provided supportive evidence, about the management of the home, were obtained. What the service does well: The successful operation of Burcot Grange is based on good lines of communication from the management to staff, and from staff to residents and their families. A friendly, welcome is given to everyone, and there is a calm and relaxed atmosphere, where respect and consideration are constantly in evidence. The extensive activities programme enables residents to maintain various interests, and encouragement is given at all times, to be as independent as possible. Staff know they are valued, their views and opinions are taken into consideration, and training opportunities are provided to ensure they have the skills to deliver appropriate care for residents. Adequate staffing levels enable the needs of residents to be met. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 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.V267501.R01.S.doc Version 5.0 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 the following standard(s): 1&2 Extensive information is available to residents, and their family or representative, and relevant documentation is in place, to enable an informed decision to be made about future care arrangements. EVIDENCE: Appropriate information is available to residents and their representatives, in the form of a detailed brochure, a statement of purpose and a service users guide. The personal approach is preferred by the management of the home, and their policy is to meet and discuss, in detail, the specific requirements of each prospective resident and their family, prior any decision being made about future care needs. A statement of the Terms and Conditions of residence, which includes a detailed contract of the care to be provided, together with all the information required by this standard, is provided for each service user. The document is signed by both parties. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 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 the following standard(s): 7,8 & 11 The positive and supportive relationships, between staff and service users, ensure the dignity of each person is respected, and their right to privacy consistently upheld, by everyone involved with their care. The individual plan of care for each resident is based on their initial assessment, and contains relevant information, although more detail is needed to provide evidence that their care needs are being fully met. Arrangements for the safe administration of medication are in place. Training is provided for staff to ensure a greater understanding of the issues regarding death and bereavement. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 10 EVIDENCE: Residents, and also their relatives, repeatedly confirmed their satisfaction with the excellent care provided and the respectful manner of staff. The courtesy and consideration with which each individual is treated was evident during the course of the visit, and was confirmed in the many positive comments made by everyone. There has been some development of the care planning process, but the need for more extensive records to be maintained, of the actual care provision for individual service users, and the outcomes of all interventions, was again discussed with the management of the home. In addition, risk assessments should be completed for all activities relating to the health and safety of service users. The home uses a monitored dosage system for medication administration, and the Pharmacist checks the procedures every 3 months. Service users are encouraged to self medicate and safe storage is provided. The medication records are maintained to a satisfactory standard. The issue identified at the last inspection has since been resolved. Specialist nurses are involved with staff, whenever appropriate in providing care for the service user who is dying. Support is also given to relatives, who are able to stay overnight in the guest room, if this is their wish. Training on palliative care has been organised for staff to assist them in dealing with the service user who is dying. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 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 the following standard(s): 12 Service users are enabled to live the life-style of their choice within the home. EVIDENCE: Burcot Grange is part of the local community and residents have complete freedom of choice in regard to their contacts, both within and outside the home. They have full control over their lives and are enabled to make choices with regard to all the activities of daily living. An interesting and extensive programme of activities is provided for those who wish to be involved, and fundraising for various charities forms quite a large part of the social life at the home. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 17 The culture of the home positively encourages comments from all interested parties. Appropriate action is taken to address any concerns, or aspects of care provision that may be identified. EVIDENCE: These standards were not all inspected on this occasion, although met previously. The management of the home encourages the free expression of the views of everyone involved with Burcot Grange. There were no recent complaints recorded, but several comments were made, or written evidence was observed, and includes the following: • ‘I am very happy and comfortable. What more can I say’ • ‘My wife and I cannot speak too highly of the home’ • ‘Management and staff have but one aim – to make life here a pleasure’ • ‘I have no wish to return to my own home’ • ‘We have an exceptionally good lady in charge of entertainment and activity’ • ‘The carers are all angels’ • ‘Everything at Burcot is excellent’ • ‘The owners are very caring’ • ‘I could not ask for a better home for my mother’ • ‘Staff are very sensitive to my mother’s needs’ • ‘The admission to the home was handled really well’ • ‘The transformation of my friend is wonderful’ Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 13 Service users are able to contact their legal adviser, whenever they wish. Access to advocacy services would be arranged in the absence of any relative or friend. Arrangements for voting are made, either by a postal ballot, or for the service user to attend in person. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 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 the following standard(s): 19,23,24 & 26 The home maintains an excellent standard of accommodation. The décor and furnishings are in good condition, and provide service users with an attractive and homely place to live. The premises are very suitable for their purpose. They are comfortable and clean, and ensure as far as possible that the safety and wellbeing of service users is promoted. The location of the house, although rural, is convenient to local services and facilities, and the layout provides more than adequate communal space for the needs of service users. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 15 EVIDENCE: Burcot Grange is a large 19th century house built in the style of that day, which was carved black oak with decorative plaster panels, and with numerous, lovely stained glass windows in evidence throughout the building. The grounds, which are extensive, and accessible to residents, are attractively landscaped, and there is an abundance of shrubs and trees, flowers in season and a variety of wild life. Some residents are involved with the gardening. The building is well maintained, and furnished to a very high standard. The décor is tasteful, with the dark wood-panelling offset by light colours, and always with an array of fresh flower arrangements. The large, all weather conservatory, two beautifully appointed lounges, several smaller sitting areas, and a delightful dining room, provide communal space that well exceeds the recommended levels. Comments from both residents and staff confirmed their appreciation of living and working in such a pleasant environment. The minimum space requirements are well exceeded throughout the home. Many bedrooms are large enough for double occupancy, although the policy of the home is to provide shared accommodation only to those people who have expressed a wish to share. Several bedrooms are used as bed-sitting rooms, and each is tastefully and individually decorated to an exceptionally high standard, with attractive, high quality furniture. The high standard of cleanliness and the consistently pleasant atmosphere within the home is commendable. A policy has been produced, and infection control procedures are implemented. There is a sluicing facility on the washing machines, although the home does not have a dedicated sluice. Previous discussions with the Proprietors agreed that this situation would be kept under review, and the appropriate response made, to an identified need. The home received a visit from the Fire Safety Officer in October 2005, and the recommendations made following his inspection are currently being implemented. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Appropriate recruitment procedures are followed, which ensure the support and protection of service users. Staff are well trained and experienced, and competent in their understanding of the needs of residents, which enables the appropriate delivery of care. An individual training and development assessment and profile is needed, to ensure that appropriate documentation is maintained. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 17 EVIDENCE: The recruitment and selection procedure at the home includes a commitment to equal opportunities, and applications for Criminal Record Bureau checks are completed, prior to an appointment being confirmed. The staff files contain two references, and having been reviewed recently, now include all the information and documentation listed in Schedule 2 of the Care Homes Regulations. A commitment to training is evident, and the ‘Investor in People’ Award had been held by the home since 1995. A matrix is used to record the training provided for each member of staff, and various training sessions have been provided during recent months, but an individual training and development assessment and profile for staff has yet to be produced. The views of staff were sought, and everyone confirmed that Burcot Grange is a good place to work, that they are very happy, and that they are given the support and training they need. A member of staff, currently doing NVQ Level 3, was commended recently, and presented with an award for being the most improved student. A personal development training programme for staff, known as ‘The Wall’, is planned for the New Year, and will include teamwork and leadership elements. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,36 & 38 The management arrangements at the home are satisfactory, and ensure that service users live in a wellrun home, where their best interests are safeguarded. Supervision procedures require a more detailed approach, to demonstrate that the staff are given appropriate supervision. The health, safety and welfare of residents and staff is promoted at the home, and procedures are in place to ensure that they are protected in regard to all safe working practices. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 19 EVIDENCE: Mr Mark Bales, with his wife Mrs Karen Bales, have developed and maintained high standards at Burcot Grange, during the past 10 years. Mark, who is the Registered Manager, is trained in hotel management and catering. He recently completed the Registered Managers Award, and has also taken a Leadership Course, which is considered to have been very beneficial to his practice. Karen has responsibility for the housekeeping and health and safety matters, and together they work with the deputy manager, Mrs Jane Neary, to ensure that the stated aims and objectives for Burcot Grange are achieved in every area throughout the home. The Proprietor verbally confirmed the financial viability of the business. Appropriate insurance cover is provided, to the relevant level, as evidenced by the certificate displayed at the home. Accounting procedures are regularly audited. The deputy manager undertakes an annual appraisal with each staff member, and staff confirmed they also had a meeting every 2 months to discuss any issues that may be personal or work related. The formal supervision of care staff should cover the areas outlined in this standard, and more detailed records need to be maintained. A Health & Safety policy has been implemented at the home, and is regularly updated to reflect changing legislation. Staff confirmed they are trained in safe working practices. The responsibility for certain aspects of health and safety is delegated to members of staff who have specialist knowledge in a specific area. The accident book was checked, and had been completed appropriately, with the exception of one notification that should have been made to the Commission under Regulation 37. Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 20 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 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 4 X X X 4 4 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X 3 X 2 X 2 Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 21 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 OP38 Regulation 37 Requirement Notification must be made to the Commission of the occurrence of all accidents, injuries, illness and incidents, in accordance with Regulation 37 and Standard 38. Timescale for action 31/01/06 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 Refer to Standard OP7 OP19 OP26 OP30 OP36 Good Practice Recommendations The recording of information on care plans should be more detailed and informative, and include risk assessments The recommendations of the Fire Safety Officer should be implemented without delay Ongoing consideration should be given to the provision of a sluice An individual training and development assessment and profile should be provided for all staff Supervision records should be more detailed and cover the items listed in this standard Burcot Grange DS0000018497.V267501.R01.S.doc Version 5.0 Page 22 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: 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. 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