Inspection on 12/04/05 for Burdyke Lodge

This inspection was carried out on 12th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Burdyke Lodge 03/07/06

Burdyke Lodge 17/10/05

Burdyke Lodge 15/11/04

Burdyke Lodge 10/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Burdyke Lodge Southdown Road Seaford East Sussex BN25 1BD Lead Inspector Gwyneth Bryant Unannounced 12 April 2005 7.50am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burdyke Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Burdyke Lodge Address Southdown Road Seaford East Sussex BN25 1BD 01323 490880 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Julian Fry Mr Julian Fry Care Home 21 Category(ies) of Old age not falling within any other category registration, with number (OP) of places Burdyke Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty one. 2. Service users must be older people aged 65 years or over on admission. Date of last inspection 15th November 2004 Brief Description of the Service: Burdyke Lodge is a family run care home in Seaford registered to provide care and accommodation for up to twenty-one older people who must be aged 65 years or over on admission. Nursing care is not provided. Both long term and respite care is provided. The house is a detached property set in its own grounds a short distance from the cliffs and Seaford Head, a local beauty spot. There are well maintained gardens on three sides of the house and they are easily accessible to service users. In the front garden there is a dovecote complete with doves. There is generous parking outside the home and a golf course situated immediately opposite. The town centre with its shops and access to bus and rail travel is approximately one mile away. Burkdyke Lodge has level access only on the ground floor, with access to other floors via stair lifts. Grab rails and toilet riser seats are installed throughout the home. There are three bathrooms of which two have assisted baths. In addition two bedrooms have en-suite showers and have two en-suite baths. Outings and entertainment in the home are arranged throughout the year. Burdyke Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and there were fifteen service users in residence on the day. The inspection took place over seven hours and its purpose was to check compliance with requirements from the last inspection and to inspect other standards. Eight service users, two members of staff and the Manager were spoken with. Thirteen key standards and seven of the remaining standards were inspected. A range of documentation was viewed including service users care plans, personnel files and medication records. A tour of the premises was carried out. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments need to be produced that clearly identify hazards to service users and include the management of the risk. Recruitment practices need to be in line with the homes policies and procedures and ensure the protection of service users. An annual development plan and quality assurance and monitoring systems need to be developed and implemented. Evidence needs Burdyke Lodge Version 1.10 Page 6 to be provided to demonstrate the safety of electrical and gas systems and appliances, including bath hoists. The use of door wedges must cease in line with latest fire safety guidance. Staff need to be trained in adult protection procedures. All medication administered needs to be recorded. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burdyke Lodge Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Burdyke Lodge Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4 All service users are clear about the services and facilities that the home provides. There are adequate systems in place to demonstrate service users needs are met. EVIDENCE: A sample of service users contracts were viewed and they clearly outline their terms and conditions. Service users or their representative sign the contract to confirm they have read and agreed to the terms and conditions. Care plans are regularly reviewed to ensure changing needs have been identified and that the home is still able to meet assessed needs. Burdyke Lodge Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 There is a care planning system in place to guide staff in meeting service users assessed needs. Service users are not protected from avoidable hazards and not all healthcare needs are met. The systems for ensuring the safe handling of medication are not followed. EVIDENCE: Service users care plans were viewed and were found to be detailed and clearly outline their care needs. The plans are regularly reviewed. Risk assessments do not reflect service users individual disabilities nor do they include arrangements for the management of identified risks. Care plans indicated that not all healthcare needs are being met and appropriate advice must be sought from the GP and Incontinence advisor. There was no evidence to show that all service users are given the opportunity to manage their own medication. Medication Administration Records were viewed and there were a number of gaps where medication administered had not been recorded. The Inspector discussed the use of homely remedies with the Manager and an agreement was made for a CSCI Pharmacist Inspector to visit the home and advise accordingly. Burdyke Lodge Version 1.10 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The home does not fully meet service users social, recreational and leisure needs. The quantity and choice of food is variable. EVIDENCE: Service users spoken with said they were ‘bored’ and that they would like more social activities during the day. The lack of suitable activities was a concern raised anonymously to the CSCI prior to the inspection. Four service users said that they missed being able to go out for walks. Service users told the Inspector that meal portions tended to be small, quality is variable and that choice is limited, especially breakfast. Weekly menus were viewed and these showed that there were choices for the main meal of the day. One care plan viewed showed that a service user was refused the cooked breakfast of his choice and was offered an alternative. The notice board in the communal area showed that the home does not provide a regular programme of in-house activities. The Manager agreed that he does not provide a planned programme of activities. Burdyke Lodge Version 1.10 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 A satisfactory procedure is in place for dealing with complaints. Systems are in place to protect service users from abuse. EVIDENCE: The home has a complaints book in which all complaints are recorded and include actions taken and outcomes. A summary of the complaints procedure is included in the service users guide and posted in the hallway. The CSCI received a letter expressing concern over the lack of social activities but did not wish it to be treated as a formal complaint. One member of staff spoken with was aware of adult protection and if necessary would be able to ensure the safety of service users. All staff need to be trained in recognising abusive practices and in adult protection procedures. The Manager was able to provide the documentation outlining the training that staff will receive in this matter. Burdyke Lodge Version 1.10 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22 and 25 The décor within the home generally good and the home presents a comfortable, safe and homely environment for service users. EVIDENCE: Areas of the home were being re-decorated on the day of the inspection and work was underway in replacing the water systems. This work also includes fitting safety valves to hot water outlets in service users bedrooms. A suitably qualified person has carried out an assessment of the premises and the subsequent report was viewed. Discussion with the Manager found that he intends to implement the recommendations as soon as possible and it was noted that additional grab rails had already been installed since the last inspection. A tour of the premises found that window restrictors had been fitted to all windows that required them. A planned programme of maintenance would ensure internal areas of the home remain in good order. Burdyke Lodge Version 1.10 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The shortages of permanent staff has resulted service users not receiving consistent care. Poor recruitment practices potentially puts service users at risk. EVIDENCE: The home maintains staffing levels by the use of agency staff. Three service users spoken with said that there are still too many agency staff and it’s tiring to have to keep telling them of personal preferences. The Manager confirmed this is an issue and has advertised for additional staff. He has employed a deputy manager since the last inspection to enable him to have more time for management tasks. One staff member said they had been short staffed but felt the employment of the deputy manager would improve matters. The home has robust policies and procedures on recruitment based on equal opportunities, however, personnel records showed that the procedures are not followed in practice. Not all staff provided two written references prior to appointment. Burdyke Lodge Version 1.10 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 38 The Manager has an understanding of where improvements need to be made within the home. There are systems in place to ensure service users and staff are regularly consulted. The home does not have quality assurance and monitoring systems in place. Staff are well supported. Arrangements to protect and promote service users safety and welfare are inadequate. EVIDENCE: The Manager has been managing the home for over five years and has various care related qualifications. He was able to provide evidence that he is due to begin work on obtaining the Registered Managers Award. The minutes from staff and service users meetings were viewed and demonstrated that both groups are given the opportunity to have a say in how the home is run. Two service users confirmed that service users meetings took place although one service user felt that they should be held more often Burdyke Lodge Version 1.10 Page 15 and give service users more opportunity to comment on specific issues. Formal quality assurance and monitoring systems have yet to be developed. A sample of staff supervision records were viewed and from these it is clear that these sessions identify training needs and good practice issues. An immediate requirement was issued to ensure the use of door wedges ceases. Evidence needs to be provided to demonstrate that electrical and gas systems and appliances have been serviced and are safe. Staff need to be trained in Moving and Handling. There were records showing the regular testing of call bells and fire alarms and fire equipment and systems are regularly serviced. There was no evidence to demonstrate that regular fire drills are carried out. Burdyke Lodge Version 1.10 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x 3 x x 3 x STAFFING Standard No Score 27 2 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 1 x x 3 x 1 Burdyke Lodge Version 1.10 Page 17 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 7 Regulation 15 (1) 13 (4) (b&c) Requirement Timescale for action 12.06.05 2. 7 3. 8 4. 5. 8 9 6. 9 Service users risk assessments need to state the nature of the risk in the context of their disabilities and include attention to the prevention of falls. (This is outstanding from the last three inspections and time scale of 30.09.03 not met) 15 (1) Risk assessments must include and 13 the management of risks. (This (4) (b&c) is outstanding from the last three inspections and time scale of 30.09.03 not met) 13 (1) (b) Dietary advice must be sought in and 14 respect of those service users (1) (a) (2) who are subject to chronic and Reg constipation. (This is 17 outstanding from the last two (1)(a)Sch inspections and time scale of 20.07.04 not met) edule 3 (o) 13 (1) (b) Advice must be sought in respect of managing continence. 12 (2) (3) That service users be given the (4) and opportunity to self-medicate 13 (4) (a- within a risk assessed c) framework. (This is outstanding from the last inspection and timescale of 15.12.04 not met). Reg. 17 That all medication adminstered (1) (a) is recorded. Version 1.10 12.06.05 12.06.05 12.06.05 12.06.05 12.06.05 Burdyke Lodge Page 18 7. 12 8. 15 Schedule 3 (k) 12 (2)(3) and 16 (2) (m) (n) 12 (2) (3) and 16 (2) (i) That a planned programme of activities is devised and implemented. 12.06.05 9. 18 10. 11. 27 29 12. 33 13. 38 14. 38 15. 38 That service users are given a choice of breakfast meals and that food quantities are suited to service users individual preferences. 13 (6) That all staff be trained in adult protection procedures. (this outstanding from the last inspection and timescale of 15.01.05 not met). 18 (1) (a) That staff hours be reviewed in line with service users assessed needs. 19 (1) (a- All staff must be recruited in c) (2-7) accordance with requirements of Schedule 2 of the Regulations, including work permits if necessary. (This is outstanding from the last three inspections and timescale of 21.10.03 not met). 24 (1) (a) An annual development plan to (b) (2) (3) be produced, and quality assurance and quality monitoring systems be formalised. (this is outstanding from last two inspections and timescale of 19.01.04 not met) 23 (4) (b) The use of door wedges must (c) (i) (ii) cease. (This is outstanding from the last inspection and timescale of 15.12.04 not met). 13 (5) That all care staff be trained in moving and handling. (This is outstanding from the last inspection and timescale of 15.01.05 not met). 13 (4) (a- That certificates are obtained to c) demonstrate the safety of electrical and gas systems and appliances, including bath hoists. (This is outstanding from the last Version 1.10 12.06.05 12.06.05 12.06.05 12.06.05 12.06.05 12.04.05 12.06.05 12.06.05 Burdyke Lodge Page 19 16. 38 23 (4) (c) (iii) (e) inspection and timescale of 15.01.05 not met). That regular fire drills are undertaken. 12.06.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19 Good Practice Recommendations A programme of routine maintenance and renewal should be produced and implemented. Burdyke Lodge Version 1.10 Page 20 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Burdyke Lodge Version 1.10 Page 21 - 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!