Inspection on 17/10/05 for Burdyke Lodge

This inspection was carried out on 17th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/04/05

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 Inspection 17th October 2005 08:00 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 Burdyke Lodge DS0000021063.V249940.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. Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burdyke Lodge Address Southdown Road Seaford East Sussex BN25 1BD 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) 01323 490880 burdyke@msn.com Mr Julian Fry Mrs Evelyn Fry Mr Julian Fry Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty one (21). Service users accommodated must be older people aged sixty-five (65) or over on admission. 12 April 2005 Date of last inspection 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 DS0000021063.V249940.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and there were eighteen service users in residence on the day. The inspection took place over six hours and its purpose was to check compliance with requirements from the last inspection and to inspect other standards. Care staff were spoken with individually and as a group. Throughout the inspection discussions took place with the Manager and his deputy. Eight service users were spoken with, one relative and a tour of the premises was carried out. A range of documentation was viewed including service users care plans, personnel files and medication records. Of the sixteen requirements from the last inspection eleven had been met. Only one additional requirement was identified during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Staff training in adult protection procedures to promote the protection of service users. Recruitment practices needs to ensure that all staff provide an Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 6 employment history and two references prior to appointment to protect service users. Quality assurance and quality monitoring systems must be devised and implemented to provide a mechanism for continuous review and improvement. All staff need to be trained in manual handling procedures to ensure service users are moved safely. Regular fire drills need to be undertaken to ensure correct procedures are followed in the event of fire. A programme of maintenance and renewal needs to be created to ensure any minor repairs are carried out without delay. 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. Burdyke Lodge DS0000021063.V249940.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 Burdyke Lodge DS0000021063.V249940.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): 3, 4 and 5. Standard 6 is not applicable Systems for assessing service users needs are satisfactory and ensure their needs can be met. EVIDENCE: Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective service users. Discussion with the Manager found that he is clear about individuals whose needs the home cannot meet. One service user had been admitted for a trial period; the Manager and staff were undertaking on-going assessment to ensure the home can meet her longterm needs. Burdyke Lodge DS0000021063.V249940.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, 9 and 10 The care planning system is clear and consistent and provides staff with the information they need to satisfactorily meet service users’ needs. Service users are protected by satisfactory systems for the recording, handling and storing of medication. Service users healthcare needs are fully met and their privacy and dignity is protected. EVIDENCE: Five care plans were viewed and found to contain comprehensive information on service users care needs. The care plans are reviewed on a regular basis, the Manager and staff have a good understanding of service users needs and were able to discuss them and explain how needs are met. Service users spoken with all mentioned the care and kindness of staff and that they felt all their needs were met. One relative was spoken with and she explained that she provides some personal care to her mother and that staff welcomes her. When asked she said she is not involved in reviewing her mothers care plan. The inspector discussed this with the Manager who was happy to facilitate this and will ensure she is consulted in future. Throughout the inspection staff were noted to treat service users with care and respect. Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 10 Medication records and storage arrangements were viewed and both aspects were much improved since the last inspection. Medication administration charts were up to date, accurate and clear. The medication cupboard had been tidied and now homely remedies are stored separately from prescribed medication. All homely remedies administered is now recorded to facilitate a clear audit trail of all medication administered. Burdyke Lodge DS0000021063.V249940.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, 13, 14 and 15 Service users benefit from a daily programme of activities and are encouraged to exercise choice over their daily lives. Visitors are welcome to the home at all reasonable times to ensure service users maintain links with family and friends. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home displays the daily programme of activities in the communal areas and in the hallway; the latter being carried out in response to a suggestion from a visitor. The one relative spoken with said she was in the home several times a week and felt welcomed and was usually invited to stay for lunch. She also takes her mother for days out and shopping in the town. Other service users spoken with said their families and friends are welcomed to the home. Two service users said that they were pleased with the introduction of service users meetings as it enabled them to ‘have their say’ over menus and activities. On the day of the inspection some service users remained in their rooms while others sat in the lounge areas relaxing or watching the doves in the garden. All service users spoken with were positive and complementary about the food Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 12 and that if they are given an alternative if they don’t like the offered meal. They also said that they are encouraged to eat in the dining room but may take meals in their rooms if they wish. Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users would be better protected if all staff were trained in adult protection procedures. EVIDENCE: The home has policies and procedures on adult protection and staff are expected to be familiar with this documents. However, all staff need to be trained in recognising abusive practices and in adult protection procedures to ensure service users are protected. The Manager provided evidence that he has undertaken training in adult protection from the local authority and intends to formulate a programme to cascade the training to all staff. Burdyke Lodge DS0000021063.V249940.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, 24 and 26 The standard of decor within the home has improved as part of an ongoing programme, with most areas homely and comfortable for service users. Resident’s bedrooms are comfortable and they are able to bring in their own possessions. Satisfactory systems of infection control are in place to protect service users and staff. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is generally good. Since the last inspection six bedrooms have been redecorated and two bedrooms refurbished to provide level access and en-suite facilities. The recently completed sun deck in the rear gardens allow service users to sit outside for meals or just relax and enjoy the fresh air. Service users are encouraged to personalise their rooms and many have done so with ornaments and pictures. Service users spoken with said they felt their rooms were pleasant, comfortable and homely. Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 15 On the day of the inspection the home was clean and satisfactory systems in place to control the risk of infection. The laundry was clean, with washing machines that wash soiled laundry at high temperatures. While the décor throughout is generally good a number of small repairs needed to be carried out. These included, missing tiles in bathrooms, a torn carpet and some windows in need of refurbishment. These were discussed with the Manager who agreed that a planned programme of maintenance would ensure internal areas of the home remain in good order. Burdyke Lodge DS0000021063.V249940.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): 27, 28, 29 and 30 The deployment and number of staff at key times is sufficient to meet service users care needs. Staff are provided with sufficient training to qualify them to meet service users assessed needs. The recruitment practice is not robust and does not provide sufficient safeguards for the protection of service users. EVIDENCE: Staff rotas were viewed and demonstrated that there are three carers on duty in the mornings and two for all other working shifts. Since the last inspection the Manager and his deputy have allocated specific tasks for care staff to ensure that service users needs are met and staff are aware of their responsibilities. The use of agency staff has decreased resulting in more continuity of care for service users. Service users spoke positively of the changes and were complementary of both staff and management. Some service users mentioned that recently there have been noticeable improvements, as did the relative spoken with. Currently five members of staff have NVQ level 2, one has NVQ level 3 with one working towards this level. Two staff are due to begin NVQ level 2 in the near future. 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 and an up to date Criminal Records Bureau check prior to appointment. Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 17 Formal induction and foundation training programmes are in place and all new staff now undertake this training. Burdyke Lodge DS0000021063.V249940.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, 32, 33, 35 and 38 The Manager is supported well by the staff and his deputy in providing clear leadership throughout the home. The ethos of the home is open and significant improvements to staff and service users consultation have been made. The introduction of formal quality monitoring systems would enable the Provider to critically evaluate the service. Systems to safeguard service users financial interests are satisfactory. There are systems in place that safeguard most aspects of the health, safety and welfare of service users. EVIDENCE: The Manager has been managing the home for a number of years and has satisfactory care related qualifications. He is in the process of gaining the Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 19 Registered Managers Award and feels that already this qualification enables him to provide a more structured and supportive leadership approach. Service users meetings are undertaken and service users said they really appreciated the opportunity to discuss the service and to request changes if required. Staff meetings are carried out in addition to a ‘hand over’ at the end of each shift. The inspector joined staff during the hand over session and care staff clearly identified service users needs on the day and communication between staff was good. The introduction of formal quality assurance and quality monitoring systems would enable the provider to critically evaluate the service and ensure it is run in service users best interests. Service users are responsible for their own finances if appropriate; relatives and solicitors support others, while the home does not handle the financial affairs of service users. When items are purchased on behalf of service users receipts are obtained and satisfactory records maintained. The use of door wedges has ceased and appropriate self-closing devices fitted where required. Evidence was available to demonstrate that electrical and gas systems and appliances have been serviced and are safe. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of call bells and fire alarms and fire equipment and systems are regularly serviced. Not all staff have been trained in Moving and Handling and there was no evidence to demonstrate that regular fire drills are carried out. Failure to meet these requirements poses a potential risk to both service users and staff. Burdyke Lodge DS0000021063.V249940.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 x x 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 x 3 x x 2 Burdyke Lodge DS0000021063.V249940.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 2 Standard OP18 OP19 Regulation 13 (6) 23 (2) (a) Requirement That all staff be trained in adult protection procedures (timescale of 15.01.05 not met). That a routine maintenance programme be developed to ensure all minor repairs are carried out promptly. All staff must be recruited in accordance with the requirements of Schedule 2 of the regulations (timescale of 21.10.03 not met) An annual development plan to be created and quality assurance and quality monitoring systems are formalised (timescale of 19.01.04 not met). That all care staff be trained in moving and handling (timescale of 15.01.05 not met). That regular fire drills are undertaken (timescale of 12.06.05 not met). Timescale for action 17/12/05 17/12/05 3 OP29 19 (1) (ac) (2-7) 17/12/05 4 OP33 24(1)(a) (b)(2)(3) 17/12/05 5 6 OP38 OP38 13 (5) 23 (4) (c) (iii) (e) 17/12/05 17/12/05 Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burdyke Lodge DS0000021063.V249940.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office 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. 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