Inspection on 03/07/06 for Burdyke Lodge

This inspection was carried out on 3rd July 2006.

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

Burdyke Lodge 17/10/05

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 3rd July 2006 07.45 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.V292798.R01.S.doc Version 5.1 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.V292798.R01.S.doc Version 5.1 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.V292798.R01.S.doc Version 5.1 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. 17th October 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. Nursing care is not provided. Both long term and respite care is provided, with one respite bed on contract to the Local Authority. 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. Access to the upper floor is via the provision of a stair lift. Outings and entertainment in the home are arranged throughout the year. The service provides prospective service users with a copy of the service users guide, the statement of purpose, a brochure and a letter offering a visit to the home as part of the pre-admission process. Copies of inspection reports and are made available if requested. Copies of all the pre-admission documents, including the last inspection report are available in the lobby area of the home at all times. The range of fees charged as from 1 April 2006 is from £360 to £525 and in-house activities are included in the fees. Additional charges are made for hairdressing, toiletries, chiropody, newspapers and dry cleaning. Intermediate care is not provided. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over seven hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. There were nineteen people in residence on the day of which seven were spoken with. A number of staff were spoken with including the manager, the deputy manager, a domestic, two care staff and one relative. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Surveys were observed to be available in the lobby of the home although none were returned to the inspector. All of the residents spoken with and the one relative spoke highly of the care given and the dedication of staff. One of the Registered Providers is also the Registered Manager. The reader is asked to be aware that where shortfalls are identified the Registered Provider is aware of them in his role as Registered Manager. Healthcare professionals were not engaged with on this occasion. What the service does well: What has improved since the last inspection? All staff have been trained in adult protection procedures ensuring that residents are protected from abuse. Fire drills are held regularly and all staff have been trained in moving and handling ensuring that both residents and Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 6 staff are safe. Each of these improvements is in respect of addressing the shortfalls identified in the last inspection report. 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. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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.V292798.R01.S.doc Version 5.1 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, 3 and 5. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to residents moving into the home which ensure that their needs can be met and they are provided with detailed information on services provided by the home. EVIDENCE: The Statement of Purpose and Service Users Guide are regularly updated and contain all the information required so prospective residents are able to make an informed choice about where to live. 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 residents. At the time of admission information is sought from social and healthcare professionals to ensure all needs are clearly identified and planned for. Two of the residents spoken with recalled the manager visiting them and carrying out an assessment of their needs and that they were invited to visit the home prior to admission. Intermediate care is not provided. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning systems provide staff with clear direction as to how to meet all aspects of residents’ personal and health care needs. Residents are protected by satisfactory systems for the recording, handling and storing of medication EVIDENCE: Four care plans were viewed and it was evident that pre-admission assessments are used to inform the care planning process. Care planning documents included information on meeting residents’ healthcare needs such as dental, hearing and eyesight checks and also provided clear direction to staff as to how residents daily care needs are to be met. Risk assessments had been carried out and they clearly identified the hazards and included sufficient detail for the management of risks. There was evidence to show that residents were involved in the care planning process and this was confirmed by two residents who agreed that their key worker discussed the plans with them. In addition to detailed care plans key workers are required to maintain a daily diary to ensure any changes in need are rapidly identified and addressed. During the staff handover session and in discussion with the manager and his deputy it was evident that staff are aware of residents individual needs and Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 10 their likes and dislikes. Throughout the inspection staff were noted to treat residents with care and respect and it was evident that good working relationships had been developed. This relaxed approach extended to domestic staff who were also observed to have a comfortable rapport with residents. Residents spoken with commented that ‘staff are fantastic’, ‘I couldn’t be better looked after’ and ‘I love it here, it’s like our own little community’. The relative spoken with also said she was very pleased with the care given and that she is informed of any changes to the care routine. Medication records and storage arrangements were viewed and systems remain effective. Medication administration charts were up to date, accurate and clear. Only staff who have been trained administer medication and this was confirmed by staff spoken with. Medication is stored in a locked cabinet in a locked room ensuring that it cannot be accessed by unauthorised persons. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for residents to experience a lifestyle that matches their expectations, choice and preferences in respect of both leisure and meals. EVIDENCE: The home displays the daily programme of morning activities in the communal areas and in the hallway of the home. These activities include exercise, musical entertainment and games. The manager recently had a sponsored leg wax and raised £140 to fund residents’ outings to local attractions. Currently there is no afternoon activity programme, as most residents prefer to have a short sleep after lunch. Discussion with the manager and his deputy found that they are exploring opportunities to provide individualised afternoon activities, based on residents’ preferences such as dominoes and cards. One relative spoken with said she is always made welcome and other visitors on the day were obviously comfortable in the home and were happy approaching staff and the manager. Residents spoken with confirmed their visitors are always made welcome and they are encouraged to go out into the community with family or friends. Meals were an area that residents continue to praise highly. Menus showed that meals are balanced, nutritious and varied. Residents said they are offered Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 12 a choice for each meal and salads were always available. The day of the inspection was very hot and the deputy manager explained the strategy for ensuring residents remain healthy during the heat wave in that fluids are available to residents at al times. On touring the premises it was observed that all bedrooms included a jug of squash or water and all residents in the lounge were provided with drinks hourly. Care plans showed that those residents with special dietary needs are identified and appropriate diets provided. The key worker for one resident who is diabetic is knowledgeable about the condition and ensures the correct diet is provided. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that residents feel that their views are listened to and acted upon and residents are further protected by satisfactory adult protection systems. EVIDENCE: The home has detailed policies and procedures on complaints, a copy of which is in the homes hallway. No complaints had been received since the last inspection. Residents said that they would be happy to speak to the manager, his deputy or staff if they had any concerns, and two said ‘I couldn’t find anything to complain about everything is wonderful’. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. The manager has undertaken a training course run by the local authority and has cascaded this training to staff. Staff were aware of adult protection procedures. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is generally good, with most areas homely, safe and comfortable for residents but could be improved if minor repairs were carried out promptly. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is generally good. There were some minor repairs needed such as repainting some window frames, repairing the tear in the lounge carpet, replacing missing tiles in bathrooms and placing a top on the tap in one of the toilets. These shortfalls detract from the general attractiveness of the home. The manager has developed a weekly maintenance programme but was aware that some repairs had been overlooked as a result of the on-going work to improve the home, including making room for an additional office on the top floor. Residents’ bedrooms were well maintained and pleasingly decorated and it was evident that residents are able to bring in their own possessions in order to personalise Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 15 their bedrooms. Residents spoken with said they felt their rooms were pleasant, comfortable and ‘feel as much like home as possible’. On the day of the inspection the home was clean and satisfactory systems were in place to control the risk of infection. The laundry was clean, with washing machines that wash soiled laundry at high temperatures. Staff were observed to be working in ways that minimised the risk of infection, by wearing gloves and aprons when required. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staffing levels are sufficient to ensure that residents’ needs are always appropriately met. The recruitment practice is robust and provides sufficient safeguards for the protection of residents and staff have sufficient training to ensure they are competent to do their jobs. EVIDENCE: Staff rotas were viewed and demonstrated that there are three carers on duty in the mornings and two for all other working shifts. There is a key worker system in operation and key workers spoken with were knowledgeable about the needs of those for who they were responsible. Residents’ spoken with were aware they had been allocated a ‘special’ person who looks after them. All residents’ spoken with mentioned the care, kindness and friendliness of staff. There are ten care staff out of a total of thirteen who have achieved NVQ level 2 or above. Currently homes are required to have 50 of care staff with this qualification therefore the Standard is exceeded. Evidence was available to demonstrate staff also received additional training in infection control, manual handling and the safe handling of medication to ensure they are sufficiently skilled to meet residents’ needs. Recruitment records were viewed and it was found that all staff had provided the required two written references, satisfactory identification and all other documents as required. Protection of Vulnerable Adult first checks are carried out for all new Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 17 staff and they do no work unsupervised until a satisfactory Criminal Records Bureau check is received. The homes staff application form does not include a full employment history and this needs to be addressed to ensure the provider is able to explore any gaps in employment records. It was identified that the induction for staff, had been completed in one day. It is anticipated that induction training is carried out over a six-week period to ensure that staff have an in-depth knowledge of the home’s routines and enable them to meet residents’ needs. Foundation training has not been provided as new staff are enrolled on NVQ level 2 courses within six months of starting at the home. However, foundation training still needs to be provided for those staff who choose not to undertake this training to ensure all staff have the skills and competence to provide high quality care. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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, 25, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from clear leadership and direction and all aspects of residents’ health, safety and welfare are protected and promoted. 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 Registered Managers Award and is clear about his management responsibilities but is also able to satisfactorily delegate some tasks to his deputy. Staff meetings are carried out monthly and minutes viewed showed they are consulted on how the home is run. These meetings are in addition to the hand over at the end of each shift. It was clear that these sessions are used as an effective means of verbally communicating residents daily care needs and that staff were familiar with the needs of each resident. A residents meeting was carried out a few weeks prior to the inspection and the minutes of this meeting were viewed. The minutes showed that residents Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 Page 19 are consulted on a range of issues and residents spoken with said they enjoyed these meetings although they could ‘talk to the manager and staff anytime if they had a problem’. Residents are responsible for their own finances if appropriate; relatives and solicitors support others, while the home does not handle the financial affairs of residents. When items are purchased on behalf of residents, receipts are obtained and satisfactory records maintained. The issue of quality assurance and quality monitoring was discussed with the manager who agreed that he has yet to organise a formal system but is aware of the type of information he needs to collate. 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 residents’ best interests. Staff supervision records were viewed and it is evident that these sessions are used effectively to identify training needs. Staff spoken with confirmed that supervision was a good time to discuss all kinds of things including training. 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. All staff have now been trained in Moving and Handling and regular fire drills are carried out each of which ensure both staff and residents are protected. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 X 3 X 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 3 17 x 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 3 X 3 Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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 3. 4 Standard OP19 OP29 OP30 OP30 Regulation 23 (2) (a) Requirement Timescale for action 03/08/06 03/09/06 03/09/06 03/09/06 5 OP33 That all minor repairs are carried out promptly. 19 (4)(ab) That the staff application form be expanded to include a full employment history. 18(1ac) That induction is carried out in (i)(ii) accordance with the Care Skills Sector guidance. 18(1ac) That foundation staff training (i)(ii) programmes that meet the Care Skills Sector specifications be created and implemented for those staff not undertaking NVQ level 2 in care. 24(1)(a) An annual development plan to (b)(2)(3) be produced, and quality assurance and quality monitoring systems be formalised. (timescale of 19.01.04, 12.06.05 and 17.12.05 not met) 03/09/06 Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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. 1. Refer to Standard OP12 Good Practice Recommendations That the plan to provide individualised afternoon activities be implemented. Burdyke Lodge DS0000021063.V292798.R01.S.doc Version 5.1 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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