Inspection on 13/04/05 for Burger Court

This inspection was carried out on 13th 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

Burger Court 21/08/07

Burger Court 05/09/06

Burger Court 08/12/05

Burger Court 11/11/04

Burger Court 14/09/04

Burger Court 17/06/04

Similar services:

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Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Burger Court 131 Barkerend Road Bradford BD39AU Lead Inspector Mary Bentley Unannounced 13th April 2005 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. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Burger Court Address 131 Barkerend Road Bradford BD3 9AU 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) 01274 726826 01274 726826 Mr B W Vincent Mrs Ann Van Lelyveld Care Home with Nursing 24 Category(ies) of Physical Disability over 65 (24) Dementia Over registration, with number 65 (24) Mental Disorder over 65 (24) Physical of places Disability (2) Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11 November 2004 Brief Description of the Service: Burger Court is registered to provide personal and nursing care for up to 24 older people. The home has 18 single and 3 double rooms, privacy screening is provided in the shared rooms. None of bedrooms have en-suite facilities. The home has two communal bathrooms, one of which is equipped with an assisted bath, and one disabled access shower. Bedrooms are located on three floors and access is provided by means of a passenger lift and a stair lift. There are lounges on the ground and first floor and there is a dining room on the ground floor. It is a converted property situated close to Bradford city centre and is easily accessible by public transport. The home is within easy reach of a number of local amenities including shops and a public house. A small number of car parking places are provided at the front of the building. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the CSCI is required to undertake a minimum of two inspections of all regulated care homes. This was the first inspection of this home for the 2005/2006 inspection year. The inspection was unannounced and carried out by one inspector who spent five and half hours in the home. The last inspection of this service was in November 2004 and the main purpose of this visit was to assess the homes progress on meeting the requirements and recommendations made during that visit. The methods used in this inspection included examination of records, observation of working practices, discussions with service users, relatives, staff and management and a tour of the premises. Comment cards were provided for residents and relatives to enable them to share their views of the service with the commission; comments received in this way will be fed back to the management of the home without revealing the identity of the respondents. What the service does well: What has improved since the last inspection? The home continues to make improvements to the environment; bedrooms that have been decorated since the last inspection have been furnished and equipped to a high standard. Recruitment procedures have improved thereby promoting the protection of residents. Some progress has been made towards providing staff with the knowledge and skills to meet the specialist needs of the people with dementia and further training in this area is scheduled to take place. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 6 There has been an improvement in the standard of record keeping and this is an area that continues to be developed. What they could do better: 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. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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 Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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) 3 and 5 Prospective residents are offered the opportunity to visit the home to enable them to make an informed decision before moving in. This is supported by the pre-admission procedures. However, the manager must continue to ensure that all the assessed needs of prospective residents can be met before agreeing to admission. EVIDENCE: The records examined provided evidence that comprehensive pre admission assessments had been carried out and the needs identified during the initial assessment were reflected in the care plans. During the inspection, the relatives of a prospective resident visited the home with a social worker and the manager made arrangements to visit the prospective resident to undertake an assessment of needs. Two admissions to the home were planned and it was evident from discussions with staff that they had been provided with information about the needs of these residents. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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 10 Overall, the home is good at meeting the physical and health care needs of service users. The mental health care needs of residents are not adequately addressed in their care records. EVIDENCE: The care records have improved since the last inspection. Individual plans of care are available and for the most part address the health, personal and social care needs of service users. The plans tend to focus on physical care needs and there is very little information on how specific needs associated with dementia such as short term memory loss will be addressed. The recoding of personal care given was inconsistent, however residents appeared to be clean and well cared for and no concerns were raised by residents or relatives with regard to personal care. The daily entries focus mainly on nursing care given and give little or no indication of how people living in the home spend their time; this emphasis on physical care needs was also evident in the daily routine of the home. There was very little evidence of involvement by residents and or their representatives in the care plans seen. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 10 The dining room is also used as a staff area and residents right to privacy was compromised by the use of the phone in this area to discuss confidential information in the presence of other residents. Greater attention must be given to respecting residents right to privacy. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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 standard(s) 12, 13 and 15 The opportunities for residents to engage in social and recreational activities are limited, as this is perceived as the role of the activities organiser and not incorporated into the daily routines of the home. Residents maintain contact with family and friends. EVIDENCE: The activities programme displayed in the home was not current, it related to the week prior to the inspection. The activities organiser maintains an individual record for each resident showing their involvement in social activities and events and has compiled a great deal of information about local attractions and events that might be of interest to the resident group. The activities organiser works 16 hours a week and it was evident that during these hours opportunities are provided for residents to engage in a variety of social activities designed to meet their expectations and capabilities. However, there was little or no information available about how residents spend the remainder of their time and they were seen to spend long periods of time in an unstimulating environment while staff were busy attending to physical care needs and daily routine tasks. Two relatives were spoken with during the inspection; they confirmed that they could visit at any time. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 12 Approximately half of the residents in the home had their lunchtime meal in the dining room; the remainder had their meals served in one of the lounges or in their bedrooms. The meal was nicely presented and residents appeared to enjoy their food. Staff were in attendance during the meal providing assistance and encouragement as needed in a discreet manner. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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 standard(s) 16 Relatives did not know how to make a complaint. EVIDENCE: The complaints procedure is displayed in the home however feedback from some relatives indicated they were not aware of the procedure, this is particularly important as many of the residents in the home lack the capacity to make a complaint on their own behalf. Since the last inspection, the home has not received any complaints and no complaints have been referred to the commission. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 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 standard(s) 19, 24 and 26 The home is a comfortable and clean environment for residents, however the procedures for dealing with the breakdown of essential equipment should be reviewed to minimise the risk to residents. EVIDENCE: There is an ongoing programme of refurbishment with bedrooms being upgraded as they become vacant, the most recently refurbished bedroom has been decorated and furnished to a high standard. The home has plans to upgrade both the ground floor and top floor communal bathrooms. There is an ongoing programme of providing adjustable height beds for residents who require nursing care. Residents are encouraged to bring personal possessions with them to the home. The dishwasher had broken down five days prior to the inspection and although assurances were given that, this was being dealt with as a matter of urgency it had not been repaired by the conclusion of the inspection. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 15 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) 27,29 and 30 The staffing levels particularly on the afternoon and evening shifts are not sufficient to provide staff with opportunities to address the psychological, emotional and social needs of residents, this was discussed at the last inspection and has not improved. There are good recruitment procedures in place to protect residents. The home is making progress on providing training linked to the needs of the resident group. EVIDENCE: During the afternoon shift the duty roster indicates there are 3 care staff on duty with a nurse, however one of these carers does kitchen duties and therefore is not available to provide direct care to residents. At 6.30pm, the number of care staff reduces to two. The overall effect is that throughout the afternoon and evening there are three members of staff available to meet the care needs of residents on three floors including communal areas on two floors. It was evident that the daily routines are centred on the completion of tasks and staff had very little time to engage with residents other than to attend to physical or personal care needs. Staff were seen to be kind and caring in their approach to residents and residents responded positively to them sometimes engaging in exchanges of friendly banter. Relatives spoken with felt that staff were caring and approachable. The staff files seen confirmed that the required pre-employment checks were carried out before new staff commence work in the home. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 16 Staff spoken with confirmed that they receive regular training on safe working practices however; they identified a need for further training on the control of infection. Two members of staff have attended palliative care training and four members of staff have attended training on dementia care, further training in both these subjects is scheduled to take place over the coming months. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 17 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) 35 The present system of paying residents personal allowance money into the home business account does not ensure that the financial interests of residents are safeguarded. EVIDENCE: The home acts as appointee for a small number of residents. The present situation is that the personal allowance allocated to these residents is paid into the homes business account; this is not good practice and is a contravention of the Care Homes Regulations 2001. This was discussed at the last inspection when assurances were given that it would be resolved, however the situation remains unchanged, the manager said that a meeting was scheduled to take place with Age Concern on April 18th 2005 with a view to providing advocacy services for these residents. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 18 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 2 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 1 x x x Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 19 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 Requirement The service users plans must set out in detail how all aspects of health, personal and social care needs will be met. The plans must provide evidence of consultations with service users and/or their representatives. Previous timescale of 11 February 05 not met. The registered persons must ensure that the privacy and dignity of services users is not compromised by working practices within the home. The registered persons must ensure that daily routines are varied and flexible and take account of the needs, preferences and capabilities of service users. All staff must receive training on the control of infection. Equipment designed to assist in the reducing the risk of cross infection must be maintained in working order. The registered persons must ensure that there are at all times suitably qualified, competent and experienced staff in sufficient Timescale for action 15 July 2005 2. 10 12 15 July 2005 3. 12 12 & 16 15 July 2005 4. 26 13 15 July 2005 5. 27 18 15 July 2005 Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 20 6. 35 20 numbers to meet the needs of service users. The registered persons must 15 July make appropriate arrangements 2005 for the management of service users finances. Personal monies recevied on behalf of service users must not be paid into the homes business account. Previous timescale of 21 January 2005 not met. The registered persons must ensure that all staff receive training in the care of people with dementia. 7. 30 18 15 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard 7 8 12 16 19 21 25 Good Practice Recommendations Care staff should be encouraged and supported in recording details of personal and social care in the service users plans. The format used for wound care plans should be reviewed to ensure that up to date and accurate information about the progress and treatment of wounds is readily available. Considertion should be given to providing a cordless phone. The home should review the current systems for ensuring that service users and their representatives are fully informed of the complaints procedures. The current systems for dealing with breakdowns of essential equipment should be reviewed. Consideration should be given to improving the availability of disabled access toilets on the ground floor. It is recommended that valves to control the temperature of hot water be fitted locally, rather than centrally, to hot water outlets accessilbe to service users. Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Burger Court J52_J03_S29144_Burger Court_V221376_130405_Stage 4.doc Version 1.20 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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