Inspection on 08/12/05 for Burgess House (Flat A)

This inspection was carried out on 8th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burgess House (Flat A) 17/08/07

Burgess House (Flat A) 09/05/06

Burgess House (Flat A) 19/04/05

Burgess House (Flat A) 12/10/04

Burgess House (Flat A) 15/04/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Burgess House (Flat A) 3 Blyth Road Bromley Kent BR1 3RS Lead Inspector Wendy Owen Unannounced Inspection 10:30 8 December 2005 th Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 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 Burgess House (Flat A) DS0000006938.V269523.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 Adults 18-65. 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. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burgess House (Flat A) Address 3 Blyth Road Bromley Kent BR1 3RS 020 8460 0636 020 8460 0597 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) Bromley Autistic Trust Mrs Pauline Cremore Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th October 2005 Brief Description of the Service: Burgess House is owned by Kelsey Housing and leased to the Bromley Autistic Trust. The premise comprises four flats. The ground floor flat (the home) is the registered establishment. The remaining flats are leased to tenants.The home is registered to provide care to four adults between the ages of 18 and 65, with learning disabilities, specifically autism. Bromley Autistic Trust is a local organisation that provides a range of services, including three care homes and a day centre, operating within the Bromley area. The home has four bedrooms, large and small lounge, two bathrooms/WCs and kitchen. There is a large rear garden, which houses a sensory building.Burgess House is staffed by a manager and support workers, providing 24-hour care.The home has access to specialist health services via the Bassetts Centre, which also accommodates the adult learning disability team. Service users access a range of activities through a variety of outlets including the Trust’s day centre and community activities. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first day of the unannounced inspection saw the staff involved with the supported living client and no service users were present. The inspection was therefore postponed to 13th December. This visit included inspecting the progress of the implementation from previous requirements and recommendation; viewing records and medication practices; and a brief tour of the home. There were no service users or relatives to provide feedback during this inspection. Discussions were held with the Manager and Deputy manager. This report will also highlight the requirements and recommendation made during a previous unannounced visit to the home. What the service does well: What has improved since the last inspection? The previous report identified an offensive odour in the kitchen, which has now been resolved. The bedroom to the front of the home was in need of redecoration and was very dark. The room, has since, been redecorated and the shrubbery at the front cut back to provide a much brighter area. Adult protection practices and pre-admissions procedures have also been improved. The last inspection identified issues with staffing. This related particularly to provide adequate staff during external visits. This was also highlighted in the last visit to the home in October 2006, where external activities had been restricted due to staffing issues. This has now been addressed by increasing the number of staff from two to three, for external visits and the Manager monitors closely the activities provided. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 6 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. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Progress has been made on the pre-admission practices to ensure the home is fully aware of the needs of the prospective service user and able to meet their needs. EVIDENCE: The admission and assessment procedures state that the home obtains the professional assessment and also BAT undertakes their assessment prior to agreeing the referral. The inspector viewed the file of the last service user admitted. All appropriate professional and Provider assessments were in place although the BAT assessment was not dated. (See requirement1) Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Care plans and risk assessments provide good information for staff to provide the care and support required for individual service users and assist service users in maintaining their independence. EVIDENCE: Two care plans were viewed and contained guidelines on many aspects of the care required. These were, in many cases comprehensive. There is a need to ensure more elaboration regarding how finances are managed and to include NHS checks as part of healthcare plan. Two service users’ guidelines also needed further details or reviewing regarding food needs to ensure they were reflective of the care required. (See requirement 2) Residents’ meetings have just commenced so there is a need to “bed in” the procedure and ensure staff fully understand the process of service users making decisions and choices in their daily lives. One service user is to be provided with key to their room whilst the Manager is to risk assess the capabilities of the remaining service users. The Manager has developed a number of risk assessments, both individual and generic, covering a wide area of potential risks to service users and staff Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 10 providing individuals with a safe environment but also enabling service users to maintain independence. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 & 17 Meals are varied and nutritious providing a healthy and balanced diet for residents. The home promotes service users’ rights and encourages them to take responsibility, whenever possible, in their daily lives. EVIDENCE: Service users are involved in the choice of meals with discussions often held each Sunday. A four-weekly rolling menu is currently being developed which, in the main, looked varied and nutritious. Service users attending the day centre are provided with a hot lunch and their meal in the evening is also a hot meal. The Manager is looking to coordinate what is offered to ensure meals are not duplicated or repeated. The inspector noted fresh fruit available in the kitchen. Service users are involved in preparation of meals or the tasks around meal times such as laying tables or clearing up. The TEACHH boards in individual rooms show residents meal routines. Service users’ rights and responsibilities are actively promoted by the Manager. The home and organisation secure the appropriate benefits and encourage participation in the voting process. However, due to the service Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 12 users’ dependencies, involvement may not always occur and the ability to make informed judgements may also be restricted. A previous visit raised concerns over the cancellation of activities during the Saturday due to staffing problems. The inspectors required the home to review the staffing level to ensure such restrictions do not occur in the future. Details of activities offered and participated in are recorded in the service user’s records. This enables the Manager to monitor where activities are not taking place and look at any patterns for reasons why activities are not taking place and initiate a review, when and if, required. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The medication procedures whilst adequate require further improvement to ensure the health, safety and well-being of service users. EVIDENCE: Medication procedures were adequate, although there is a need to ensure full guidelines are in place for “as required” medication with the appropriate cross reference on the medication record; also MAR needs to indicate where guidelines are in place. The home also needs to detail the amounts of medication, entering and leaving the home, especially when service users take medication on visits. The home maintains a list of staff authorised to administer medication together with corresponding initials and photographs were in place for all service users check previous The system would benefit from an improved system for checking current medication such as cross referencing with the previous medication record and prescription. (See requirement 3 & recommendation 1) Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The Manager encourages service users and their relatives to raise concerns. These concerns are listened and responded to in order to be resolved. Areas for improvement are recognised by the Manager in pursuit of improved standards for the individual. EVIDENCE: The home has a complaints procedure which meets with the regulations. It is difficult, due to the dependency of the clients, to determine whether they are able to make complaints or how they feel they are responded to. The majority of complaints are made by relatives or other interested parties. There is a system to record the complaints made and of the investigation and outcome. Staff awareness of adult protection and the home’s procedures in relation to the protection of the service users’ has improved over recent months Since the last inspection report, there have been two adult protection investigations, both of which, were passed to the relevant agencies and investigated. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 26 The home provides a safe, comfortable and homely environment with progress made in the redecoration of the private rooms. EVIDENCE: The home was of a reasonable standard of repair with one of the bedrooms redecorated to a good standard, since the last inspection. It was also positive to note that the shrubs and trees at front have been cut to give more light in the same room. New flooring and furniture has also been provided. Each of the bedrooms had been decorated with service users, whenever possible, choosing colour schemes and decoration. Bedrooms also reflected individual tastes with personal belongings, equipment and momentoes giving an individual and homely feel. The carpet in the hallway has been cleaned but due to its light colour and material, stains very easily. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 & 36 Recruitment practices and training of new staff are not robust enough to provide adequate protection to service users. EVIDENCE: Recruitment practices were inspected with the file of the last member of staff employed, viewed. There is a need for some improvement. Whilst many of the details and documents had been maintained in the home including application forms and references, all other documents are kept at the Head Office. Discussions between the Manager and Head Office showed that no exploration of gaps in the application form had been undertaken; there was no evidence of the qualifications gained to date and no interview schedule. The organisation must ensure that Schedule 2 (amended July 2004) and Schedule 4 of the Care Homes Regulations are adhered to (See requirement 4) The file viewed provided details of recent supervisions. However, there is some delay in the induction of new staff, through the organisation three -day induction training. The staff member recently recruited in October 2005 will not be attending induction training until at least January 2006. Staff training has been provided in some many core areas including First Aid, Health and Safety and Food Hygiene. An exception to this is moving and handling training, which has not been undertaken by staff since 2003. There is also a need to provide more specialist training, such as autism and communication and challenging behaviour (Requirement 5) Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 17 Of the seven support workers three have NVQ 2 in Care with one member of staff also nearing completion. This meets the current standards. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39, 41 & 42 The health, safety and well-being of staff and service users are promoted by the Manager who is well-organised and provides leadership and guidance for staff. The organisation does not have a formal quality assurance system, which means there is no formal system in place for monitoring or continually improving the quality of care. EVIDENCE: The Manager has over the last few years, due to staff shortages, included herself in the roster for working shifts with other staff. This has left little time for monitoring and management tasks. This has now been reviewed to ensure she now has more time for the management role. This is a positive step. The Manager is receptive to any ideas for improvement in the service and has a good relationship with staff and service users encouraging involvement and bringing forward new ideas. She is also able to lead by example and provide guidance to staff, especially being a small staff team. Her qualifications include NVQ 4 in Care; Registered Managers Award and a Certificate in Autism, which Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 19 whilst geared towards education the knowledge is easily transferred into this service provision. A sample of service records were viewed and found to be in order. The inspectors also made a weekend visit during November 2005 to inspect the weekend routines. The report highlighted a concern regarding residents opening the main door of the house to visitors, with no member of staff supervising. The Manager has stated that, this has now been addressed with the staff in the home. The last report detailed the need for the organisation to develop a quality assurance system. The Commission has had no update on the progress in this to ensure service users are benefit from a service that is continually monitored, reviewed and improved to meet service users’ changing needs. The inspector also noted that the Provider monthly monitoring visits have not been completed in recent months. (See requirement 7) Burgess House (Flat A) DS0000006938.V269523.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burgess House (Flat A) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 x 2 3 X DS0000006938.V269523.R01.S.doc Version 5.0 Page 21 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 YA41 Regulation 17 Requirement The Registered Person must ensure that all records are signed and dated. Specifically assessments completed by the organisation must have the name of the person completing the assessment and the date on which the assessment took place. The Registered Person must ensure that care plans are fully reflective of the care required. The Registered Person must ensure that medication procedures are improved. Specifically, the system for recording “on leave” medication must be improved and the guidelines for the administration of PRN medication must also be improved. The Registered Person must ensure that the recruitment procedures are improved to ensure service users are fully protected. The Registered Provider must ensure that staff are provided with induction training and more specific service user related DS0000006938.V269523.R01.S.doc Timescale for action 01/02/06 2 3 YA6 YA20 15 13 01/02/06 01/02/06 4 YA34 19 01/02/06 5 YA35 18 01/02/06 Burgess House (Flat A) Version 5.0 Page 22 6 YA39 24 7 YA39 26 training, without undue delay. Please provide the Commission with an action plan detailing induction training planned for new staff and an action plan detailing more service user specific training. The Registered Provider must implement a system for reviewing and improving the quality of care. The Registered Person must ensure that monthly visits are required under Regulation 26 are completed with a copy of the report sent to the Commission. 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The Manager should review the procedures for checking receipt of the correct medication each month for service users. Burgess House (Flat A) DS0000006938.V269523.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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