Inspection on 09/05/06 for Burgess House (Flat A)

This inspection was carried out on 9th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 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) 08/12/05

Burgess House (Flat A) 19/04/05

Burgess House (Flat A) 12/10/04

Burgess House (Flat A) 15/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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 Key Unannounced Inspection 9th May 2006 09:30 Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 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.V290609.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 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.V290609.R01.S.doc Version 5.1 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.V290609.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 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 has a range of services, including three care homes and a day centre, operating within the Bromley area. All referrals and placements are made through the Bromley Social Services. Burgess House is located on a residential road within walking distance of Bromley town centre and its good transport links, as well as excellent shopping facilities. It has four bedrooms, large and small lounge, two bathrooms/WCs and a kitchen. There is a large rear garden, which houses a sensory building. The home is staffed by a Manager and support workers, providing 24-hour care. There is 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. Placements to the home are made in line with the Service Level Agreement between BAT and Bromley Social Services. The current fees are £1079.76. Residents paid privately for newspapers, personal telephone calls, hairdressing, some activities, toiletries and medical services not provided by the NHS. Information regarding the home, including the inspection reports, are made available through the home or the BAT Head Office. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection site visit took place over two visits: the course of one early evening and one afternoon. The process included a tour of the home; viewing of records, discussions with residents, Manager and staff and feedback from a health professional, Care Manager and four relatives. Compliance with requirements and recommendations made at the last inspection were reviewed. What the service does well: The home provides a good standard of care to residents with a balance between independence and protection of the residents. One relative stated. “…In all my years as a parent X has never been so well looked after and happy in a residential home.” There are specific and comprehensive guidelines and risk assessments in place providing staff with information on how to provide care and support to the residents an important aspect for this client group. Residents also participate in a variety of activities and interests including social and community contact. Feedback form relatives showed that they, and their family member, are fully involved in the care provided, attending regular reviews with the Manager, key-worker and Care Manager. The reviews provided input on how the resident were progressing towards their goals. The feedback also provided positive comments on good care and support provided by the staff, as well as the way they have enabled residents to improve in many areas of their lives. In general the staffing within the home was praised, with a relative stating that, “The staff are very capable. The Manager and Deputy Manager always try to do their best for the residents.” There are good pre-admission procedures in place to ensure they are able to meet the needs of any prospective residents. The Provider has systems in place for reviewing and improving the quality of care and monitoring the standards within the home, including service user and relative surveys and visits by the Provider. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 6 Residents within the home have various abilities to communicate. However, the staff encourage residents to communicate through pictorial form, signs and symbols as well as verbal communication. This enables some residents to make basic choices and decisions whilst others are more able to become involved in decisions on how they wish to spend their days and live their lives. Staff are expected and encouraged to attend the comprehensive training provided by the organisation through internal and external courses. The undertaking of the NVQ qualification is also expected of all staff. What has improved since the last inspection? What they could do better: Improvements are required in relation to the monitoring and reviewing of the quality of care including the undertaking of the monthly Regulation 26 visits. These should be undertaken each month and are currently spasmodic. The Provider should also ensure that where surveys are completed the information provided should be collated, analysed and any areas for improvements detailed in a report with actions required to address these areas. The home must also be more robust in the way it recruits new staff ensuring the required checks are made. Whilst the environment is homely and comfortable there are some improvements, such as redecoration/refurbishment of the bathroom, shower room and which would benefit the residents. The home must also investigate and resolve the issue of the strong odour in one of the bedrooms. The training provided is of a good standard, although the home should ensure the induction is tailored and structured to meet the needs of new members of Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 7 staff and their job role. This induction, including the home’s induction should be recorded. 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.V290609.R01.S.doc Version 5.1 Page 8 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.V290609.R01.S.doc Version 5.1 Page 9 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): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures in place which ensures staff have the information on which to provide good care and allows the prospective resident and family to make decisions on whether the home is suitable for their needs, although some improvements could be made in relation to the information provided before admission. EVIDENCE: The home has developed a Statement of Purpose and Service Users Guide. The Service Users Guide is produced in a simple easy to read format with associated pictures and symbols. Both documents are being reviewed at present. There is little evidence to show that information in relation to the home (Statement of Purpose and contractual agreements) are made available to prospective resident’s or their family members, prior to admission. This must be addressed to ensure prospective residents and/or their relatives are aware of what to expect before making a decision. (See recommendation 1) There have been no new admissions since the last inspection. However, the policies and procedures provide comprehensive guidance for staff. All referrals are made through Bromley Social Services departments. The Care Management assessment is obtained by the home, followed by the assessment carried out by the Manager. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 10 All prospective residents are encouraged to visit the home, including overnight stays. Any agreed admissions are structured ensuring current residents and prospective resident’s needs, can be met. These visits are important to give the Manager and residents in the home, as well as the prospective resident, the opportunity to see if they fit in to the home. The Manager is aware that, once the home has agreed after assessment that they are able to meet the individual’s needs, this must be confirmed in writing. All residents are funded by the Local Authority with agreement on the care and supported detailed in the Service Level Agreement between BAT and the Local Authority. There is also a tenancy agreement between the Housing Association and the tenant (resident) and BAT has recently developed a new contract between the home and resident. This contract is in draft form at present, awaiting amendments before finalising. The files viewed contained evidence of the tenancy and placement agreements. Written feedback received from all relatives showed that the home is able to meet the needs of the residents living in the home. Feedback was received from relatives and one Care Manager who agreed that the care provided to the resident is good. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home balances well the risk between promoting independence, empowerment and safety of the residents. Residents are encouraged to make choices and decisions through an open and inclusive relationship with the Manager and staff. EVIDENCE: After admission the home develops care plans detailing the care and support required for the residents. The two individuals’ file viewed contained comprehensive information on all aspects of the residents’ life including goals. Each element of the care and support required was documented with prompts to staff in respect of communication. A clear photograph and description were available. There were good guidelines in respect daily routines and leisure activities. Other relevant information included in the files, were SCIP and supporting risk assessments. Some risk assessments were slightly overdue. (See recommendation 2) Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 12 There was evidence of multi disciplinary input into the residents’ care with documentation from a speech and language specialist, the day centre and chiropody. Each resident also has a key-worker who is responsible for completing monthly summaries on how the objectives are being met. This form needs to be fully completed with dates and signatures. (See recommendation 3) Feedback form relatives showed that they, and their family member, are fully involved in the care provided, attending regular reviews with the Manager, key-worker and Care Manager. The reviews provided input on how the resident were progressing towards their goals. The feedback also provided positive comments on good care and support provided by the staff, as well as the way they have enabled residents to improve in many areas of their lives. The case files were large and cumbersome with some of the information contained within it not current. This had been addressed by the second day of the inspection making it a more user-friendly system. Residents within the home have various abilities to communicate and the staff encourage residents to communicate through pictorial form, signs and symbols, as well as verbal communication. This enables some residents to make basic choices and decisions. There was evidence of residents meetings taking place. The notes viewed showed meetings were at various intervals varying from weekly to less frequently. The records themselves were variable in content and information dependant on who had taken the notes. The meeting focused on leisure activities, food preferences and outings. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 13 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): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. From the evidence provided and comments made by residents and relatives they were satisfied with their lifestyle enjoying a number of activities and community involvement. The meals provided were also satisfactory with residents taking some part in their provision and the Manager recognising where improvements could be made. EVIDENCE: The records viewed and observations made during the visits showed the residents to be attending a variety of activities. These include day centre attendance with its variety of activities; shopping; pubs; bowling; visits to the park; Gateway project and drum workshop. Residents have been seen accessing local transport as well as gong out in the home’s minibus. During the inspection one resident went shopping before the evening meal, one had gone on a regular family visit and others were in their rooms watching TV and relaxing after their day at the day centre. It is evident from feedback and observations that contact with family is important and encouraged unless there are reasons not to. Residents visit the family and families can visit the home. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 14 Residents receive a varied diet with a daily hot meal provided at the day centre and evening meal in the home. Residents take it in turn to be involved in the preparation, shopping and setting the table and clearing away. Some work is required in relation to the menus which need to be more varied. The Manager is addressing this and has recently developed new system for determining choices in the home. The choices are to be prepared from fresh foods. The Manager was advised to seek advice from the community dietician to ensure a healthy, nutritious and balanced diet is provided. The Manager is advised to ensure the home maintains records of the food provided for each resident. Records are maintained regarding food and fridge temperatures ensuring the health and safety of the residents. Some members of staff have recently attended training in relation to the Disability Discrimination Act and the rights of the resident’s. This is good practice. Staff working in the home and at the Head Office are also involved in ensuring the residents receive their benefit entitlements. Residents meetings are held regularly with residents encouraged to participate. The Manager is aware that the quality of these meetings vary dependent on staff and therefore is currently establishing guidelines to ensure residents get the most out of them rather than be a “paper exercise”. The new guidelines should incorporate the action the home is taking in relation to the issues raised. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 15 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans had improved since the last inspection and indicated how resident needs were being met in respect of health, safety and welfare. Medicines were safely managed and residents and relatives said staff treated them with respect. EVIDENCE: There are good guidelines in place in respect of how personal care, dressing and grooming is attended to detailing specific support required. No residents currently require assistance and support with mobility. The files viewed also contained good details of risk assessments and healthcare support required with epilepsy guidelines in place and evidence that seizures are being monitored and support from specialists in place. There was also a comprehensive health questionnaire recently completed (OK Health Check) and the records maintained by the home contained information on various NHS and specialist healthcare appointments. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 16 The home has communicated any issues, events or incidents in the home as required under Regulation 37. Medication procedures and practices were inspected with records viewed. In general these were satisfactory with records completed on prescribed medications. A recent pharmacy inspection showed the systems in place to be satisfactory. There were guidelines in place for medication given when required and medication records showed medications entering and leaving the home were signed, counted with appropriate signatures. Medications were also adequately stored. Improvements should be made in ensuring the list of authorised signatures is updated; allergies are to be recorded and medications saying “as directed” should give more guidelines, especially as some are being administered as required. (See requirement 1) Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Feedback from relatives, records viewed and previous communications with the Commission provide evidence that the home takes seriously issues relating to the protection of the vulnerable individual’s in its care and refer them to the appropriate agencies. There is also evidence that the home listens to any concerns raised by residents or their families and take action to resolve them therefore ensuring the care is regularly improved and residents’ needs met. EVIDENCE: The organisation has adequate policies and procedures in place to ensure residents are listened to, concerns investigated and action taken to resolve the problems. Procedures have also been developed to protect vulnerable individuals from abuse. These are currently being reviewed and updated to ensure they reflect current good practice, including referral to the Protection of Vulnerable Adults register. There is one outstanding complaint being investigated by the Commission with one verbal complaint made since the last inspection. This has been addressed. Improvements in the record-keeping in relation to these should be made to ensure there is more detailed information regarding the complaint, how they are managed and details on the way it is investigated. (See recommendation 4) The home has restraint procedures in place and all staff have been trained in SCIIP and other training regarding the management of challenging behaviour including positive interventions, which helps to understand why this happens. There is evidence that restraint used is recorded and care plans evidence where this may be required and which techniques is to be used. There are Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 18 times when there are issues between residents which may result in implementing the adult protection procedures. In these instances the home notifies the appropriate agencies, although these are not always investigated by the external agencies but addressed with specialist support. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 19 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): 24,25,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was maintained to a satisfactory standard with residents and relatives were satisfied with this. However, there is a need to redecorate and refurbish some areas and to ensure offensive odours are addressed ensuring residents have a homely and comfortable environment in which to live. EVIDENCE: Flat A has a homely and comfortable environment with personal touches made in residents’ rooms. Previous reports have commented on how the home involves residents in choosing the décor. The furniture is comfortable and practical. There are, however, some areas, which require attention and are looking a little basic. The bathroom requires some updating and the shower room requires redecoration due to a water leak on the ceiling. The radiator is also very rusty possibly due to condensation. In general the home is to a fair standard of cleanliness. However, there was on the second day of the inspection a very offensive odour emitting from a Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 20 resident’s bedroom. The cause of this is being investigated and must be resolved without delay. The laundry room required soap and hand towels to be in place. The gardens are maintained to a satisfactory standard. (See requirements 2 & 3) Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were maintained and the staff team presented as having the skills needed to meet the residents’ needs with some good training provided to meet core and specific needs of the client group. However, recruitment procedures must be improved to ensure vulnerable residents are protected. EVIDENCE: There are currently five staff employed excluding the Manager. Of these five three have NVQ 2 or above; one is working towards NVQ 2 and the remaining two are working towards their LDAF training uses BILD materials, workbook and three days training through BAT. There is some good training in place with both core and specific training identified for staff. The home has just appointed a new senior who has worked within this sector previously within the organisation but has not worked in a registered setting except for some sessional work. Induction is currently taking place however, the inspector recommends such training is structured around the individual’s needs and job role. This includes more detailed medication training. (See recommendation) Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 22 There has been one new member of staff employed since the last inspection. Thee required checks have not taken place mainly due to the individual being employed by the organisation in another capacity. There were certificates in place and the member of staff explained the selection and interviewing process. However, there was no evidence of any up to date Criminal Records Bureau Check (with POVA check), no proof of identification or photograph in place. Nor were there any other records such as application form maintained in the home. Whilst the inspector understands that the previous employment was from within the organisation the Manager must satisfy themselves as to the checks required and obtain some form of reference. (See requirement 4) Discussions with the new member of staff showed adequate qualifications and training in relation to the client group. However, there was little evidence of experience of supervising and monitoring of staff. Please refer to previous comments regarding tailored induction training needs to be recorded. (See recommendation 5) The Commission received mixed feedback regarding the knowledge, understanding and competency of the staff. However, in general there was satisfaction with the service provided with some excellent comments amongst those given. There was evidence of regular supervision with staff formally supervised approximately every six weeks or so. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 23 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, 39, 41, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is experienced and qualified to manage the service. She provides leadership and guidance to staff. There are systems in place for monitoring the quality of care provided and whilst adequate improvements could be made in ensuring the regularity of Provide visits and reports on outcomes of surveys made available. EVIDENCE: The Manager is well qualified with a number of years experience of working with residents with learning disabilities, specifically, autism. Feedback from relatives showed that the home is well managed with the Manager ensuring regular contact and communication with families and external agencies. Feedback from a health professional confirmed a sound working relationship between the home and the agency. The required insurance and registration certificates are in place. Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 24 The organisations’ policies and procedures are currently being reviewed to ensure they are up to date and reflect good practice within this sector. There is some evidence in the home that some procedures are being monitored eg medication and that Regulation 26 visits are occurring albeit not as regularly as they should be. The last three visits took place in April 2006; December 2005 and September 2005. (See requirement 5) Previous reports have also highlighted the need to undertake a review of the quality of care provided which includes consultation with residents or their relatives. The inspector has been supplied with results of last years surveys completed by residents and relatives and understands that surveys have been undertaken for the current year. There was no report on the outcome of the survey to the Service Managers absence due to an unfortunate accident and this has slowed down the progress the Provider was hoping to make in this area. However, the Commission is assured that a report on this years survey will be completed and a copy sent to the Commission. This should include where the home is doing well and highlighting any shortfalls or areas for improvement with the action plan to address this. The organisation also monitors the service as required by the agreement between Bromley Social Services and BAT and regular reporting takes place in relation to this. (See recommendation 7) The systems in place for ensuring the health, safety and well-being of residents and staff are satisfactory with regular service checks made on the equipment and staff trained in core areas such as moving and handling, First Aid and health and safety. There was also evidence of adequate systems in place in relation to fire procedures and fire prevention and ensuring the protection of residents from outbreak of fire. The home has adequate procedures in place to ensure resident’s personal allowances are safe-guarded. A member of the financial team at BAT Head Office is an appointee for two residents. The monies relating to two residents were audited and found to be accurate with the appropriate receipts in place for most expenditure. The inspector would recommend that signatures and dates are also recorded onto the receipts to allow for easier auditing. The organisation has yet to be successful in setting residents up with individual bank accounts, mainly due to the reluctance of the financial institutions. The organisation is currently looking at systems for ensuring more clarity over residents’ monies, in particular the apportioning of residents mobility allowances and the records kept in relation to the benefits paid. The Inspector has provided advice and guidance in this area and will monitor the progress at the next inspection (See recommendation 6) Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 25 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 Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x 3 3 3 Burgess House (Flat A) DS0000006938.V290609.R01.S.doc Version 5.1 Page 26 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 YA20 Regulation 13 Requirement The Registered Provider must ensure that the medication records record allergies (or none known); update the list of staff authorised to administer medication along with initials used in the records; provide clearer guidelines where medication is labelled “as directed”. The Registered Person must produce an action plan detailing the redecoration and/or refurbishment of the bathroom and shower room. The Registered Person must ensure there the offensive odour in one of the bedrooms is addressed and hand-washing facilities are provided in the laundry room. The Registered Person must ensure that the recruitment procedures are improved to ensure service users are fully protected. Timescale 1/02/06 The Registered Person must ensure that monthly visits are DS0000006938.V290609.R01.S.doc Timescale for action 01/08/06 2 YA24 23 01/08/06 3 YA30 13 & 23 01/06/06 4 YA34 17 & 19 01/07/06 5 YA39 26 01/06/06 Burgess House (Flat A) Version 5.1 Page 27 6 YA23 25 required under Regulation 26 are completed with a copy of the report sent to the Commission. Whilst this has improved they are required to be undertaken monthly. Timescale of 1/02/06 has expired The Registered Person must ensure that, the procedures in relation to management of residents’ monies, is made clearer. In particular, the Provider must address how it apportions residents’ mobility allowances in accordance with the usage. 01/08/06 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 2 3 4 Refer to Standard YA1 YA9 YA6 YA22 Good Practice Recommendations The Statement of Purpose and other information produced by the home should be made available to prospective residents and their families. Risk assessments should be viewed in accordance with the review date specified. Monthly review records should be signed and fully dated by the person completing the review. The registered Person should ensure that there are clear records relating to complaints made which include the investigation route; the outcome, action taken and if the complaint was resolved. Induction in the home should be tailored to meet the needs of the individual and the job role The Registered Person should ensure records in relation to residents allowances are more clearly recorded with dates and signatures recorded onto the proof of purchases by those responsible for the expenditure. The Provider should ensure that a report and action plan is produced in relation to the outcome of surveys completed on the quality of care provided. DS0000006938.V290609.R01.S.doc Version 5.1 Page 28 5 6 YA32 YA23 7 YA39 Burgess House (Flat A) 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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