CARE HOMES FOR OLDER PEOPLE
Burgess Park Nursing Home Burgess Park Picton Street Camberwell London SE5 7QH Lead Inspector
Alison Pritchard Unannounced Inspection 21st October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000007011.V253181.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000007011.V253181.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Burgess Park Nursing Home Address Burgess Park Picton Street Camberwell London SE5 7QH 020 7703 2112 020 7701 4220 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) Exceler Healthcare Services Limited Mrs Spiwe Ruth Rondozai Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (0) of places DS0000007011.V253181.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Two persons may be aged 60 years to 64 years Date of last inspection 14th April 2005 Brief Description of the Service: Burgess Park Nursing Home is located in a residential area of Camberwell. The home is registered to provide care for sixty older people who have nursing needs. The facilities in the home are spread over three floors. There are lounges on the ground and first floors of the home and dining facilities are are on the ground floor. Bedrooms are located on all three floors of the home. There are two double bedrooms and the remainder are single. Twenty three of the bedrooms have en-suite facilities. There is a passenger lift allowing all residents to have access to all parts of the home. There is a garden to the front of the home and parking is available on the street as well as in a car park to the rear of the home. DS0000007011.V253181.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out by two inspectors between 10am and 5.20pm on a weekday in late October 2005. There were forty eight residents at the time of the inspection. The inspection methods included discussion with the Registered Manager, observation of a lunch time meal, conversations with residents and staff, examination of files and a tour of the building. All but five of the standards were examined at the last inspection of the home in April 2005. As a result the main focus of this inspection was on the compliance with previous requirements. What the service does well: What has improved since the last inspection?
The managing organisation has limited the number of residents during the period since the last inspection so that attention could be focussed on addressing the changes required. The requirements of the last inspection have been met. This represents a considerable achievement, as there were a significant number of wide ranging improvements to be made. A refurbishment programme has begun in the home, some bedrooms have been re-carpeted and redecoration is underway. The arrangements at meal times have improved so that residents who need assistance benefit from the individual attention of an allocated member of staff. DS0000007011.V253181.R01.S.doc Version 5.1 Page 6 More effective nutritional and weight monitoring is carried out and the home is working closely with the GP and other health care professionals to address residents’ health care needs. 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. DS0000007011.V253181.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000007011.V253181.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The statement of purpose has been amended so that it includes all of the required information. The home gathers sufficient information to make a decision about whether they can meet potential residents’ needs. Potential residents and their relatives are encouraged to visit the home so that they can decide whether it is a suitable placement. EVIDENCE: As required at the last inspection the statement of purpose has been reviewed and now contains the required information. The files of two recently admitted residents were examined. They showed that thorough assessments had been carried out prior to the admissions. A copy of the placing authority’s assessment was also on file. Potential residents and their family members are encouraged to visit the home prior to admission. Admissions are usually planned allowing the home and the potential resident to gather all of the necessary information before a decision about the home’s suitability is made.
DS0000007011.V253181.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, Residents would benefit from the development of care plans so that they document the range of assessed needs and include information from assessments by other health care professionals. The Registered Manager has ensured that the requirements made at the last inspection about the management of medication have been met. Staff need to ensure that records of medication administration are fully completed. EVIDENCE: Four residents’ files were examined. It was found that on two files the residents’ assessed needs were not adequately reflected in the care plan. An example of this was a resident who had assessments undertaken by specialists from the Care Homes Support Team. The reports of the assessments gave useful information but they had not been incorporated into the care plan. Another example seen was a resident’s care plan, which did not adequately address the issues raised by diabetes. Although the documentation was not comprehensive the files showed that residents are referred appropriately to a range of health care professionals,
DS0000007011.V253181.R01.S.doc Version 5.1 Page 10 including the GP, psycho-geriatric services, specialist nurses, podiatry and dental services. Information was provided by the Registered Manager to confirm that two previous requirements relating to the management of medication have been met. She has ensured that when a resident is discharged from hospital, all changes to their medication regime are implemented and that all prescribed food supplements are given to residents. Other aspects were found to be met at the announced inspection of April 2005. At this inspection it was found that a record of medication administration was not completed fully. Although a code had been used on the chart to indicate that two doses of a medication had not been given the reasons were not included on the record. DS0000007011.V253181.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, The home has made progress towards meeting residents’ cultural needs. There needs to be further attention paid to recording activities and incorporating residents’ social needs into the care planning system. EVIDENCE: At the announced inspection of April 2005 it was found that there was a good programme of activities in the home but some residents, particularly those who do not leave their rooms, needed to have an individualised activity programme devised so that all residents’ social needs are met. It was also required that residents’ cultural needs needed to be more effectively addressed by the home. In response to the previous inspection report the Registered Person informed the CSCI that reviews of the social needs of the people who rarely leave their needs have been held and choices provided. In addition meetings with family members have been held to gather information about residents’ cultural and linguistic needs. Three of the residents attend a culturally appropriate day centre. The menu has been changed to further reflect residents’ cultural needs. DS0000007011.V253181.R01.S.doc Version 5.1 Page 12 The ‘life review’ forms are completed by residents’ family members and friends to assist the care staff to learn about the residents’ social histories and cultural needs. In the case of one resident who rarely leaves his room there was detailed information about his social history available and also advice from a health care professional about how to address his social needs. As noted above this had not been incorporated into the resident’s care plan. Care notes for the week prior to the inspection were examined and there were no references to any activities. Some of the good practice of the home is not recorded for example culturally appropriate music is provided for a resident but there was no reference to this on the person’s file. Representatives from a local church visit the home to offer communion. The statement of purpose states that the home will make efforts to facilitate residents’ attendance at local churches. The lunch time meal was observed by the inspectors. It was noted that there were considerable improvements to the arrangements for helping residents who need assistance with their meals. Since the last inspection the cook has undertaken training in catering for older people and food and nutrition. DS0000007011.V253181.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): As all of these standards were assessed and met at the announced inspection of April 2005, they were not examined on this visit. EVIDENCE: DS0000007011.V253181.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 The residents have benefited from the refurbishment and redecoration programme. This has made the building more homely and attractive. Suitable arrangements have been made to ensure that fire doors are not wedged open. EVIDENCE: There have been considerable improvements to the building as a programme of refurbishment is underway. In accordance with a requirement of the last inspection report arrangements have been made to fit devices to ensure that fire safety measures are not compromised. DS0000007011.V253181.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The recruitment procedure has been amended following a requirement of the last inspection. This has ensured that independent references are always taken up so that residents benefit from safe and thorough recruitment practice. EVIDENCE: It was found at the last inspection of the home that there are enough staff on duty to make sure that residents’ needs for care and support can be met. It was also found that the home has a significant number of staff who have undertaken training to NVQ level 2. Recruitment practices were examined in relation to three recently recruited staff. Although some documents were not on file at the time of the inspection the Registered Manager has provided information to confirm that the documents had been sent to the Head Office of the managing organisation. In all other respects the records were in good order. DS0000007011.V253181.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The residents benefit from a range of quality assurance systems that are in place. EVIDENCE: The remaining key standards were examined at the announced inspection of the home. Quality assurance and quality monitoring exercises are conducted by the home to assess the performance in a number of key areas. For example an audit of the quality of care was conducted in April 2005, and an audit of ‘customer care’ was conducted in May 2005. Quarterly meetings have been introduced by the Registered Manager to gather the views of residents and their relatives. Senior managers from the managing organisation conduct visits as required by regulation 26 of the Care Homes Regulations. The visits are made on an
DS0000007011.V253181.R01.S.doc Version 5.1 Page 17 unannounced basis and the reports indicate that the views of residents and staff are gathered as part of the monitoring exercise. DS0000007011.V253181.R01.S.doc Version 5.1 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. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X 3 X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X DS0000007011.V253181.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP7 OP8 Regulation 14(2)(b) 15(1) Timescale for action The Registered Person must 01/04/06 ensure that care plans document the range of residents’ assessed needs and include information from assessments by other health care professionals. The Registered Person must 01/02/06 ensure that records of the administration of medication are completed fully, including recording the reason why medication was not administered. The Registered Person must 01/04/06 ensure that care plans include residents social, cultural and linguistic needs and that recording includes reference to activities as well as physical and medical aspects of care. Requirement 2 OP9 13(2) 3 OP12 15(1) DS0000007011.V253181.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000007011.V253181.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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