Inspection on 07/12/05 for Burgh House

This inspection was carried out on 7th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burgh House 09/11/06

Burgh House 11/07/05

Burgh House 03/02/05

Burgh House 09/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Burgh House High Road Burgh Castle Great Yarmouth Norfolk NR31 9QL Lead Inspector Hilda Stephenson Announced Inspection 7th December 2005 09:30 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 Burgh House DS0000027440.V260177.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 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. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burgh House Address High Road Burgh Castle Great Yarmouth Norfolk NR31 9QL 01493 780366 01493 789250 info@burghhouse.co.uk 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) Burgh House Residential Care Home Ltd Mrs Helen Harris Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-three (33) Older People may be accommodated. Date of last inspection 11th July 2005 Brief Description of the Service: Burgh House is a care home providing personal care and accommodation for 33 older people and is owned by Mrs Church-Greiner and Mr Greiner. The home is situated within the village of Burgh Castle on the outskirts of Great Yarmouth. The home was opened in 1987 and consists of a two-storey building. It has 29 single and two shared bedrooms with en suite facilities, one of the single bedrooms is used for respite accommodation and has no en suite. Access to the first floor is via a shaft lift. The premises consist of a two-storey building situated in large attractive grounds with ample parking at the front of the building. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place during the day on Wednesday 7th December. Evidence was gathered to complete the report from talking with fourteen of the twenty nine residents, three visitors, five staff, the operational co-ordinator Joe Greiner and Mrs Church-Greiner, one of the proprietors who is also managing the home while the current manager is taking maternity leave. Further evidence was obtained by checking through care records and a random sample of the policies and procedures, as well as the regulated checks on the servicing of the equipment to ensure that it is all in good working order. Written information was received from relatives through comment cards that were sent direct to the Inspector. The home was very clean and tidy, there was adequate numbers of staff on duty, and the residents looked comfortable and well cared for. What the service does well: The home has a small loyal staff team who have worked at the home for some time. The manager is currently off for a short period of time and the home is currently being managed between the operational co-ordinator and one of the proprietors. Residents and visitors have been kept informed and knew who to speak to if they had any issues or concerns, while the manager is away. The home is run as an efficient business offering services and facilities described within the statement of purpose, but attention to personal care is paramount from the caring staff. The environment consists of two main lounges and one dining room with two other smaller areas for the residents to entertain visitors. A new entrance has been completed consisting of a small conservatory area increasing the internal area for residents. The home was very clean, tidy and free from odour and is cleaned on a daily basis, and has been tastefully dressed with Christmas decorations throughout the lounge areas. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 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 Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 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): 2,3,4,5 Written information is given prior to admission to define the facilities offered at the home. All residents are admitted after an assessment of their needs. EVIDENCE: Written information about the home after they receive an enquiry is sent out. Every resident is offered an assessment when the proprietor and operational co-ordinator will visit the prospective resident to ask him or her questions about their personal care and social needs. The proprietor encourages the prospective resident or their relative to visit the home prior to admission so they can see their room. Some residents who spoke to the Inspector knew the home beforehand and just moved straight in. Each resident is offered to stay for a trial period for a month when a review meeting takes place and the resident can make there mind up whether they wish to stay, and whether the home can meet their individual needs. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 9 The home also takes residents for short-term respite, with an initial assessment before their first visit; this enables relatives to take a break from being a full time carer at home. Each resident is given a copy of the terms and conditions of residency to explain these fully and protect both parties. A copy of the terms were seen and contained details from how the trial period works, if a resident wishes to leave or is reassessed for nursing care, what written information is kept about the resident, fees to be paid, how to complain, and the services the homes provides. The resident or their close relative are then encouraged to sign the document to ensure they have understood the terms of residency. The majority of residents spoken to confirmed that they had a copy of the terms and conditions. Several copies of the assessment undertaken of residents before they moved into the home were seen and found to contain activities of daily living needs; these are then used when the care plan is devised. One resident also confirmed ‘I came to visit the home to see my room and decided to stay’. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10 Care plans and health needs of residents are identified, reviewed and are met, with knowledgeable staff having a good understanding of the residents needs. Safe procedures are in place for the administration of medicines. EVIDENCE: The care staff act as key workers and have two or three residents who they take responsibility for, this includes writing the care plan and reviewing the care needs on a regular basis. A sample of care plans were seen and some were signed by residents to confirm that they are included when the care plan is written. A sample of care plans was seen and when speaking to those particular residents it was evident that the care plans were consistent with the care that was actually offered. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 11 One resident stated ‘I was asked what I wanted when I moved in, and the staff sometimes asks me if there is anything that I would like changed, but they are so kind, I couldn’t think of any changes’. The home is supported by local GP surgeries with regular visits provided by district nurses for any nursing tasks that residents require. The care plans that are developed by the key workers should include more in depth social history and personal interests of each of the residents, to help carers in preparing for any deterioration with memory in the future. The medicines are stored and administered by staff that have undergone the recent medications course provided through a local college. Although one member of staff had not undertaken the medication training and should update her knowledge and current procedures on medicine administration. The home has a medication policy and encourages residents to self medicate if appropriate with relevant risk assessments in place. Medication was stored in a secure locked facility. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 12 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): 12,14,15 Social activities are well managed with several group and individual interests for residents living in the home, with lunch and teatime included as a sociable event. EVIDENCE: The home is renowned for their organised daily activities from Monday to Friday with residents preferring a quieter weekend. Each afternoon the home has outside people visiting to arrange an activity for groups, with the home’s own staff arranging individual interests if they do not wish to take part. The week ends with ‘boozy bingo’ arranged by the proprietor with visitors regularly taking part as well. This month a booklet has been published to show the arrangements in place for the run up to Christmas including the Christmas party, a musical afternoon, a pantomime, a visit to the local school for carol singing and a Christmas Boozy bingo. All of the residents confirmed that the home has a good selection of social activities and do not feel pressured to take part if they do not wish to. Many of the residents and relative’s help with the arrangements that is very good practice ensuring Burgh House is their own. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 13 Several visitors were seen during the day, with two confirming that they are always made to feel welcome and take part in some of the arranged activities. The lunch was served to residents during this visit with the majority of residents going to the dining room. This was nicely laid out in tables to seat up to four people. Several residents confirmed that the cook asks them there preferences for meals and that plenty of snacks and drinks are served during the day. Any resident who requires a specialised diet can also be catered for. At teatime, the bulk of the preparation is carried out by the cook before she goes off duty, and a delegated member of the care staff on duty prepares fresh food and serves this to the residents. The proprietor must ensure that all staff who undertakes any food preparation, completes the food hygiene training to ensure the procedure is risk free. The kitchen was clean and lunch was being prepared during the tour of the premises. Copies of the menu were supplied and contained a wide variation of meals taking into account seasonal changes and special occasions such as birthdays. One resident stated ‘I think the food here is very tasty, and there is plenty of it, there’s always something else if I don’t fancy anything on the menu’. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a satisfactory complaints system with evidence that residents’ views are listened to and acted upon. EVIDENCE: The home has a detailed complaints procedure and complaints are recorded with the necessary action taken. Residents and staff commented that they prefer to speak to the Proprietor or operational co-ordinator if they had any concerns. No complaints were received during this inspection. Two visitors and one resident were asked how they would complain and would they feel uncomfortable about complaining, they confirmed that they would prefer to speak to the proprietor who would be their first choice. A procedure for responding to allegations of abuse was in place. The proprietor has a adult protection booklet for all the staff to keep up to date on matters of abuse, and staff confirmed that they had received these and regularly kept up to date by attending adult protection workshops which is very good practice. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 15 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): 19,20,24,26 Residents live in a home that is clean, tidy and provides a comfortable environment for them. EVIDENCE: Burgh House is a detached two-storey property within the village of Burgh Castle. It is surrounded by well-maintained large gardens with a seating area and patio at the rear. Car parking facilities are at the front of the building. The front entrance has been completed providing a spacious entrance area. The majority of the bedrooms are single with en suite facilities. The proprietors have plans in place for the following year and have recently upgraded four bedrooms since the previous inspection, as well as redecorating the hallway and replacing the carpet, and replacing some windows on the first floor in line with the regulations and repainting the external windows on the north side of the property. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 16 A tour was undertaken; the home was clean and tidy with two comfortable lounges and dining room. There are two smaller areas situated off the main corridors where residents can entertain visitors if they do not wish to go to their rooms. A resident was also entertaining visitors within the new small front conservatory. Several bedrooms were seen during this visit where some of residents were spoken to. All the bedrooms contained residents’ own personal possessions making them more homely. None of the residents were unhappy with their room, each one had a call bell to enable them to ring for assistance when they required it. It was observed during this visit that none of the residents waited too long before their call was answered. One resident stated ‘I don’t wait too long for one of the staff to answer the bell’. The home was cleaned on a daily basis by designated staff and was clean and tidy and free from any offensive odour. The home carries out all of the residents’ personal laundry. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Sufficient numbers of staff are on duty to meet residents’ needs with extra staff brought in to cover busy periods. Good recruitment procedures are in place. EVIDENCE: The home has a core team of staff with the majority having worked at the home for several years. During the morning three care staff and the deputy manager are on duty reducing to two care staff and one senior until the evening, with two care staff overnight. The proprietor has introduced a system of ‘on call duties’ to include the deputy manager, senior carer and operational co-ordinators who can respond when an urgent matter arises. The staff has increased the number of staff who have achieved or are undertaking the recommended NVQ training and should be praised for this. Staff confirmed that they feel well supported by the proprietors and operational co-ordinator regarding the amount of training they are offered. Staff training records identified areas of training that the majority of staff have recently undertaken including moving and handling, food hygiene refresher, fire training, diabetes blood sugar monitoring training, first aid, medication administration and catheter care. Not every member of staff has undertaken all of the above training and to ensure that good practice continues, must complete medication and food hygiene. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 18 Newly employed staff is monitored through the TOPSS induction programme and are supervised by the deputy manager or senior care staff. Recruitment records for the last two members of staff who have been employed were seen. The proprietor ensures that the recruitment procedure is strictly adhered to ensuring the protection of residents with relevant references and CRB checks being carried out before employment commenced. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 19 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): 32,33,35,36,37,38 The home has good health and safety procedures in place to ensure the safety of both residents and staff. Staff are supervised and supported to care for residents’ needs. Residents’ best interests are safeguarded. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 20 EVIDENCE: The home is being managed between the proprietor and operational coordinator while the current manager is taking maternity leave. The operational co-ordinator ensures the health and safety procedures are followed and staff attends supervision sessions to check their progress with training or personal concerns. The home is run in an ‘open and inclusive’ manner, feedback received from some of the comment cards received prior to the inspection and comments received from the three visitors who were spoken to during this visit confirmed this. A quality assurance system is in place with the proprietor auditing the service, providing the opportunity for residents and relatives’ views on the home, monitoring care plans, regular supervision of staff and providing feedback during meetings. Residents have a locked facility within their bedroom if they wish to tend to their own finances, although several have assistance from their relatives. The home does keep some personal spending money for residents, with the relevant records in place. A sample of the records was checked and found to be accurate. A sample of the required certificates were seen, health and safety procedures including fire, accidents, environmental health, infection control and adult protection records, which were all satisfactory. The water, central heating and radiators were all in working order. The registration and insurance certificate was valid and displayed. Overall, the home is managed in a safe and satisfactory manner putting residents and staff’s health and safety first. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 21 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 X 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X 3 3 3 3 Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 22 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 2 Standard OP9 OP30 Regulation 13.2 18.1c Requirement All staff that administers medication must undertake accredited medication training. Staff who prepares food must undertake the food hygiene training. Timescale for action 30/01/06 30/01/06 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 OP7 Good Practice Recommendations The resident’s life history and past interests should be included within care plans especially for those who have any memory impairment. Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Burgh House DS0000027440.V260177.R01.S.doc Version 5.0 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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