Inspection on 09/11/06 for Burgh House

This inspection was carried out on 9th November 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 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 07/12/05

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 Linda Wells Unannounced Inspection 9th November 2006 10:30 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.V320206.R01.S.doc Version 5.2 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.V320206.R01.S.doc Version 5.2 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 Mr Joseph Greiner Mrs Helen Harris Care Home 33 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (33) of places Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-three (33) Older People may be accommodated. Date of last inspection 7th December 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. 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. The current range of fees for living at the home are from £334.50 -- £361.50 per week with additional costs for hairdressing, chiropody, toiletries, newspapers and magazines. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgments for each outcome group. What the service does well: What has improved since the last inspection? What they could do better: Residents are well cared for and enjoy a good standard of life. The requirements and recommendations from the last inspection have been complied with however, there were four requirements and two Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 6 recommendations made to further improve the experience of living and working at the home for residents and staff. • • • • • • Plans of care must all contain a photograph of the resident to aid in identification and to protect their health and safety. (Already held on file) The loose flooring in the rear entrance porch must be repaired to ensure the safety of those entering and leaving the home. (The manager immediately arranged for repair of this area.) The radiators that are not low surface temperature must be guarded or replaced to ensure the health and safety of residents is assured. The owner must produce a monthly report on the standard of care, services and environment and send a copy to CSCI. It is recommended that the thorough risk assessments held on each resident be stored in the plan of care of the resident to ensure their information is stored correctly. It is recommended that the quality assurance audit produced be further developed, a summary of the findings and planned improvements produced and a copy sent to stakeholders and CSCI. 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. The summary of this inspection report can be made available in other formats on request. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, (6 N/A) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The written information available about the home is complete and fully enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to visit or stay there. EVIDENCE: Case tracking confirmed good practice. The manager or owner had visited service users prior to admission and had carried out a thorough assessment of their care needs. Written information was also held, that had been collected from the service user, family members and other professionals and together with the home’s assessment made a full and comprehensive assessment of the health, social and personal care needs of each service user. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 9 A Statement of purpose, Service users Guide and leaflet has been produced that contains all of the information about the home, service provided and facilities. Most of the service users spoken to said that they had been given copies, that staff had explained the contents to them and they had signed a terms and conditions contract. This was seen in their plan of care. A service user spoken to who had lived at the home for two months said that she and her family had looked around the home, they had been given enough information to help them decide if the home could meet her needs, that staff had made her feel welcome and helped her to settle in. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were well looked after, they were protected by the medication policies and procedures, their health and personal care needs were met and records were complete. EVIDENCE: Case tracking confirmed good practice. The service user plans of care were good and were generally complete and up to date. They did not all contain a photograph of the service user to aid in identification (they were held o file) and the thorough risk assessments that had been completed were stored together with the information of other service users. One requirement and one recommendation were made. Staff members had completed basic and accredited training in the safe administration of medication and the records held were accurate and complete. Reviews were carried out monthly by the Provider Assistant who organised the Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 11 activities and spoke to every service user each week to check that they were satisfied with the care and activities they were receiving. Senior staff updated plans of care as changes occurred and health and safety checks had been completed, were recorded and were up to date. This resulted in service users being protected and their care needs being met. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social and creative activities and meals provide daily variation and interest for those living at the home. EVIDENCE: Case tracking confirmed good practice. A full and varied programme of activities was devised and implemented and records showed that service users were consulted and their interests catered for. Records were maintained of the activities that service users joined in with, their opinion of them and their choice of what they would like to do. The provider assistant said that as part of her role she arranged for group and individual activities and spoke to each service user at least once a week to ensure they were happy with the care they received and how they spent their leisure time. Service users said “there is always lots to do here if you wish to” and “I do so enjoy the entertainments”. Two service users spoken to said that they did not Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 13 like to join in with others but preferred to stay in their bedrooms and read. This resulted in service users living the lives they wished. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: No complaints had been received by the home and a complaints procedure was available to all service users and was included in the service users guide. Service users all said they felt safe, listened to, and able to speak to the staff or manager if the were unhappy about anything to do with their care, the service provided or the facilities. Staff members spoken to and case tracked had completed training in protecting service users from abuse, were aware of the complaints procedure and gave good examples of how they would deal with complaints or issues of protecting vulnerable adults. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is comfortable and meets their needs, however, their health and safety is not fully protected in two areas of the home. EVIDENCE: The home was clean, tidy and contained no offensive odours. Service users live in a home that is maintained to a good standard and is well decorated and furnished. Most of the bedrooms are single and en-suite and there are adequate bathrooms, toilets and equipment. The communal space is generous and the garden well maintained with pleasant places to sit. However, not all of the radiators in the home are low surface temperature and those that were not were not all guarded and the wooden Parquet flooring in an entrance porch had pieces missing and posed a risk of trips and falls. The manager said that he Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 16 would immediately replace the radiators with those that are low surface and arrange for the flooring to be repaired. Two requirements were made. Service users said that they liked their bedrooms, they were comfortable and said, “this home is so clean” and “it is like being in a hotel”. The rooms of those service users who were case tracked showed that they had all personalised their bedrooms and had access to equipment and a call bell system. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The training of staff provided safeguards to protect people living at the home, recruitment checks were carried out and records were complete. EVIDENCE: Case tracking confirmed good practice and adequate staffing levels. Service users all complimented staff and two said, “staff are very good and are patient” and all said, “staff give you every help and are so kind”. Observation of staff with service users demonstrated that staff had a relaxed approach, included service users, communicated with them at their pace and that service users had positive interactions with staff members. Two new staff members from overseas had been recruited and the home is fully staffed. Complete and thorough recruitment and proof of identification checks had been carried out and the records showed that service users were protected, that staff took part in handover at shift changes and attended staff meetings. Staff members are trained to meet the needs of service users, certificates were seen to show that they have completed updated training and a list of the Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 18 training staff members have completed has been produced and is maintained. This means that staff members are competent and trained to do their jobs. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff members are supported and supervised, the needs of residents are met and complete systems of record keeping, policies and procedures are held. EVIDENCE: Case tracking confirmed that the home was well organised and that the new manager had an ‘open’ approach to leadership. Service users spoke very highly of the management team and said that they felt safe living at the home, that all staff were approachable and that “nothing is too much trouble for them”. Records showed that the home is run in the best interests of service users, that the health, safety and welfare of service users is promoted and that staff are supervised. However, the Proprietor had not completed a monthly Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 20 provider report on the home and sent a copy to CSCI. A requirement was made. The quality assurance systems in place are effective and the manager is proactive in addressing quality issues within the home. The views of service users and relatives had been sought and demonstrated a high level of satisfaction from those whose opinions were sought and returned their questionnaire. The manager said that he planned to seek the views of staff through appraisal but agreed that staff members and healthcare professionals should be asked at the same time as everyone to complete the quality audit and that a summary of the findings and plans of action should be made available to stakeholders and CSCI. A recommendation was made. Servicing and maintenance records were complete and up to date and showed that the health and safety of service users is fully protected. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 22 NO 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 OP7 Regulation 17 Requirement The registered person must ensure that all plans of care contain a photograph of the service user. The registered person must ensure that the loose flooring in the rear entrance porch is repaired. The registered person must ensure that the radiators that are not low surface temperature are guarded or replaced. The registered person must ensure that monthly quality review reports on the standard of care provided are completed and a copy sent to CSCI. Timescale for action 31/01/07 2. OP19 13.4 31/12/06 3. OP19 13.4 31/03/07 4. OP33 26 31/01/07 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 It is recommended that the thorough risk assessments DS0000027440.V320206.R01.S.doc Version 5.2 Page 23 Burgh House held on each resident be stored in their own plan of care to ensure their information is stored correctly. 2. OP33 It is recommended that the quality assurance audit produced be further developed, a summary of the findings and planned improvements produced and a copy sent to stakeholders and CSCI. Burgh House DS0000027440.V320206.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V320206.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!