Inspection on 25/09/07 for Burlam Road Nursing Home

This inspection was carried out on 25th September 2007.

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

Burlam Road Nursing Home 09/10/06

Burlam Road Nursing Home 16/01/06

Burlam Road Nursing Home 15/07/05

Burlam Road Nursing Home 24/11/04

Burlam Road Nursing Home 21/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Burlam Road Nursing Home 113 Burlam Road Middlesbrough TS5 5AR Lead Inspector Jane Bassett Unannounced Inspection 25th September 2007 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 Burlam Road Nursing Home DS0000000154.V351064.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. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burlam Road Nursing Home Address 113 Burlam Road Middlesbrough TS5 5AR 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) 01642 824947 01642 850632 burlam.road@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd Ms Karen Miller Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (12) of places Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th October 2006 Brief Description of the Service: Burlam Road is a care home providing both nursing and personal care for older people. It is a two-storey purpose built home, with an extension, providing single and double accommodation for 50 Residents; the 38 single bedrooms are a minimum of 10 sq.m. and the 6 double bedrooms are a minimum of 16 sq.m. There is a passenger lift giving access to all floors. There are three lounges, one on each floor and the third in the extension and a large communal dining room on the ground floor and a smaller dining room in the extension. The home is close to local shops and amenities with a car park at the front of the home. The current fees structure is £355.00 to £460.00 a week depending on the level of care the Resident requires. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report includes information obtained from an Annual Quality Assurance Assessment (AQAA) completed by the manager of the home. Two visits to the home were carried out, the first visit was unannounced. During the visits, which lasted seven hours the inspector walked around the building and looked at documentation including staff records and residents files. The inspector spoke to seven residents, seven staff members and the manager. As the inspector walked around the home she carried out indirect observation of interactions between residents and staff. Four relatives and three staff returned surveys to CSCI. Seven residents completed surveys some with support from relatives or staff at the home. What the service does well: What has improved since the last inspection? The home has acquired some new garden furniture and purchased a new bath that on the day of the inspection was waiting to be fitted. There is now a comments book available in the dining area, for people to register their feelings about the meals provided, as recommended at the previous inspection. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burlam Road Nursing Home DS0000000154.V351064.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 Burlam Road Nursing Home DS0000000154.V351064.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): Outcomes for standard 3 were looked at. People who use the service experience good quality outcomes in this area. Prospective people to use a service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: During the inspection two files of residents recently admitted to the home were examined. Both were seen to contain an assessment of need carried out by the authority funding that person’s care and information recorded by the home prior to the person’s admission. One of the files also contained evidence of visits to the home of the resident prior to them living there. Comments on one survey received by CSCI indicated that the person was given ‘ a detailed tour and information’ prior to admission. The home does not offer intermediate care. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 7, 8, 9, & 10 were looked at. People who use the service experience good quality outcomes in this area. The health and personal care that people receive is generally based on individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: During the inspection four residents care files were examined. There was evidence in all files that an assessment process had been followed, however the assessment documentation was not always complete. In one persons file dates and signature were missing, in another a continence assessment was not fully completed and there was no evidence of a plan of care despite entries in daily recordings indicating incontinence pads were used. In another file there was no evidence of an assessment of risk in relation to the use of a lap strap. In other files assessments in relation to the use of bed rails contained only one signature. There was no evidence of discussion and agreement. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 10 All files contained plans of care, evaluation and reviews, however plans did not always reflect the individual’s capabilities and preferences. There was evidence of involvement of health professionals such as GP, optician, speech therapy and district nurses when required. A sample audit of medication on the day of the inspection found no major concerns with the ordering, storage and administration of medication. It was noted that a number of ‘blister packs’ of medication were being stored on open shelves in the treatment room. The room was found to be locked at the time of the inspection. The inspector was told that only qualified staff administer medication. Staff who spoke to the inspector were able to demonstrate a good knowledge of individual residents and their needs. Staff described how resident’s choice and privacy were respected. All said residents could choose how they spent their day. Comments received from residents and their families included ‘care is proactive caring professional and exemplary’, ‘ I always receive the support I need’ and ‘I always receive excellent care and I am happy here’. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 12, 13, 14, & 15 were looked at. People who use the service experience good quality outcomes in this area. People who use the services are able to make choices about their lifestyle, and are supported with social, and recreational activities that meet individual’s expectations. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Residents who spoke to the inspector told her they were happy with their lifestyle, and there are variety of activities offered. The home employs an activities coordinator. The inspector was told activities included bingo, quiz, games, and trips out. There are links with local churches. Residents have access to computers. Residents who spoke to the inspector told her ‘ there are plenty of activities’ and ‘ there is something every day’. All who spoke to the inspector told her visitors are always made to feel welcome and can visit in the privacy of the person’s own room if they wish. The lunchtime meal on the first day of inspection was seen to be of good quality and well presented. Residents who spoke to the inspector said meals were generally very good and there was always a choice. Comments received Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 12 included ‘I always enjoy the meals’, ‘the food is lovely’, and ‘ if I don’t like the choices at meals they will make me something else’. A comments book was seen to be available in the dining room for residents to use if they wished. It was seen to contain comments recorded by the resident or a staff member on their behalf. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 16, & 18 were looked at. People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse and have their rights protected. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Information contained in the AQAA returned by the home indicated that in the previous12 months the home had received two complaints and made one safeguarding referral. Records of complaints were seen to contain information relating to the complaint, investigation, outcome, actions taken and complainant’s satisfaction. Information received in surveys returned to CSCI and discussion with residents indicated that people were aware of how to raise any issues. Residents told the inspector that they were ‘listened to’ and they were happy with how issues were handled. Staff who spoke to the inspector told her they had received training in relation to prevention of abuse and the ‘ no secrets’ guidance. All were able to describe the action they would take if they had any concerns. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Outcomes for standards 19 & 26 were looked at. People who use the service experience good quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe, generally well maintained and comfortable environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Residents who spent time with the inspector said they were generally happy with the current environment and the furnishings within the home. The home has recently acquired some new garden furniture. They have also purchased a new bath, which on the day of inspection was being stored in empty bedroom waiting fitting. It was seen that equipment such as carpet cleaners, and trolleys were being stored in corridor areas, due to limited storage facilities within the home. A number of kitchen fridges were seen to be in the resident’s dining room, detracting from the ‘homely’ environment. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 15 Some corridor walls and door frames were seen to be marked and damaged by movement of equipment, and one ground floor shower room had some broken tilling. As the inspector walked around the home she was able to look at a number of residents bedrooms. These were seen to contain furniture and equipment to meet individual’s needs and were seen to be arranged to meet individual’s preferences. Rooms were seen to be personalised to taste with the resident’s own ornaments and pictures. On the day of inspection the home was found to be clean and generally odour free. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 16 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): Outcomes for standards 27, 28, 29, & 30 were looked at. People who use the service experience good quality outcomes in this area. Staff at the home are trained and generally in sufficient numbers to support the people who use the service. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: On the day of the inspection there were 40 residents of varying dependency living at the home. A staffing rota seen on the day of the inspection indicated there were two qualified nurses and six care staff on duty on the mornings, two qualified nurses and five care assistants on an evening and one qualified nurse and three care assistance overnight. The home has separate domestic, laundry and catering staff. Residents who spoke to the inspector and comments on surveys returned to CSCI indicated their care needs are met, however staff are ‘busy at times’ Comments received included ‘I always receive the support I need’, ‘the home deals with every aspect of my welfare’ and ‘staff seem caring and knowledgeable’. Three surveys returned to CSCI commented on ‘always seem short of staff’ Staff who spoke to the inspector said they are meeting the needs of the residents but this can be a struggle, staff also said dependency levels are increasing. Staff stated one resident required the assistance of four care staff on average 8 – 10 times per day. Other residents required the assistance of 2 or 3 care staff. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 17 The inspector examined staff files of two staff recently recruited, both were seen to contain the appropriate documentation including references and CRB. Other records seen indicated that an annual check of qualified staff PIN is carried out. A sample audit of staff files and other documentation indicated staff have received induction training and further training including moving and handling, fire safety, first aid, health and safety, challenging behaviour, conflict management, and safe handling of medication. The inspector was told 56 of care staff have completed NVQ at level 2 or above. Staff told the inspector training and development are available and encouraged. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 18 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): Outcomes for standards 31, 33, 35, & 38 were looked at. People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness and respect, and has effective quality assurance systems. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered manager of the home is a first level nurse with a number of years of management experience. People who spoke to the inspector told her the manager was approachable and acted on issues raised. Information contained in the AQAA indicated the home has a range of policies and procedures, and these were reviewed in March 2006. Other information in the AQAA indicated that the home and equipment are maintained as required. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 19 Records seen during the inspection confirmed fire alarms are tested weekly, hot water temperatures are checked and recorded on a monthly basis. During discussions with the manager the inspector was told that hot water temperatures at bathing facilities were now to be recorded weekly. Accidents were seen to recorded and an analysis carried out. The inspector was told communication was good. Staff who spoke to the inspector confirmed they received regular supervision, shift handovers and staff meetings. Residents confirmed that they had the opportunity in meetings or individually to raise issues and discuss events that affect them. Comments received by the inspector included ‘I am always kept informed’, ‘ we are constantly updated’ and ‘ we have a good rapport with home staff’. Regulation 26 visits take place and reports were made available. The manager has also to complete a 3 monthly team audit that looks at all aspects of the service provided. The home continues to use a joint bank account for the retention of resident’s personal monies, however individual computerised records are maintained for each person. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 20 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 21 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 Regulation 15 Requirement The registered provider must ensure that a comprehensive assessment of need is carried out for all residents. The registered provider must ensure there is a plan of care for all identified needs. Timescale for action 01/12/07 2. OP7 15 01/12/07 Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 22 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. 5. 6. Refer to Standard OP7 OP9 OP19 OP19 OP27 OP35 Good Practice Recommendations Plans of care should be developed further to reflect the person’s capabilities and preferences. Consideration should be given to the provision of additional lockable cupboards for the storage of medication. Consideration should be given to a programme of refurbishment and decoration. Consideration should be given to the provision of storage for fridges and equipment. The Manager should review the needs of the Residents’ to ensure that there is sufficient staff on duty. Individual bank accounts should be obtained for residents. Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 Burlam Road Nursing Home DS0000000154.V351064.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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