Inspection on 09/10/06 for Burlam Road Nursing Home

This inspection was carried out on 9th October 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

Burlam Road Nursing Home 25/09/07

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 Julia Connor Key Unannounced Inspection 9th October 2006 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.V314670.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.V314670.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 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Ms Karen Miller Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To allow a maximum of 5 services users with a physical disability who are 50 years to reside in the home. The Manager (Mrs Karen Miller) should attain a relevant Management qualification by 2005. Six named individuals who are under the registered age category are allowed to reside in the home. 16th January 2006 Date of last inspection 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. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 9.30 a.m. and concluded at 3.15 p.m. Residents’, one visitor and three members of staff spoke to the Inspector. Six Three of the Residents’ expressed concern over the food served to them. One Resident stated that the meals ‘were alright I suppose’ and another Resident stated that ‘good quality food is ruined’ and went onto explain that in her/his opinion the food was not cooked properly. Another Resident stated that the meals at teatime were boring, always soup and sandwiches. Four Residents’ stated that in their opinion there was insufficient staff on duty. One Resident made the comment that s/he knew there where a number of Residents’ who required a lot of attention but when s/he needed assistance s/he needed it sooner rather than later. The current fees structure is £338.00 to £440.00 a week depending on the level of care the Resident requires. What the service does well: What has improved since the last inspection? The home has purchased new lounge chairs, a fridge freezer as well as crockery and bedding. New trolleys’ have been purchased for the dining room and digital scales to weight the Residents’. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 6 Six bedrooms have been decorated with the Residents’ choosing the colour and fabric. The dining room had been decorated with the opinion of the Residents’ being sought first. The garden at the side and front of the home has had decorative gravel laid. 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. Burlam Road Nursing Home DS0000000154.V314670.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.V314670.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents’ have their needs assessed prior to them being admitted to the home. EVIDENCE: There was evidence in the Residents’ care documentation that they had been assessed either by the Social Worker or the discharging ward prior to moving into the home. The Manager or her representative carries out a pre admission assessment. Burlam Road Nursing Home DS0000000154.V314670.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Residents’ health, personal and social needs are recorded in an individual plan of care and their health care needs are met. Residents’ feel that they are treated with respect and dignity and their privacy is upheld. The home has a policy and procedure for medication. No Resident currently administers his/her own medication. EVIDENCE: Four sets of Residents’ care files were audited and all contained an adequate amount of information. There was evidence that Residents’ or their representative had agreed the plans of care. Doctors, District Nurses, Chiropodists etc are requested to visit the Resident as and when necessary. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 10 There is a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. No Resident currently administers his/her own medication. The Residents’ who spoke to the Inspector stated that the staff always treats them with respect and dignity. One Resident stated that the staff were ‘lovely girls’ and her daughter stated that she liked that the fact that the staff would give her Mother a kiss and cuddle. Another Resident stated that the home ‘was a lovely place’ and that ‘the girls make it a happy home’. This Resident stated that s/he was always treated with respect and dignity and the staff would always knock before entering his/her bedroom. Burlam Road Nursing Home DS0000000154.V314670.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents’ are satisfied that the home meets their social, religious and recreational needs. Residents’ maintain contact with their family and friends and are encouraged to make decisions regarding their every day lives. There were Residents’ who voiced their concern over the food served to them and the choice given to them at teatime. EVIDENCE: There is an activities organiser in post who works 20 hours a week. The Residents who spoke to the Inspector stated that there were regular activities such as Bingo, Play Your Cards Right and Skittles. One Resident stated that s/he preferred to stay in his/her bedroom and watch T.V. but stated that s/he did attend the evening entertainment and was looking forward to the Race Night on the 20th October. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 12 Another Resident stated that s/he did not could not attend the activities on offer and so found the days long. Another Resident stated that s/he stayed in her/his bedroom but kept occupied by a listening to the radio, watching T.V. or doing crosswords or some artwork. There were visitors’ in the home on the day of the inspection. The Residents’ who spoke to the Inspector stated that their visitors’ were always made welcome; the visitor who spoke with the Inspector confirmed this. Many of the Residents’ had telephones in their bedrooms or carried a mobile ‘phone with them. One Resident informed the Inspector that s/he like to be as independent as possible and the staff respected her/his wish. Another Resident stated that s/he made her/his own decisions but was aware the staff were available should help be required. Three of the Residents’ expressed concern over the food served to them. One Resident stated that the meals ‘were alright I suppose’ and another Resident stated that ‘good quality food is ruined’ and went onto explain that in her/his opinion the food was not cooked properly. Another Resident stated that the meals at teatime were boring, always soup and sandwiches. One Resident stated that s/he had a special diet and was satisfied with the meals s/he was given. Another Resident described the food as ‘quite good’. It would be beneficial if the Manager spoke to the Residents’ living at the home, either in a group or individually, to ask their opinion of the food and how they felt it could be improved. Burlam Road Nursing Home DS0000000154.V314670.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents’ are confident that their complaints will be listened to seriously and action taken. There are polices and procedures in place to follow should abuse be reported. EVIDENCE: There is a complaints policy and procedure in place, which outlines the stages the complainant should take to make a formal or informal complaint. Complaints are recorded appropriately and are available for inspection. The Residents’ and visitor who spoke to the Inspector were confident that should they make a complaint it would be taken seriously and acted upon. Policies and procedures are in place in relation to adult protection and prevention of abuse. The home has a copy of the Teeswide No Secrets Protection of Vulnerable Adults Guidance. There was evidence that training had been given regarding the Protection of Vulnerable Adults. The staff who spoke to the Inspector were aware of the action to take should they witness any form of abuse. Burlam Road Nursing Home DS0000000154.V314670.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Residents’ live in a clean, hygienic and well-maintained environment and have access to comfortable indoor and outdoor communal facilities. EVIDENCE: On the day of inspection the home was clean, pleasant and odour free. The Residents’ who spoke to the Inspector were satisfied with décor of the home. Six bedrooms have been decorated with the Residents’ choosing the colour and fabric; a Resident confirmed this. The dining room had been decorated with the opinion of the Residents’ being sought first. The garden at the side and front of the home has had decorative gravel laid. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 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): 27, 28, 29 and 30 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Although the duty rota indicated the appropriate number of staff where present in the home on the day of the inspection there were Residents’ who felt that there were insufficient staff on duty to meet their needs. Staff are being trained to NVQ level 2 which should ensure that they can meet the Residents’ needs. The Residents’ are protected by the home’s recruitment practices and staff receive training to enable them to care for the Residents’. EVIDENCE: On the day of the inspection there were two qualified nurses’ and six care assistants’ on duty for the day shift, two qualified nurses’ and four care assistants’ on duty for the evening shift, and one qualified nurse and three care assistants’ on duty on a night shift. There were Residents’ who felt that there was insufficient staff on duty to meet their needs. One Resident made the comment that s/he knew there where a number of Residents’ who required a lot of attention but when s/he needed assistance s/he needed it sooner rather than later. Another Resident stated ‘the girls’ are always busy and you have to wait to go to the toilet but when you need the toilet you can’t wait’. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 16 Another Resident stated ‘I’m sick of having to wait for the staff to assist me’ then went onto say that it was not the staffs fault that she had to wait there just was not enough of them. The Manager recorded in the pre-inspection questionnaire that 88 of the care staff had an NVQ level 2 or 3 in care, which is an increase of 33 since July 2005. An audit of four personnel files showed that the home complied with the requirements stipulated in Schedule 2 of the Care Home Regulations 2001. Four training files were audited and showed that training had taken place, for example fire, manual handling and infection control. Staff who spoke to the Inspector confirmed that training takes place. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 17 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): 31, 33, 35 and 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Manager has the experience to ensure that the needs of the Residents’ are met. There was evidence that quality assurance and quality monitoring takes place. The Residents’ personal finances are safeguarded and there are polices and procedures in place for the staff to access. EVIDENCE: The Manager has the experience to ensure that the needs of the Residents’ are met; she is currently studying for her NVQ Level 4 in management, which she hopes to have completed by the end of the year. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 18 There is a quality assurance and quality monitoring system in place within the home. A nominated person within Four Seasons Healthcare carries out a yearly audit; monthly regulation 26 reports are sent to the Commission for Social Care Inspection. The Residents’ combined monies are kept in an interest bearing account; at the end of each year the interest accumulated goes into the Residents Activity Account. The home has Health and Safety policies and procedures in place. The Manager had recorded in the Pre-inspection questionnaire that equipment was maintained as required for example the lift had been serviced on the 16th May 2006 and the emergency lighting on the 12th April 2006. Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 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.V314670.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP15OP15 OP27OP27 Good Practice Recommendations Burlam Road Nursing Home DS0000000154.V314670.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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