Inspection on 10/11/05 for Burleigh House

This inspection was carried out on 10th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burleigh House 26/06/07

Burleigh House 29/08/06

Burleigh House 23/06/05

Burleigh House 04/10/04

Burleigh House 24/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Burleigh House Foxearth Leek Road Cellarhead Stoke On Trent Staffordshire ST9 0DG Lead Inspector Mrs Linda Clowes Unannounced Inspection 10th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burleigh House DS0000004922.V265313.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. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burleigh House Address Foxearth Leek Road Cellarhead Stoke On Trent Staffordshire ST9 0DG 01782 550920 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) Day Care Services Limited Mrs Jane Day Care Home 15 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (2), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (15), Physical disability over 65 years of age (4) Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. MD - REGISTERED FOR 2 - MINIMUM AGE 55 YEARS AND OVER ON ADMISSION NUMBER OF SERVICE USERS IN THE COMBINED CATEGORIES MD(E), MD AND DE(E) SHALL NOT EXCEED A TOTAL OF 6 PEOPLE. 23rd June 2005 Date of last inspection Brief Description of the Service: Burleigh House was an impressive detached property set in its own mature gardens in a pleasant rural location. It was registered to offer care and accommodation for fifteen older people and provided 13 single bedrooms, one shared bedroom and ample communal space. The home had good access by road to local towns and was within a couple of miles of the village of Werrington which had extensive community facilities including GP surgery, library, churches, post office, shops, pubs and restaurants. There was ramped access to the front door. Accommodation covered two floors and access to the first floor was by staircase and shaft lift. There were two main lounges with a large dining area and a conservatory for use by service users. Externally there was a decked area with table and seating. There were several other areas in the grounds and on the patio with seating and shading so that service users could enjoy the sunshine and the gardens. The home was warm, clean and pleasantly decorated. It was equipped with appropriate aids to daily living to meet the needs of its service users. There was an on-going commitment to training at all levels that was reflected in the good quality of care provided. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A full inspection of the care home addressing all the National Minimum Standards (NMS) had been carried out at the last inspection. This inspection was focussed on monitoring progress in relation to the requirements made in the last report, speaking with service users and relatives and sampling care records, fire and maintenance records, staff training and supervision records. Not all the NMS will, therefore, have been inspected on this visit. This report should be read in conjunction with the report for the visit of 23rd June 2005. Since the last inspection there had been a concerted effort to address the requirements relating to the fabric of the building and the grounds. A programme of maintenance and refurbishment had been introduced with a number of areas in the home having been addressed – these are outlined in the report. There had been extensive work carried out to clear the grounds and gardens of overgrown trees and shrubbery that had increased light levels in the home. The inspection identified that on-going work needed to be carried out to improve facilities in the laundry area and there were some health and hygiene issues to be addressed. The home was fully staffed and mandatory training had been carried out. Training was planned for all staff in January 2006 to cover Protection of Vulnerable Adults from Abuse. What the service does well: Burleigh House had a great number of satisfied customers. Relatives spoken with on the day were happy to express their satisfaction with the care provided and the positive attitude of staff at all levels. The home had robust recruitment procedures that protected service users. The home co-operates fully with the CSCI to improve services for its service users. Burleigh House DS0000004922.V265313.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. Burleigh House DS0000004922.V265313.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 Burleigh House DS0000004922.V265313.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): 3,4 and 5 Burleigh House had written information about the care home and the services provided. It was the home’s policy that prospective service users were subject to a pre-admission assessment to establish whether their needs could be met. Short Stay admissions/trial visits were available for service users to “test the water” before making decisions regarding admission to the home. EVIDENCE: The Statement of Purpose and Service User Guide was not inspected on this occasion, however the last inspection found comprehensive information about the home and its terms and conditions of residency was readily available to all service users. Copies of the documents were observed in service users bedrooms during the inspection. The manager or her deputy carried out an assessment to ensure that the home could meet individual needs for each service user. The home did not offer intermediate care facilities. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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 It was evident that the health and personal care needs of service users were promoted by the home. Service users and relatives expressed satisfaction with the care provided. EVIDENCE: The home had personal care plans for service users that were relevant to their needs. These had been reviewed and updated on a monthly basis. A small random sample of service user plans was inspected. The care plans showed that a daily record was maintained for each individual. There was appropriate and timely referral for medical intervention. Routine medical procedures such as chiropody, dental, hearing were accessed. The inspector monitored the medication trolley and checked the medication administration record and found these to be satisfactory. The home had appropriate policies and procedures for the receipt, recording, storage, handling and administration and disposal of medication. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 10 The home promoted a “home for life” philosophy and endeavoured to maintain service users in the home as long as their needs could be met. There had been no deaths in the home since the last inspection. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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 Discussions with service users and observations made on the day confirmed that the daily routines in the home were relaxed and flexible. Contact with family and friends was maintained and community links were encouraged. The home regularly sought the views of its residents regarding suggestions for its Activities Programme. EVIDENCE: Without exception, service users expressed satisfaction with their life in the home. On the day of the inspection service users were listening to and singing along with favourite songs. Many had attended the wedding of the Deputy Manager and told the inspector about the enjoyable day they had. Residents had decided they did not want a Christmas Party in the home this year and so they were all going to a local restaurant in December (organised and funded by the home) to have a Christmas Meal. Several confirmed that they were looking forward to this. Service users went along with the managers to do shopping for the home and to select personal items. Links with families and friends were encouraged. There was a three-week rotational menu and food was always on the agenda of the Residents Meetings. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 12 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 The home had a formal complaints procedure that was made available to service users and other stakeholders. Policies and procedures were in place to protect vulnerable service users. Staff received training in relation to the protection of vulnerable adults from abuse as part of their induction and ongoing training. EVIDENCE: The home had a comprehensive complaints procedure that was included in its Service Users Guide and displayed in the main hallway. An inspection of the complaints book found that there had been no formal complaints since the last inspection. The Commission had not received any complaints regarding Burleigh House since the last inspection. The Statement of Purpose stated that service users would be encouraged to take part in voting. The Deputy Manager confirmed that all residents had been included on the electoral roll and that arrangements were made for postal votes to be used. The home had a Vulnerable Adults Procedure and staff were advised of this during their Induction Training. Sensitive and kindly interaction was observed between service users and staff. Service users spoken with indicated that they felt comfortable and safe in the home. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 13 The home was not involved in the finances of any service users preferring family members to take on this responsibility. Small amounts of “pocket money” cash were held for residents. The records and monies were checked and found to be satisfactory. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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): 19,21,24 and 26 There had been a big improvement in the environment both internally and externally since the last inspection. The home had introduced a programme of maintenance for the building and had redecorated several areas. There had been a great improvement in the grounds with work continuing to make the gardens attractive and safe for service users to access. EVIDENCE: Burleigh House was owned and managed as a family run business together with another residential home, Four Seasons in Meir. The location and layout of the home was suitable for the needs of its service users. There were sufficient communal lavatories and washing facilities and several rooms had en-suite toilet facilities. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 15 At the last inspection it was noted that the building and grounds were in need of maintenance and refurbishment and requirements were made for this issue to be addressed. The manager introduced a programme of refurbishment and repair and the inspector carried out monitoring visits following the last inspection. There was a vast improvement to the grounds and service users and relatives commented that these were now very attractive and had allowed more natural light to enter the building. A new “Burleigh” sign had been erected at the front gate. The kitchen had been renovated and the carer using it on the day of the inspection commented that it was a big improvement. The office, upstairs landing and three bedrooms had been redecorated and a new carpet put in one room. Liquid soap and disposable towels had been provided in communal areas, although block soap was seen. The deputy manager was asked to remove the block soap to reduce risk of infection in the home. The ground floor communal bathroom and toilet had been redecorated. The dining area had been redecorated. It was noted that the extractor fan in the downstairs communal toilet was not working and a requirement was made for this to be repaired. It was also noted that plugs were missing/broken in two communal bathrooms. A requirement was made at the last inspection for separate hand washing facilities to be installed in the laundry area, together with liquid soap and paper towels. The one large basin in the laundry was used as a sluice. The home had not addressed this issue and a requirement was made as part of this report for this matter to be addressed. It was also noted that there was a build up of scale and dirt in the toilets in the home and particularly the upstairs bathroom. It was appreciated that the home had to take account that it is on a septic tank but a means must be found to clean the toilets in the home to prevent a build up of scale and prevent spread of infection. A requirement was made for this to be addressed. It was also noted that there was a need to provide an impermeable finish in the area round the downstairs communal toilet which should be readily cleanable to prevent the spread of infection and a requirement was made in relation to this issue. The home had appropriate specialist equipment available and aids to daily living to promote the independence of service users. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The home carried out robust recruitment procedures that included the taking up of references and police checks. There were sufficient staff with the skills mix to meet the needs of service users. The home had a full complement of staff. EVIDENCE: Deployment of staff provided for a minimum of two care staff throughout the 24-hour day, plus a manager and deputy manager during the busiest part of the day. There was no separate cook in the home – management and care staff undertook cooking duties between them. It was identified that three staff had National Vocational Qualification (NVQ) level 2 in Care with two of these also having NVQ level 3 in care. Three care staff were studying for NVQ level 3 in care and one studying NVQ level 2 in care. One was studying NVQ level 2 for domestics. The Deputy Manager confirmed that all staff had Food Hygiene certificates. Staff had received appropriate Fire Training with fire training for night staff needing updates during November 2005. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 17 There were plans for staff to attend training on the Prevention of Abuse in January 2006 and the Deputy was booked on a three-day Advanced Prevention of Abuse course in January 2006. The deputy was due to update her Trained Trainer Moving and Handling Training on 30.11.05. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 The home was managed by an experienced and competent manager and an experienced management team. Good working relationships were observed. Service users best interests and safety were promoted by staff at all levels. EVIDENCE: The home was managed by an experienced and competent manager who was currently undertaking her NVQ level 4/Registered Managers Award. The Deputy Manager was awaiting funding to study this Award. There were clear lines of accountability in the home and good leadership promoted professional relationships throughout. In this small home the views of service users about the care and services they received were obtained through Residents Meetings. Residents Meetings had Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 19 taken place on 22.6.05 and 7.10.05 and these had an agenda and were recorded. The Deputy Manager indicated there were plans to carry out a Quality Audit exercise for stakeholders before Christmas 2005. The Quality Audit will be monitored at the next inspection. Regular staff supervision took place and the last staff meeting took place on 27.10.05. The manager carried out supervision on the Deputy Manager and day care workers and the Deputy Manager was responsible for the supervision of night care workers. It was found that fire records and equipment maintenance records were up to date. It was found there was a shortfall in the statutory monthly visits/audits to be carried out by the responsible individual/director required under regulation 26. A requirement has been made as part of this report to address this situation and it is imperative that this be addressed promptly. The Accident Book was inspected and found to be satisfactorily completed and monitored by the home. A cupboard in the downstairs bathroom was ajar and a duvet was seen on the floor. It is a requirement that the cupboard be kept locked and that inflammable materials are not stored in it. The manager removed the duvet on the day of the inspection but it is important that this situation is monitored. Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 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 3 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 3 x 1 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 3 X 3 3 2 2 Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes, see requirement 2 below. 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 19 Regulation 23(2) Requirement The registered person shall ensure that the extractor fan in the downstairs toilet is repaired and maintained in good working order. The registered person shall provide a separate hand washing basin with paper towels and liquid soap that is separate from the sluicing area to prevent spread of infection The registered person shall ensure that a means is found to clean the lavatories in the home to eliminate the build up of scale and prevent the spread of infection. The registered person shall provide an impermeable finish to the area surrounding the downstairs lavatory to prevent the spread of infection. The registered person shall ensure that a responsible person shall carry out the unannounced monthly visits and complete an appropriate record of such visits to comply with regulation. DS0000004922.V265313.R01.S.doc Timescale for action 17/11/05 2 26 13(3) 12/12/05 3 26 13(3) 30/11/05 4 26 13(3) 30/11/05 5 37 26 30/11/05 Burleigh House Version 5.0 Page 22 6 38 12(1)(a) The registered person shall ensure that the cupboard door in the downstairs bathroom is kept locked at all times and that the cupboard is not used to store inflammable materials. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burleigh House DS0000004922.V265313.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Burleigh House DS0000004922.V265313.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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