Inspection on 11/05/07 for Burleigh House

This inspection was carried out on 11th May 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

Burleigh House 07/01/09

Burleigh House 09/01/08

Burleigh House 08/12/06

Burleigh House 14/06/06

Burleigh House 19/01/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall 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 41 Letchworth Road Baldock Hertfordshire SG7 6AA Lead Inspector Patricia Rogan Unannounced Inspection 11th - 21st May 2007 14:00 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 DS0000064005.V339141.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. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burleigh House Address 41 Letchworth Road Baldock Hertfordshire SG7 6AA 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) 01462 893216 01462 894799 Manage Care Homes Ltd Manager post vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability over 65 years of age of places (19) Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2006 Brief Description of the Service: Burleigh is a detached Edwardian House situated in a residential area of Baldock. It is close to the A1 and within easy walking distance of local amenities and shops. The home has nineteen single rooms; ten with en-suite shower facilities and all are on the ground floor. In all there are fourteen toilets, one assisted bathroom, one assisted shower room, two conservatories and a dining room and lounge. There is ample parking to the front of the home and a garden to the rear. Accessed via the rear garden is a large wooden building, which provides office accommodation for the manager and space for meetings. Information regarding the service is available in the Statement of Purpose and the Service User Guide. These and a copy of the most recent inspection report are freely available on request. Fees at the time that this inspection took place, ranged from £407.89 to £550 per week. Charges for additional services such as hairdressing and chiropody are explained in the individual service contracts. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector was present for this unannounced inspection of all key National Minimum Standards. The contents of this report are based on information received by the Commission since the last inspection and during two visits to the service. The second visit was a more in-depth unannounced visit that took place when the recently appointed manager was on duty. This provided an opportunity to inspect policies and care plans and to discuss what changes had been implemented since her appointment. Time was spent meeting in private with people who use the service and with members of staff. Observations of the daily activities and the way that care was delivered was made during tours of the premises and whilst spending time in the communal areas. Many of the people who use the service said they wished to be referred to as residents and this term will be used in this report. What the service does well: What has improved since the last inspection? The appointment of the new manager has had a positive impact at Burleigh House. Good co-operation was seen between the manager and staff. Service users spoke favourably about the improvements so far, including a preference for the new staff uniforms. The dining area has been refurbished with good quality tables and chairs and rearranged in a more domestic setting. The entrance hall and corridors have been redecorated and new carpets have been laid. The menu is now even more varied and economy foods are no longer used. Fresh vegetables and named brand foods have been introduced for daily use. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 6 Some residents went out on a day trip and other communal events such as war time music and meals have been enjoyed by many of the residents. 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. Burleigh House DS0000064005.V339141.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 Burleigh House DS0000064005.V339141.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): 3 (Standard 6 is not applicable to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents have the information they need to make an informed choice about where to live. Assessments are carried out prior to admission. EVIDENCE: The pre-admission assessment is carried out in a professional manner and the service user or their representative is involved in this assessment. Prospective service users are offered the opportunity to visit the home prior to a decision being made to accept the placement. An inspection of the case files of recent admissions to the home showed that assessments had been in-depth and had included the views of the prospective residents. A further review had taken place shortly after the person moved into the home and this offered further opportunity for the new resident to add information to the assessment. Burleigh House DS0000064005.V339141.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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care plans were well set out and individualised. Health care support such as GP and district nursing is readily available. A medication policy in place. Residents felt they were treated with dignity and respect. Two-way locks were needed for toilets. EVIDENCE: The new format care plans are now in use and include many aspects of the residents health, personal and social care needs. The care plans are reviewed as needs change and at regular intervals. Residents are encouraged to carry out as many personal tasks that they feel they are able to do in order to maintain independence. The relationship between health and social care professionals and the residents in this home is good. Care staff were seen responding in a friendly and discrete manner. A few residents said they sometimes had to wait ages for a carer. The shower room did not have a lock on the door and not all toilets had two-way locks which would have allowed residents to have privacy and staff to have access in an emergency. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 10 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents have enjoyed some group activities. However, due to the limited number of staff, residents often have many hours without meaningful daily occupation. The refurbished dining room is pleasant and the menu is even more varied. Insufficient catering staff result in care staff leaving their duties to prepare meals, snacks, drinks and to do other tasks such as washing up and shopping. This increases the risk of cross infection and reduces the amount of care staff available to assist the residents. EVIDENCE: Many residents had thoroughly enjoyed the recent group activities. One said, The trip out into the big wide world gave us something to look forward to. A day spent re-creating wartime meals, music and uniforms had been a success. More than one person made comments about the lack of individual daily activities. One resident said, far more of us came out of our rooms because there was something going on. Another said This place varies, it can be a hive of activity and then it all goes back to afternoon naps. An inspection of the rota and discussion with people who use the service and visitors to the home indicated that there were not enough staff on duty at times to ensure Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 11 that the residents have appropriate support to enjoy an interesting and individual life style. Instead of the previous long refectory table arrangement, the dining tables, which seat four people, are now easily accessed from all sides and provide a more homely appearance, with fresh flowers on each table. There was already a varied menu and this has been further improved with the managers introduction of fresh vegetables and insistence that economy labels are no longer used. One person said, My mother is getting a wonderful array of meals now and the dining room is so much better. Residents do not always have flexibility and choice when wanting a drink or a snack because of the shortage of catering staff. At these times, there is also an increased risk of cross infection when carers have to leave the tasks they are doing in order to go into the kitchen to prepare a meal or make a drink. This also reduces the number of care staff available to assist residents and this is particularly problematic when staffing levels are low. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 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. 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 the service. The complaints procedure is robust and residents said they felt confident that any concern or complaint would be taken seriously. Staff have had training in Adult Protection issues and understand the whistle blowing procedures. EVIDENCE: There have been no complaints since the last inspection. Discussion with residents and responses from family members showed they were all sure that any concern or complaint which may arise would be attended to. A relative said, One evening, I spoke to a carer about a worry I had and by the next day, the manager came to see me and had sorted everything out. I thought the carer and the manager were really quick to respond. Staff have had relevant training and understand the rights of the people who use this service and the complaints procedure is transparent and clearly set out for people who use the service and their families and representatives. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 13 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A redecoration and refurbishment programme has improved several parts of the home. The conservatories have needed attention for some time with repairs to the leaking roofs and fixing sun blinds still outstanding. Further refurbishment is needed to raise the quality of the environment for residents. Care staff are carrying out some housekeeping tasks which takes them away from assisting residents. EVIDENCE: The hallway and corridors are freshly painted and new carpets have been laid. A resident remarked, This colour is really lovely and summery. Many people have expressed satisfaction with the improvements in the dining room. The tables seat four people and there are fresh flowers on each table. The small lounge area in one corner of the dining room is being refurnished and will offer Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 14 a comfortable, quiet place for residents to relax in and meet visitors in somewhere other than their bedrooms. The previous inspection report stated that despite thorough cleaning, some of the chairs were badly stained and that the refurbishment programme in the communal areas should be prioritised. The proprietor has had all the lounge chairs steam cleaned but this has not been successful in removing all the stains. The furniture and occasional tables are not of a good standard. The two conservatories are used as the communal lounges and both roofs have leaked for a considerable time. When it rains, buckets are placed in the lounges to catch the water. The buckets present potential hazards and the lounges are not of good quality for the residents. It has been mentioned during previous inspections that blinds are needed to provide shade for the people using the conservatories but these are not yet in place. The managers office is located in an outside building at the rear of the home. One of the bricks in the garden steps leading to the office in the building at the back of the home is partly broken. This could cause a tripping hazard for anyone going to and from the office and particularly for those people with impaired vision or reduced mobility and especially in poor light and in the dark. Care staff said they sometimes were asked to do housekeeping tasks such as laundry and that they did not feel this allowed them time to spend helping the residents. During the tour of the premises on the first brief visit to the home, some soap dispensers were empty and two toilets had very little paper left on the toilet roll. Burleigh House DS0000064005.V339141.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. 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 the service. Staff were seen to work hard and in a professional manner. At times there are shortfalls in staffing levels. The recruitment policy is robust and staff records are properly stored. Training is of a high standard. EVIDENCE: Sometimes, low care staffing levels results in residents having insufficient support to enjoy daily, meaningful and individualised occupation. This lack of activities is particularly noticeable in the afternoon and evening. The cook is part-time and insufficient catering staff from early morning to early evening results in care staff having to go into the kitchen to prepare meals, drinks and snacks and to do the washing up and loading the dishwasher after lunch. The dishwasher does not have the 80°C hot rinse as specified by the Health Protection Agency infection control guidance. The manager is observing staff to ensure that thorough hand washing and infection control guidance is being followed but there is a real risk of cross infection when care staff who are carrying out personal care have to frequently go into the kitchen Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 16 Several residents need two members of staff to assist with personal care. When there are only two members of staff on duty, there is nobody to oversee or assist the other residents. One person said Sometimes the carers are really busy and I can wait ages before I see a carer walk past to help me. Care staff carry out housekeeping tasks such as laundry and washing up in the kitchen. This reduces the amount of time when care staff should be with residents. The manager has been preparing catering lists and doing the shopping and preparing the evening meal. These non-managerial tasks result in less time to keep up to date with a managers essential duties and responsibilities. Burleigh House DS0000064005.V339141.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager is very experienced and well qualified to run this service. Her registered manager application is underway. The manager has used her expertise to make many improvements to the above standards. Residents’ finances are safeguarded and managed properly. EVIDENCE: There has been a noticeable improvement in this home and a more modern approach to care provision has benefited both the residents and the staff. The manager has understood the disquiet felt by those who dislike change and has been clear about the high standard she sets for the residents. A visiting professional commented, The manager certainly seems to be on the way to bringing this home up to scratch. The manager recognises the skills of the Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 18 staff and has promoted some staff to more senior positions. Due to low staff levels, the manager has been carrying out non-managerial tasks and therefore record keeping, supervision and other important duties are becoming delayed. The manager has discussed these difficulties several times with the proprietor in the hope of finding an early resolution. Burleigh House DS0000064005.V339141.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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 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 2 Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 20 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 P provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13 (4) (a) Requirement Timescale for action 01/09/07 2 3 OP26 OP26 23 (2) (b) 23 (2) (d) 4 OP27 18 (1) (a) The service provider must arrange for both conservatory roofs to be repaired so that they do not leak when it rains. The service provider must keep 01/08/07 the home in a good state of repair internally and externally. The service provider must 01/09/07 ensure that furnishings are maintained to a clean, reasonable standard. The service provider must 01/09/07 ensure that there are catering, housekeeping and care staff in sufficient numbers to ensure that service user’s personal, health and social care needs are met at all times. 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 DS0000064005.V339141.R01.S.doc Version 5.2 Page 21 1 2 OP19 OP19 The broken step in the garden should be repaired in order to safeguard people going to and from the office. People should be able to sit in the conservatories, protected from excessive heat or sun glare. Burleigh House DS0000064005.V339141.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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