CARE HOMES FOR OLDER PEOPLE
Burleigh House 41 Letchworth Road Baldock Hertfordshire SG7 6AA Lead Inspector
Patricia Rogan Key Unannounced Inspection 8th - 18th December 2006 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.V324865.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.V324865.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.V324865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th August 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, 1 assisted bathroom, 1 assisted shower room, 2 conservatories and 1 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. Fees at the time that this inspection took place, ranged from £400 to £460 a week. Services such as hairdressing and chiropody are not included in these fees. The individual service contract should stipulate what additional services are charged for and detailed, itemised invoices would be issued. Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection of all the key standards and the overall quality of this service is satisfactory. The inspection included a visit to the premises to meet residents and staff and the proprietors. Discussions also took place with professionals who are in contact with the home. Time was spent observing the interaction between residents and staff and inspecting record keeping and file management. What the service does well: What has improved since the last inspection? What they could do better:
The proprietors purchased the services of a pharmaceutical company to audit medication storage and administration. The medication trolley had not been delivered but on the final date of the inspection, the acting manager confirmed that the trolley was en route. Therefore a requirement will not be made. Refurbishment of the home has commenced but despite thorough cleaning, some of the chairs are still badly marked and a recommendation has been made that the refurbishment programme should be prioritised to ensure all communal areas are domestic in appearance and the furniture is of a good
Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 6 standard. This must include the rear lounge/conservatory which, according to staff and residents is rarely used apart from when the hairdresser visits the home. Some residents said they had not realised this area was for general daily use and that staff automatically take me to the main conservatory or they remained in the dining room where there is additional seating. One or two residents said they did not think the area was a nice place to relax in and the other said they felt it was draughty because the door to the outside was often opened as staff accessed the outside office. Most of the residents enjoyed the activities in the home but two said they felt they did not get enough exercise but needed help to walk up and down .One resident expressed a preference to sitting playing cards and another suggested a supper dance would be enjoyed. A requirement will be made that residents are supported in pursuing their recreational interests and lifestyle. When the inspector has been in the home, all the residents were taken to their rooms in the early evening. The care staff on duty said that is what the residents prefer. Some of the residents said this had always been the practice and although some were quite happy about it, one resident thought they were put in their rooms early to help the night staff. A requirement will be made that residents are supported in making choices about their daily lifestyle. 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.V324865.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.V324865.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 this service. A system is in place to assess any prospective resident prior to moving into the home. The assessment will be carried out by a senior member of staff. EVIDENCE: There had not been any recent new admissions but the acting manager was able to show the assessment format and this covered all areas necessary to ensure a new residents care needs could be met. A discussion with the last two residents who joined Burleigh House and their families, showed that they had been involved in the assessment and felt that they were supported during the admission process. Burleigh House DS0000064005.V324865.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 this service. Care plans are detailed and individualised. Liaison with medical professionals is effective. There is a policy for self medication. The delivery of the medication trolley and fridge has been delayed for months but the acting manager said this was due within a few days. Observation of the interaction between staff and residents was generally good. EVIDENCE: The care plans have been improved and are well set out and are individualised. The files are in good order and information is easily accessible. Medical professionals who have contact with the residents and staff feel there is a good working relationship. There is a policy in place for residents to administer their own medication although no-one does this at present. The proprietors have purchased a medication audit service but there has been a long delay delivering the trolley and fridge. The acting manager and proprietor said delivery was due so a requirement will not be made regarding storage of medication. Residents said they felt the staff treated them with respect .
Burleigh House DS0000064005.V324865.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 this service. Generally, residents were satisfied with their life in the home but when explored further, many of the residents felt they would like to do more individual hobbies or exercises and some felt bored during the evening. Residents are encouraged to maintain contact with their family and friends. Not all residents wanted to go to their rooms so early in the evening and accepted it as common practice. The menu is varied and residents have a choice of meals. EVIDENCE: There are variety of activities available during the day and most residents said they enjoyed these. When one resident said they would like to be helped to go for a daily walk up and down, another agreed. Two said they used to have hobbies but did not do them now. One resident said she would like to have a few little chores to do sometimes. A requirement will be made that residents are enabled to pursue a lifestyle which matches their recreational and social needs. Residents are taken to their rooms in the early evening. The care staff said that is what the residents prefer. Some residents said this had always been
Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 11 the practice and were quite happy about it, one resident thought they were put in their rooms early to help the night staff. One resident expressed a preference to sitting playing cards and another suggested a supper dance would be nice. A requirement will be made that residents are supported in exercising more choice and control over their lives. All residents said they enjoyed the varied menu and home cooking. The produce is freshly purchased and there is fresh fruit available. Burleigh House DS0000064005.V324865.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 this service. There is a complaints procedure in place and all residents and their representatives are made aware of this. The staff are aware of the whistle blowing policy. Plans are in place to ensure that every member of staff who joins Burleigh House will have training in adult protection EVIDENCE: There is a robust procedure in place to investigate any complaint which is made and the appropriate authorities are informed as required. Guideline are held regarding the Hertfordshire Adult Protection policy. All residents asked, said they would speak to the person in charge or one of the proprietors if they wanted to make a complaint. Burleigh House DS0000064005.V324865.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 this service. A refurbishment programme is ongoing for the whole of the home but priority must be given to communal areas as this is where residents spend most of their waking day. The armchair fabric had been scrubbed but several still looked soiled and were not satisfactory. EVIDENCE: Refurbishment of the home has commenced and the entrance and some corridors have been painted and the carpet is being replaced. Despite thorough cleaning, some of the chairs are still badly marked and a recommendation has been made that the refurbishment programme should be prioritised to ensure all communal areas are domestic in appearance and the furniture is of a good standard. This must include the rear lounge/conservatory which, according to staff and residents, is rarely used apart from when the hairdresser visits the home. Some residents said they had not realised this area was for general daily use and that staff automatically take me to the
Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 14 main conservatory or they remained in the dining room where there is additional seating. One or two residents said they did not think the back lounge was a nice place to relax in and the other said they felt it was draughty because the door was often opened as staff went to the office outside. Burleigh House DS0000064005.V324865.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 good. This judgement has been made using available evidence including a visit to this service. Staff files are in order and there are recruitment policies and procedures in place. A training programme has been established. EVIDENCE: There has been a marked improvement in the way that staff records are stored and each has an individual indexed file. Recruitment policies including ensuring Criminal Record Bureau checks and reference checks are in place. A training programme has been established with all staff expected to receive mandatory training and other training as learning needs are identified. Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The registered manager has left and there is an acting manager in post. However, a care consultant has been in the home for several days almost every week. It is with this expertise that there has been a great improvement and all the above standards. EVIDENCE: There has been a marked change and modernisation of working practices since the consultants were commissioned. Several residents and some relatives had been sorry that the manager had left but all said they felt that changes had been made for the good. Purchases which are made on behalf of the residents are recorded and receipted. Staff supervision has been established and is ongoing. Up to date policies and procedures are used and the health, safety and welfare of service users is promoted and protected.
Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 17 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 3 x x x x x x 2 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 x 3 x 3 x x 3 Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 18 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 2 Standard OP12 Regulation 16(2)m&n 12(2)(3) Requirement Residents must be enabled to pursue individual recreational interests and hobbies. Residents must be enabled and encouraged to make decisions about how they would like to spend their evenings and about their lives in the home. Timescale for action 28/02/07 28/02/07 OP14 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The refurbishment programme should be prioritised to ensure that all communal rooms, including the rear conservatory, receive early attention in order to create pleasant, homely, useable areas. Burleigh House DS0000064005.V324865.R01.S.doc Version 5.2 Page 19 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
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