Inspection on 09/01/08 for Burleigh House

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Adequate service.

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 11/05/07

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 9th January 2008 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 DS0000064005.V357518.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.V357518.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.V357518.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2007 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, a conservatory which is used as the communal lounge, a dining room and small lounge area in the dining room. There is ample parking to the front of the home and a small patio next to the conservatory and a small paved area with seating in the garden to the rear of the building. Accessed via steps in the rear garden is a large wooden building, which provides open plan office accommodation for the manager and the proprietors and is also used 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 from the manager or proprietor of the home. A copy of the report is also available from the Commission for Social Care Inspection, whos contact details are on the back page of this report. Fees at the time that this inspection took place, range 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.V357518.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The decision on the quality of the outcomes for people who use this service has been reached by gathering information from various sources. This included sending questionnaires to a random selection of people who use the service and family members and professionals who visit the service. Telephone discussions took place with some members of staff and family members and professionals to ask them for their views about the service. The manager and the proprietor have regularly provided written information about the service since the previous inspection of the key standards in May 2007. Two inspectors visited the service and whilst one inspector met with the manager and proprietor and examined documentation, the other inspector spoke privately with people who use the service and with members of staff and visitors to the home. A tour was made of the premises, including the kitchen and food storage and the laundry. What the service does well: What has improved since the last inspection? A manager has been appointed after an interval of a few weeks following the resignation of the previous manager. This manager had started working in the home two days prior to the inspection visit. Many of the lounge chairs have been replaced with new ones and some residents said they were fairly comfortable and a vast improvement on the old ones. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 6 The small patio area outside the conservatory lounge has been cleared and a ramp installed creating an increased outdoor area. More outdoor seating, tables and sun umbrellas are planned for this area. Some more areas of the home have been redecorated and there were several comments that the home appears brighter and so much lighter when you walk in. New chairs have been arranged to one side of the dining room and this had been in consultation with residents who said they would like a quiet place to sit and read or meet with families. However, a television has since been placed in there which several people said they had not requested because they had wanted a quiet area. What they could do better: There has been a period of unsettlement following the resignation of the previous manager and the appointment of the new manager, when some of the staff had not been working together as a team. People living in the home were aware of some of these issues, which would indicate that staff were indiscrete when discussing these matters. Concerns which had arisen while no manager was in post, had not been investigated correctly by the proprietor, in that he had not followed the homes own procedures. This involves referrals in writing as soon as possible to outside agencies as appropriate, including the Commission for Social Care Inspection and to Hertfordshire County Councils safeguarding adults team. We have not made a requirement regarding notifications, as we were satisfied that the owner will notify us in the future. The care plan format is good but most had not been updated and some lacked sufficient detail to enable care staff to provide care and support in the way that each person would prefer. The manager is beginning care plan reviews as soon as possible. Prior to the inspection visit, we had received several comments that there were enjoyable themed activity days but that on a day-to-day basis; there was a limited variety of things to do in the home. This means that there is less opportunity for people to follow their own personal interests and hobbies when they wish. Repairs had been made to a small area of the brick steps leading to the office following the previous inspection. On the day of this inspection, there were several more uneven and broken bricks on the steps and the outdoor lighting created shadows on the steps. Repairs to the steps and improved lighting will ensure the safety of everyone who uses the steps. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 7 Several people said the daily menu options had recently become more limited and they felt this restricted their choices of meals available at each mealtime. 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.V357518.R01.S.doc Version 5.2 Page 8 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.V357518.R01.S.doc Version 5.2 Page 9 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. Admissions are well planned and people moving into the home know that the service can meet their needs. EVIDENCE: The pre-admission assessments of the last three people to move into Burleigh House were in depth and included the proposed resident and family members and professionals involved. The service user guide was given to each prospective resident and this contained sufficient information to enable an informed decision to be made. One of the pre-inspection questionnaires stated, The manager didnt pressure us into making a decision there and then whether to move my relative into the home and she gave us loads of information. All prospective residents are invited to visit the home and meet staff and people who live in Burleigh House in order to have a better idea about what it is like to live there. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place but some lacked sufficient detail to ensure individualised support. Input from the primary care team and medical practice is good. Medication practice is in need of some improvement in order to fully protect the people living in the home. Most people are satisfied with the way they are treated but some felt upset about the discord between a few staff. EVIDENCE: The care plans have information about the persons health, personal and social care needs but some lacked sufficient detail about the way that the individual person would prefer to have those needs met. There is regular contact with the health and social care professionals and advice and assistance from them is easily accessed. The pharmaceutical companys recent full audit of medication administration and storage identified several areas needing attention. This included the Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 11 controlled drugs cupboard requiring secure fixing and that over-stocking of medication needs to be curtailed. The manager said she would be working with the staff that are trained in medication administration, to ensure that issues arising from the audit will be met within the audit reports defined time scales. Most people who use the service are satisfied with the care they receive from staff in the home and there were such comments as, Shes always so kind to us, its obvious she loves her job. and Some of them are just so nice. However, some people living in the home and some visitors to the home have been drawn into the poor relationship between some members of staff, which seem to have developed when the manager left. There were several remarks about this, including, Most of the carers are lovely but its upsetting when some of the staff are criticising each other in front of us. This shows that some members of staff were putting their own feelings above those of people living in the home and with visitors to the home who could have been made to feel anxious at the poor atmosphere. The manager is addressing this as a matter of urgency. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 12 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. There are activities arranged in the home but they are not individualised so that people are less able to continue with activities of their own choosing. The home encourages visitors so that people living in the home can see friends and family at any time. Menus have become more limited recently so that people living in the home have a more restrictive choice of meals. EVIDENCE: Information is on file about peoples individual interests and previous hobbies. Several people who use the service said they took part in some activities and many thoroughly enjoyed the special themed days. However, some people living in the home said they felt bored quite often. On the day of the inspection, people were sitting in silence in the lounge and when the proprietor was asked what there was for people to do, we were told there would be an activity at eleven oclock. This means that although there are some activities, people are not always given the individual support to spend their day in the manner and times they choose for themselves. A member of staff said there is a quiz every afternoon and all the residents really enjoy it. When this quiz took place in the lounge, not everyone Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 13 benefited from the quiz because some were unable to take part due to visual or sensory impairment and there were no alternative activities made available to suit each persons individual interest or ability. The dining room was refurbished earlier this year and many people said they were very pleased with this and said that the food was plentiful and nicely served. Many people said the menus had been Much improved when the previous manager was in post but felt that recently, the choices on the daily menus had less variety. The new manager said she intends to follow this up and ask the people who live in the home what they would make meal times better and more enjoyable. Several people said they had been asked whether they would like a quiet area, to one side of the dining room, but felt disappointed that they had not been asked for their views again before a television was later installed because this meant that they were less likely to use this area for reading or spending time with visitors. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the home will listen to their concerns but cannot be assured that the home will always follow its own procedures, which are there to protect them. EVIDENCE: People who use the service and their friends and families are given a copy of the complaints procedures and are reassured that they must complain if they are dissatisfied in any way. Those people who responded to questionnaires and phone calls said they were confident about making a complaint. All staff are aware of the safeguarding adult procedures. An allegation of poor conduct by a member of staff was brought to the attention of the proprietor who investigated it because there was no manager in post. The proprietor made notes but he did not follow the procedural guidance, which is in the home, and therefore the appropriate authorities were not informed. This has been discussed with the proprietor who gave his assurance that the correct procedures will be followed should there be any concern, complaint or allegation in the future. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 15 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. Some areas of the home are recently decorated and well maintained, however there is not a regular audit of the condition of all parts of the home, equipment and grounds. This means some repairs, redecoration or replacement of worn out items are not always carried out in a timely manner to ensure the safety and comfort of people using the home. EVIDENCE: The grounds at the back and front of the house are kept neat and tidy with shrubs and flowering plants. The small patio next to the conservatory has been extended and ramped to enable more people to sit outside. Redecoration and refurbishment of some areas of the home are continuing but there does not appear to be a system for reporting repairs needed inside and outside the home so that risks to people in the home are minimised. Following Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 16 a recommendation at the previous key inspection, three of the broken bricks on the steps leading from the office had been repaired. These steps are in constant use during the day and evening, and yet on this inspection, several bricks were obviously broken or uneven and the security light did not provide sufficient illumination, which means that any person using the steps can be at risk of falling or injury. Most areas of the home appeared to be cleaned to a reasonable standard and the manager is going to ensure that a thorough cleaning and infection control programme is established so that people living in the home are protected from infection as far as possible. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 17 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 this service. There have been occasional staff shortages, which meant that people who use the service did not always have the opportunity to enjoy a full and varied lifestyle. Staff recruitment and training offer some protection to people living in the home. EVIDENCE: People in the home, spoke well of the majority of the staff, considering them to be kind and knowledgeable. When there has been staff shortages caused by sickness absence or by staff leaving, people living in the home said staff worked hard but had no time for a chat and sometimes its been rush, rush, rush. Several people said they didnt like to ask them for anything because they were just so busy. This results in people living in the home not being able to spend their days in the way they would prefer, when there are staff shortages. Staff training had been good with many staff having gained, or are in training for their National Vocational Qualification, although some training has been delayed recently while there has been no manager. Most staff members are very good and put their experience and knowledge into practice. However, a few people living in the home, and some visitors, spoke of the disagreements that some staff had not been discrete about. One said, We could hear the Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 18 carers talking about each other and its not nice to listen to. People living in the home may have felt unhappy or uncomfortable by this sort of behaviour and such practice is unprofessional and does not show that those members of staff have been properly trained in person centred care. The recruitment procedures are robust and the same procedure is always followed. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 19 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is newly appointed and is not yet registered with the Commission but holds the necessary qualifications and has the experience to manage the home for the benefit of people living in the home. The homes own quality assurance system had not been completed to show how the service is run in the best interests of the people who live in the home. Appropriate systems are in place to safeguard personal finances so that people can be confident that their financial interests are protected. EVIDENCE: The manager who had been in post prior to this inspection had made many improvements to the service, and people who use the service and many others who visited the home, acknowledged this. However, there had been a great Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 20 deal of administrative work for the manager to do. This meant that the manager was not given the time to fulfil some of the managerial responsibilities, including establishing a robust quality assurance system which determines the standard of care that visitors and people living in the home can expect. This included a regular monitoring system to audit medication, maintenance, care planning, complaints, care and catering and domestic services. The maintenance person said he is asked to carry out almost all maintenance tasks inside and outside the home and several people remarked on how hard he worked. However, there does not appear to be a formal system of reporting or auditing the premises for repairs or replacements needed so that they can be rectified in a timely manner to ensure that people in the home arekept safe from harm. One example of this is that several of the bricks on the steps leading to the office are worn or broken and the lighting in that area is inadequate which could cause a fall or injury to anyone using the steps but there were no records to show that this had been reported so that repairs could be carried out as soon as possible. Checks are carried out on equipment but there did not seem to be a thorough system of ensuring that compulsory checks of all equipment in the home are carried out as necessary and in accordance with health and safety guidance. When this manager left, records show that there had been no formal supervision to address the poor relationship between some members of staff and as a result some people living in the home felt uncomfortable when they heard staff disagreeing. One of the proprietors manages the finances for the service and oversees the individual personal allowances for the people living in the home. Each person in the home has individual invoices for purchases, which were made from the personal allowance. Discussions took place with the proprietor and very recently appointed manager regarding the outcome of the inspection and about how the service is to progress for the benefit of the people who use the service. The manager has the qualifications and prior experience to be able to address many of the issues, which have arisen during this inspection, and she has begun completing the Annual Quality Assurance Assessment for forwarding to the Commission. Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 21 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 3 x x x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 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 2 x 2 x 3 2 x 2 Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(b) Requirement The brick steps leading to the office must be repaired so that people using the stairs can do so safely. Timescale for action 15/02/08 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 OP12 OP14 Good Practice Recommendations People living in the home should be supported to enjoy a varied lifestyle which suits their individual interests and abilities so that they have as fulfilled a life as possible. People should be enabled and encouraged to be involved in decisions about the way their home is run, for example helping to devise weekly menus or discussing where the television should go, so that preferences can be ascertained and where possible, acted upon. There should be a regular audit of all interior and exterior parts of the home in order to ensure that the home and all equipment is kept in a good state of repair for the safety of the people who use the service or visit the home. 3. OP19 Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Burleigh House DS0000064005.V357518.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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