Inspection on 16/03/06 for Burley Hall Nursing Home

This inspection was carried out on 16th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burley Hall Nursing Home 11/10/07

Burley Hall Nursing Home 22/02/07

Burley Hall Nursing Home 26/07/05

Burley Hall Nursing Home 05/10/04

Burley Hall Nursing Home 27/04/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOMES FOR OLDER PEOPLE Burley Hall Nursing Home Cornmill Lane Burley In Wharfedale Ilkley West Yorkshire LS29 7DP Lead Inspector Hebrew Rawlins Unannounced Inspection 16th March 2006 09:00 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 Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burley Hall Nursing Home Address Cornmill Lane Burley In Wharfedale Ilkley West Yorkshire LS29 7DP 01943 863363 01943 863392 mosslo@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd 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) Mrs Sandra Elizabeth Hustwick Care Home 45 Category(ies) of Dementia - over 65 years of age (20), Physical registration, with number disability over 65 years of age (25) of places Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Burley Hall is in the village of Burley in Wharfdale and is accessible to all local amenities. There is a large car park and extensive private gardens that are accessible to residents. The home is registered to provide nursing care for up to 45 people over the age of 65 years. The home has two separate units, one providing general nursing care and the other providing specialist care for people with dementia. Accommodation is on two floors accessed by a passenger lift. There are 39 single bedrooms and three doubles, all with en suite facilities. There are two lounges and two dining rooms as well as a licensed bar. There are a number of communal bathrooms and toilets throughout the home. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place on the 26th July 2005. There have been no further visits until this inspection, which is unannounced. The purpose of this inspection was to monitor progress in meeting the requirements made at the last inspection and to look at the standard of care for people living in the home. One inspector between 9.00am – 4.00pm on the 16th March 2006, carried out this inspection. During the inspection, I looked at records, I saw staff carrying out their work and spoke with residents, visitors and staff. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). Comments received in this way are shared with the manager, without revealing the identity of those completing them. What the service does well: The home creates a good first impression on entering, with plenty of information on display about the events going on. The staff team are good at respecting the privacy of the individual and also at making people feel valued and cared about. There is the ability to respond flexibly to a person’s needs and changing abilities. Residents said “You can do as you like here, but there’s always someone there if you need help”. There were very good comments about the food, residents appreciating the “home cooking” style of the meals. The home continues to provide a high quality provision in its premises. The inspector was provided with numerous examples of residents and their families’ satisfaction with the service. The atmosphere in the home was relaxed. Several residents described the staff as ‘caring and helpful’. Families visiting the home stated their overall impression was favourable. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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 Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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): 1, 3 & 4. The home makes every effort to ensure that residents have the information they need before coming into the home. The standard of written information is good and the home is very flexible about pre-admission visits, to fit in with the needs and preferences of the individual. The home is careful to obtain sufficient assessment information about prospective residents, so as to inform them of likely care needs. EVIDENCE: The home has a comprehensive Statement of Purpose in each resident’s room. This outlines what the home can provide and how it intends to achieve that. One resident recently admitted described how her family had been for visits and obtained information on her behalf, before she came for a trial visit herself. She felt reassured through the whole admission process, particularly as she felt the home had a good reputation locally. She felt her care and support needs were being met very well. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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. Care plans are clear and enable staff to understand what residents need assistance with, although those on the dementia unit are in the process of being reviewed. There is good attention to meeting health care needs and residents are treated with respect. There are safe systems in place for storage, administration and recording of medicines within the home. However staff on the dementia unit did not always follow the home’s policy and sign the medication sheets. EVIDENCE: Care plans for four residents were looked at in depth, the findings confirmed by discussion with those individuals about their care, or with staff delivering the care. Where a need has been identified for specific equipment to promote independence, this could be seen in place in the resident’s room. Resident also confirmed that what was written in care plans, was what was being provided. For example, preferring to see GP in private or eat meals in private. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 10 The newly appointed unit manager was reviewing the care plans on the dementia unit, as a number of them required updating. Throughout the day, it could be seen that care and other support staff were respectful of privacy, always knocking before entering bedrooms or asking residents if it was all right with them to do housekeeping tasks. Residents were satisfied with the arrangements for GP visits, dentist, opticians and chiropody. One resident said that she had been feeling a little unwell, but was reassured by staff that it was nothing to worry about. She was confident that if she requested, her GP would be called. The medication system was examined. Storage facilities are secure and the accompanying record sheets appeared to have been accurately completed on one unit. This was not the case on the dementia unit, staff had not always signed the medication sheets as evidence that resident had received their medication. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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,and 15. There is a varied programme of organised activities that provide residents with opportunities to mix socially. The home encourages visitors, which enhance residents’ social opportunities. The quality of the meals at the home is very good and residents enjoy the food. EVIDENCE: Residents spoke to the inspector about daily life in the home. It was apparent that there was something “organised” nearly every day, so that they could take part in if they wished. Those who prefer a more private social life said they did not feel under pressure to “join in” if they did not want to. An activities co-ordinator was seen on each unit both seemed to be very popular. It was clear that individual chats and one-to-one time took place as well as group activities such as cards, flower arranging, bingo and trips out. The four residents who were case-tracked were spoken to in their own rooms, all of which were arranged differently, according to the individual’s taste and care needs. They spoke about how they had decided what personal possessions they needed to bring. When asked about daily life, they all expressed satisfaction with the home, particularly the “home’s cheerful Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 12 atmosphere”. It was evident that they all enjoyed passing the time in different ways and were still able to do this. During the inspection residents were seen receiving visitors. They were all comfortable in entering the home and were offered refreshments during their stay. There were very good comments once again about the food and it was clear that the home cooking was appreciated. The menu and preparation of meals was complimented. The chef always made himself available for residents to give feedback on the meal. On the day of the inspection the meal of the day was cream & vegetable soup, florida cocktail, roast beef & Yorkshire pudding, cheese omelette, broccoli & mixed vegetable, sauté potatoes, apple & raspberry crumble & custard and tea or coffee. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents are confident their complaints will be handled appropriately. EVIDENCE: Residents said they felt confident to raise any concerns directly with the manager and it was evident that visitors also knew about the complaints procedure and how that worked. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25, and 26. The home is well maintained, decorated and furnished and provides a comfortable environment, inside and outside. There is good attention to hygiene and cleanliness throughout. EVIDENCE: The grounds provide an interesting and level tour round the garden, residents make use of the level pathway to enjoy the walk, sit and look at the wild life. Even those who cannot get outside so easily can enjoy the garden from their room window; one lady had a bird table that was sited so that she could view it from her chair. There is more than adequate provision for residents both personally and communally. The bedrooms seen were pleasantly furnished with a good array of personal items. Several bedrooms had French windows opening onto the garden, which provides a very pleasant outlook. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 15 The residents appear to have as good a relationship with the domestic staff as they do the care staff; the person doing the cleaning that day was heard to knock on doors and ask permission to enter, etc., and the residents were heard to call her by name. There was a good level of cleanliness seen throughout the home, with appropriate protective equipment (gloves, aprons, etc.) available for the staff. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 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): 29. Recruitment procedures follow good practice guidelines. Staff were confident, courteous and respectful towards residents. EVIDENCE: The recruitment records were seen for the newest member of staff. These contained a completed application form, two written references and evidence that Criminal Bureau Checks had been carried out. Reflection on staff practice in the home was very positive from residents and they complimented their care and kindness in meeting their personal needs. Staff spoken to during the inspection displayed a commitment to the service and an understanding of the residents in their care. Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this visit. EVIDENCE: Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 18 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 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 4 X X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? yes 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 op7 Regulation 15 Requirement All residents on the dementia unit must have an up-to-date care plan that shows how health, social and personal care needs are met.(not fully addressed from last inspection) The home has a medication policy, which it should always adhere to (previous inspection). Timescale for action 15/05/06 2. OP9 12 15/05/06 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 Burley Hall Nursing Home DS0000019893.V283431.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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