Inspection on 22/02/07 for Burley Hall Nursing Home

This inspection was carried out on 22nd February 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

Burley Hall Nursing Home 11/10/07

Burley Hall Nursing Home 16/03/06

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 Stephen French Unannounced Inspection 22nd February 2007 09:30 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.V327895.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. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 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.V327895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2006 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. The provider informed the Commission for Social Care Inspection on 22/02/07 that fees range from £700.00 to £850.00 per week. Additional charges include hairdressing, private chiropody, Physiotherapy, newspapers and some selected activities. Service users can receive Information about the home and the services provided in the statement of purpose and service user’s guide, which can be obtained by contacting the home. Burley Hall Nursing Home DS0000019893.V327895.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 visit carried out on the 22nd February 2007. The inspector arrived at the home at 9:30 am and left 3:30pm. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management team. The inspector read care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the visit 10 service user questionnaires were sent to the home to obtain service users’ views about living at the home. Questionnairs were also sent to General Practitioners. At the time of writing this report completed questionnaires were returned from three GP’s who were happy with the care the staff provide for their patients. Some service users in the home are very frail and would not be able to complete a questionnaire. There were forty-one service users resident in the home on the day of this visit. Relative surveys were also sent out and none were returned. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and a pre inspection questionnaire completed by the manager. The inspection has concluded that residents’ needs, both personal and recreational, are met. Residents reside in a relaxed and informal homely environment What the service does well: The home offers a safe, comfortable, well maintained, homely environment in which the service users can live All service users are appropriately assessed prior to admission to ensure that there needs can be met by the home and its staff. Care plans set out the needs of the service users so that staff know what care needs to be delivered and the way in which the service user prefers their care to be delivered. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 6 Appropriate activities are arranged for service users to participate in if they wish to. The food served is nutritious, of a good standard and a choice is available. The home is well managed and the staff are well trained and are employed in such numbers as to meet the needs of the service users. Systems are in place to ensure the home meets the expectations of the service users. 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. The summary of this inspection report can be made available in other formats on request. Burley Hall Nursing Home DS0000019893.V327895.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 Burley Hall Nursing Home DS0000019893.V327895.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): 3,6 Service users needs are assessed and they have the information they require. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that before any service user moves into the home a pre admission assessment is completed by herself or one of the unit managers. This assessment determines the level of care the service user will require and if the home and its staff can meet those needs. Records examined showed that assessments are conducted appropriately and have involved the family members or the representative of the person wanting Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 9 to move into the home. Where the assessment has been undertaken through the local authority care management arrangements, the manager obtains a summary of the assessment and a copy of the plan. The manager said that the home does not provide intermediate care. Burley Hall Nursing Home DS0000019893.V327895.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): 7,8,9,10 Service users health care needs are met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the visit, five service users care files were examined. These contained information gathered from the pre admission assessment and community care assessment. Care plans were in place for problems identified in these assessments. Risk assessments were in place for such things as nutrition, oral health, moving and handling and skin integrity. Where assessments identified that the service user was at risk a detailed care plan was in place. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 11 The manager said that staff make sure each person’s plan is reviewed monthly and if the person is willing and capable, they are asked to get involved in the review. Family members can also take part if agreed by the service user. There is evidence to show that the plans are updated and the necessary action staff are to take to respond to any changes is documented. People living at the home said that they are supported to be as independent as possible when washing and bathing. Completed questionnaires received by the Commission for Social Care Inspection from General Practitioners(GP’S) confirmed that staff take appropriate action and decisions when service users can no longer manage their care needs. The records show that, the arrangements for health and personal care ensure that service user’s privacy and dignity are respected, with the staff being heard to speak to people in respectful ways, and with service users themselves saying that the staff are kind, caring and very patient. The medication of five service users was checked and all found to tally with the records held. Systems are in place to ensure the safe storage and disposal of medication. To prevent these systems being compromised staff should record the stock balances of medication brought forward from the previous month and record these onto the medication administration records. Burley Hall Nursing Home DS0000019893.V327895.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): 12,13,14,15 Service users are able to have control over their lives. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two part time social activities organisers who are responsible for arranging and supervising all social activities within the home. Activities include one to one, artwork, baking, outside entertainers, quizzes, bingo, gardening, film and music and movement. In the summer months there are trips out to places of local interest. Visiting clergy of each denomination visit the home monthly and conduct Communion. On the day of the visit service users living on the unit, which cares for people with a dementia type illness were playing scrabble and on the other unit service users were potting plants. Service users spoken to said that they enjoyed the activities that were on offer and could join in if they wish. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 13 Observations made on the day show that staff treat people politely and respect their individuality. Service users said that friends and family are encouraged to visit at any time, and are made to feel welcome by the staff. Several service users said that they were happy with the meals provided and that there was always plenty of choice available, the menus confirmed this. Service users are able to eat their meals in the dining rooms or in their own room if they prefer. Meals were seen presented in an attractive manner and in pleasant surroundings. Two members of staff was observed to be assisting service users to eat in a calm, relaxed manner with appropriate conversation Burley Hall Nursing Home DS0000019893.V327895.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): 16,18 Service users are safe and complaints are acted upon. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is up to date, clearly written, and easy to understand. The complaints procedure is displayed in the entrance area of the home so that anyone visiting the home has access to it. Any complaints received are fully investigated and responses given to complainants within the timescale set out in the policy and procedure. There have been five complaints received by the home since the last visit. Records of complaints received by the home were seen during this visit and these had been dealt with appropriately. The policies and procedures regarding the protection of vulnerable people are satisfactory. Training of staff in the area of protection is periodically arranged by the home, training records examined confirmed this. Staff spoken to gave good responses to questions asked on this subject, confirming that they were aware of their responsibilities in reporting any abuse to the manager. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 15 Service users living at the home said that they are satisfied that any complaint they had would be investigated and they also said that they felt safe living in the home. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 16 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): 19,20,21,23,24,25,26 Service users live in a safe well-maintained environment, where their bedrooms are bright and airy and suitable for their needs. The home is clean and fresh. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this visit a tour of the building was conducted, this included a number of service users’ bedrooms, communal lounges, dining rooms, bathrooms and toilets. Service users’ bedrooms were personalised with their own belongings such as ornaments, pictures and small pieces of furniture. Some of the bedrooms on Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 17 the ground floor had patio doors leading out to the garden were service users can sit in the summer months. Within the unit which cares for service users who have a dementia type illness there were picture boxes fitted to the outside of the door. Contained in these boxes were photographs and objects, which would help the service users to identify their rooms. Two service users who were visited in their room by the inspector stated that they were very happy with their accommodation and liked the décor of the home. There are a number of communal lounges were service users can sit. There is also a licensed bar were service users can purchase alcoholic drinks if they wish. Communal areas and service users bedrooms are decorated to a very high standard and were bright and airy. There are a number of communal toilets and bathrooms in close proximity to the lounges and bedrooms. Bathrooms contain assisted baths for service users who have mobility problems. The standard of cleanliness throughout the home was good and there were no offensive odours present in any part of the home. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 There are adequate numbers of trained competent staff on duty to meet the needs of the service users Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has two units consisting of a nursing unit and a twenty-bed unit for people who have a dementia type illness. Each unit is staffed separately. The staff duty rota was checked for the months of January and February and consisted of the following staff. Nursing Unit AM; 1 qualified nurse and four care staff, PM; 1 Qualified Nurse and three care staff, and on night duty there is 1 Qualified Nurse and 1 carer. Dementia Care unit AM; I qualified nurse and 3 care staff throughout the day and 1 qualified nurse and 1carer at night. Service users spoken to said that there where staff available to assist them should they require it. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 19 The manager is responsible for the recruitment and selection of staff. The records for five staff recently employed by the home were examined. These contained application forms, interview assessments and references. Confirmation that checks with the criminal records bureau had been undertaken were seen. These checks ensure that new employees do not have a criminal record or are exempt from working with vulnerable people. New staff complete an induction program which consists of completing five units of training, which includes, amongst other things, the needs of the service users and the role and responsibilities of staff, as well as training in moving and handling, fire awareness, the philosophy of care of the home as well as abuse training. Senior staff supervises new employees until they feel confident and competent in their role. One staff member spoken to by the inspector had recently commenced employment and confirmed that they had received appropriate training and support in order for her to function in her role as a carer. At the moment over 50 of the care staff employed by the home has an N.V.Q level 2 qualification. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 The home is well managed and the views of the service users are sought and any shortfalls are addressed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is a qualified nurse who has had many years of experience in working with older people, unit managers supports her in her role. There is an expectation that all managers of a care home complete a Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 21 recognised management course such as the registered managers award, which this manager has completed. The manager completes monthly audits of the home and the services they offer to ensure these meet the expectations of the service users. Areas audited included, medication, care documentation, complaints and accidents and health and safety. The manager also completes monthly statistics and is responsible for ensuring staff receive the training they require in order for them to be competent at the job they are performing. Evidence was seen that most of the staff have received training in moving and handling, fire prevention and health and safety training. The home also seeks the views of the service users and relatives about the care that they receive by sending out service users questionnaires annually; the results of which are sent out to service users and relatives. The home does not hold any personal monies for service users. Service users either have their own bank accounts or their relatives deal with their finances. It is expected that all staff receive at least six formal supervisory sessions per year during these sessions staff discuss future training needs as well as the philosophy and aims and objectives of the home. Records examined confirmed that staff have received regular supervision. The fire alarm system is checked weekly and certification in relation to gas, electricity and water is in place and up to date. Electrical equipment such as hoists and the passenger lifts are serviced regularly. Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 22 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 3 X 3 3 3 3 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 3 X 3 Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Daily entries in the care files should reflect the service users social and psychological well-being. Staff should avoid the use of the word “Regularly” in care plans and should set specific time scales. The stock balances of medication brought forward from the previous month should be recorded on the MAR sheet. 2. OP9 Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Burley Hall Nursing Home DS0000019893.V327895.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!