Inspection on 26/07/05 for Burley Hall Nursing Home

This inspection was carried out on 26th July 2005.

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 22/02/07

Burley Hall Nursing Home 16/03/06

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 Cornhill Lane Burley in Wharfedale Ilkley LS29 7DP Lead Inspector Gillian Sangster Announced 26 July 2005 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 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 J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burley Hall Nursing Home Address Cornmill Lane Burley in Wharfedale LS29 7DP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01943 863363 01943 863392 Bupa Care Homes Mrs Hustwick Care home with nursing 45 Category(ies) of Dementia - over 65 (20) registration, with number Physical dis - over 65 (25) of places Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 5/10/04 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 J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by one inspector between 10am and 5.10pm. Time was spent talking to residents, relatives, a visiting GP and staff. I also looked at records including duty rotas, residents’ care records, assessments and observed the lunch time meal. Some bedrooms and other areas of the home were checked. The manager was present for the inspection and had provided detailed information in the pre-inspection questionnaire. Comment cards were sent out to the home for relatives and residents to complete before the inspection. Twenty cards were returned from relatives and nine from residents. Generally feedback was positive although eight of the cards returned by relatives said that they felt there were not enough staff. Some differences were noted between the two units in relation to care records and activity provision. All of the requirements from the last inspection have been addressed. Requirements and recommendations from this inspection are included at the end of the report. What the service does well: There is good information available about the home. The admission process is thorough and residents’ needs are fully assessed before admission. Care planning on the general nursing unit was good, providing detailed information to show how residents’ needs are met. Residents and/or their relatives were involved in the care planning process. Residents and relatives were unanimous in their praise of the staff describing them as “friendly”, “good”, “helpful and caring” and “full of smiles”. Residents said that they felt well cared for and were treated with respect by staff. Feedback from a visiting GP and an agency carer working in the home for the first time was positive. Residents said that they enjoyed the food and praised the chef. There are a good range of activities provided on the general nursing unit. The home is kept clean and furnished and decorated to a good standard. The home is well managed and staff feel supported. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 6 There is a planned programme of ongoing training and development. This ensures that all staff have the skills and knowledge they need to carry out their jobs. 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 J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 6. The home provides sufficient information to allow prospective residents to make an informed choice about moving in. All residents are assessed before admission to make sure that the home can meet their needs. EVIDENCE: There is a wealth of information about the home in the reception area. People making initial enquiries are sent a letter, copy of the home’s brochure and other relevant information such as the BUPA booklets on dementia care and moving into a care home. In each resident’s room there is a Welcome Pack and a copy of the home’s Statement of Purpose, which provides detailed information about the service and facilities. The manager assesses all residents before they move into the home and offers a trial visit. Residents I spoke with said that they had been happy for their relatives to look round on their behalf. The home does not provide intermediate care. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10. Care planning is variable between the two units and this must be addressed to make sure that staff have the information they need to meet residents’ needs. Residents’ health care needs are met. Residents’ are treated with respect. EVIDENCE: There was a difference in the standard of care plans on each unit. Two care plans seen on the general nursing unit provided detailed and personalised information clearly showing how care needs are met. The care plans had been signed and agreed by the relatives on the resident’s behalf and had been reviewed regularly. Three care plans on the dementia unit were looked at and all needed updating and reviewing. There was some detailed information in the care plans but often this did not match up with information found elsewhere in the records. For example in one care plan it said the resident needed a stand aid hoist and two staff to transfer yet the moving and handling assessment said the resident could transfer independently. The manager of this unit, who has only been in post for four months, was aware of the shortfalls and said that she is working with the staff to make improvements. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 10 Arrangements are in place for residents to access health care services such as the dentist, chiropodist and optician. Care records showed specialist input from a speech therapist and tissue viability nurse. The home employs a physiotherapist who visits regularly. One of the GP practices visits on a weekly basis and regularly reviews medication. I spoke to a visiting GP who said that he thought it was a very good home. He said that staff were efficient and prompt in reporting concerns. He said that they were good in monitoring the residents’ health care and using their initiative to send off specimens when required. He said that he was always given the information he needed when coming to see a resident. Staff were seen transferring one resident with a hoist that was incompatible with the resident’s condition. Staff were using the hoist in accordance with the moving and handling assessment. The manager agreed that this practice would be reviewed with the physiotherapist. Residents said that they felt well cared for and said that staff treated them with respect. Residents said that they could get up and go to bed when they wanted and felt that the choices they made were respected by staff. One resident said “staff are very good and all seem to get on well together which creates a nice, happy atmosphere”. Nine comment cards were returned by residents and eight were satisfied with everything with one stating “this place is wonderful”. The other comment card stated that they only felt well cared for sometimes. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. The level of recreation varies between the two units and must be reviewed on the dementia unit to make sure that residents have meaningful and fulfilling daily lives. Contact with relatives and friends is encouraged and supported. Residents’ choice and control is sometimes limited by the staffing levels. Residents enjoy the food but the same standard of service should be available to all. EVIDENCE: Activity provision differs on the two units. On the general nursing unit there is an activity organiser who plans activities on a weekly basis. Residents said “there’s plenty going on if you want to join in”. One resident said how much she enjoyed the flower arranging session and another was looking forward to the entertainer who was visiting that afternoon. Many residents choose to stay in their own rooms and said that they were content entertaining themselves by watching television, reading or listening to the radio. Several residents said how much pleasure they got from the gardens and watching the birds and squirrels. The dementia unit has been without an activity organiser for several months. The home has advertised and a new person was recruited but only stayed in post for few days. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 12 The entertainer also performed in the lounge on this unit, which was enjoyed by the residents. However two regular visitors said that there were few activities and felt that more stimulation was needed. Another visitor said that they were satisfied with the activities provided for their relative and described the frequent walks in the garden to the duck pond. The manager acknowledged that the activity level on this unit could be improved but said that she wanted to be sure she got the right person for the activity coordinator post. Visitors on both units said that they were able to visit at any time and were always made to feel welcome. Two visitors had specific concerns relating to their relatives which they were pursuing with the home’s manager. Twenty comment cards were returned by relatives and twelve of these were satisfied with all aspects of the home. The following comments were made about staff “very friendly”, “always helpful and caring”, “always appear happy and full of smiles”. Most residents said that they had control over their daily lives in relation to how they spent their days. Some residents who needed assistance from staff said that their choice and control was sometimes limited by the staffing levels. Examples given were having to wait for a long time to be taken to the toilet and sometimes a long wait for call bells to be answered. Residents praised the food and made the following comments “the food’s very good”, “lots of choice”, “we have a wonderful buffet and all our relatives can come”, “the chef is brilliant and will always go that bit extra”, “the chef can’t do enough for you”. Breakfasts are served from 8am to 10am and most of the residents chose to have this in their rooms. One resident who chooses to get up at 6.30am said that she had her breakfast at 9.45am but would have liked to have had a cup of tea in between. Lunch on the general unit is served from a heated trolley by the kitchen staff and delivered to the dining tables by a waitress. This service does not extend to the dementia unit where meals are served by the care staff. It is recommended that the same service is offered to all residents. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 standard(s) These standards were not inspected at this visit. EVIDENCE: Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 standard(s) 20, 24 and 26. The home provides a clean and pleasant environment. Bedrooms and communal areas are decorated and furnished to a good standard. EVIDENCE: Only some areas of the home were inspected at this visit. Communal areas are furnished and decorated to a good standard providing light and spacious accommodation. Externally there are well maintained accessible gardens, including a safe private garden for the residents with dementia. Bedrooms seen were decorated and furnished to a high standard. Residents said that they were pleased with their rooms and were glad to have many of their own personal belongings with them. Several of the bedrooms have patio doors leading into the garden. All areas of the home were clean with no malodours. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. Staffing levels must be reviewed in light of the comments made by relatives and residents to make sure that residents needs are being met appropriately. Staff maintain their competence through ongoing training and development programmes. EVIDENCE: Feedback from residents and relatives suggest that staffing levels need to be reviewed. Eight of the twenty comment cards returned by relatives said that they felt there weren’t enough staff. Three relatives I spoke with during the visit expressed their concerns about the staffing levels in both units. One relative said that this issue had been brought up repeatedly at residents and relatives meetings. People said that the staffing levels seemed to be based solely on the numbers of residents rather than the dependency levels, which were felt to be high. Three residents in the general nursing unit described having to wait a long time for staff to attend to them. The home has a comprehensive training programme for all staff. In the last year staff have attended a number of training courses including dementia care, wound care and prevention of pressure ulcers, continence awareness, nutrition and health and safety. Six of the care staff have achieved National Vocational Qualification (NVQ) level 2 and a further six are undertaking this qualification. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 32. The home is well organised and the manager provides effective leadership. Staff work well together as a team and in the best interests of the residents. EVIDENCE: The registered manager is a qualified nurse with many years management experience. She provides strong leadership and support to the staff team. The home is well organised. Staff I spoke with were clear about their roles and responsibilities. They said that they enjoyed working in the home and all worked together as a team. I spoke with an agency health care assistant who was working her first shift in the home. She said that she had worked in many different nursing homes and this was the best one she had been to. She said that she had worked alongside the staff nurse and been given clear and good information about the residents and the home. She said that she thought hygiene standards were particularly good as the nurse she worked with had washed her hands after Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 17 each resident. She said that staff spoke nicely to the residents and didn’t rush them. Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION x 3 x x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x x x x Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered 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. The moving and handling assessment for the resident identified on the dementia unit must be reviewed. Activity provision on the dementia unit must be reviewed to ensure that the residents social needs are being met. Staffing levels and working practices must be reviewed to ensure that residents needs are being met appropriately. Timescale for action 30/11/05 2. op8 13 1/09/05 3. op12 23 31/10/05 4. op27 18 31/10/05 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 op15 op15 Good Practice Recommendations All residents should be offered the same standard of dining service. Residents should be offered a hot drink if waking early and not having their breakfast till mid-morning. J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 20 Burley Hall Burley Hall J52 S19893 Burley Hall V232392 260705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley 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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