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Inspection on 04/10/05 for Burlington Hall Care Home

Also see our care home review for Burlington Hall Care Home for more information

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of the environment within this home is good providing service users with a clean, attractive and homely place to live. The home is equipped with pressure relieving devices and moving and handling equipment, thus enabling staff to meet specific health care needs. Residents have access to a variety of health care services external to the home Service users spoke highly of the care received in the home. A good level of interaction was noted between service users and staff.

What has improved since the last inspection?

The Care plans have improved. Level of detail included within these plans of care is informative, relevant and subject to review. The home has employed a new manager, who is in the process of applying for registration.

What the care home could do better:

The provider needs to ensure that the recruitment of staff is done in line with Regulation 19 and Schedule 2 of The Care Homes Regulations. This needs to be monitored more effectively by the area manager. Training must be planned in advance to ensure that all mandatory training is up to date. The records relating to the safe keeping of service users money must be maintained appropriately and audited with records of audits maintained.

CARE HOMES FOR OLDER PEOPLE Burlington Hall Care Home 9 Station Road Woburn Sands Milton Keynes Bucks MK17 8RR Lead Inspector Mrs Caroline Roberts Unannounced Inspection 4 and 10 October 2005 th th 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 Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burlington Hall Care Home Address 9 Station Road Woburn Sands Milton Keynes Bucks MK17 8RR 01908 289700 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) Burlington Care Homes PLC Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (1) of places Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 53 older people with 1 person with a physical disability over the age of 65. 13th April 2005 Date of last inspection Brief Description of the Service: Burlington Hall is a care home for Older People in Woburn Sands it is ideally situated for access to the local amenities.Burlington Hall has 52 bedrooms all with en-suite facilities; the home has four lounges, all with small kitchenette facilities. The home has six bathrooms, which provide disabled bathing facilities.An assistant manager and a senior team of fourteen, as well as a welltrained group of care staff assist the manager with the management duties. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the un-announced inspection carried out at Burlington Hall on the 4th and 10th October 2005. The first day being unannounced and the second day announced. The lead inspector was Mrs Caroline Roberts. The inspection consisted of meeting with service users and staff, viewing records and documents pertaining to the provision of care and the running of the home. The inspector toured the building, gaining permission from a number of service users to enter their bedrooms and viewing a further number from the doorway. The inspector met and discussed the inspection findings with the manager before leaving on the second day. This inspection has resulted in three requirements being served. The inspector found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspector would especially like to thank the service users for their time and for allowing the inspector into their home. What the service does well: What has improved since the last inspection? The Care plans have improved. Level of detail included within these plans of care is informative, relevant and subject to review. The home has employed a new manager, who is in the process of applying for registration. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 6 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. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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 Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): 3 and 6 The admissions procedure appears consistent, and the level of detail obtained during the assessment allows the home to make an informed decision as to whether they can meet the resident’s needs. Therefore residents appear to be placed appropriately. EVIDENCE: The home has an admissions procedure, which includes meeting with potential residents and/or their representative prior to admission. The records for the 2 most recent admissions were viewed and were found to be completed. Preadmission visits are conducted by the manager, her deputy and/or care staff. Intermediate care is not provided in this home. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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 working documents, are up to date and subject to regular review. This ensures residents identified needs are known to staff to enable them to provide the appropriate care. The home has developed good working relationships with external health care providers; therefore ensuring residents have access to a variety of health care services. Medication Administration Records were found to be appropriately signed with all medication administered, stored and disposed of in a satisfactory manner; ensuring Service Users are protected by the systems in place. Staff practice in giving and assisting with such elements as personal care and arrangements for medical examination ensure the privacy and dignity of Service Users. EVIDENCE: The standard and format of care plans has improved. Individual plans of care are available, and three were viewed. All were well completed with relevant Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 10 information relating to identified health, personal and social care needs, and how the home was to meet these needs. Each plan of care contained an up to date risk assessment, weight monitoring chart and moving and handling assessment, which were subject to regular review. Evidence of access to health care services was seen. Residents spoken with and documentation in the care plans show how independence is promoted. Residents are referred to district nurses for assessment of pressure area risk. Regular visits from the chiropodist are arranged through the home and access to other healthcare professionals is arranged via the GP or district nurses. Medications were seen as stored appropriately, the medication administration sheets had no unexplained gaps. The pharmacist undertakes the disposal of unused/unwanted medication, the returns book was seen which evidenced that the home disposes of medications appropriately. Residents spoken with described how staff treat them with respect. Residents stated that they receive their mail unopened, and are called by their preferred term of address. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): 12,13,14,15, The Home is implementing activities suitable for the Service User group, this enables Service Users to interact on a social level and form new friendships with each other as well as staff. Visitors are welcomed at the Home during all reasonable hours with no restrictions in place. This enables Service Users to maintain their friendships and relationships whilst residing in the Home. The dietary needs of service users are well catered for, with a balanced and varied selection of food available that meets with resident’s tastes and choices. EVIDENCE: The Home provides activities, which are age appropriate, interesting and enjoyable. An activities organiser liaises with the service users and involves them in the planning and implementing of activities. Outside entertainers come to the home for such things as pantomimes, quizzes, and games. Visitors are welcomed at the home, which ensures Service Users are able to maintain their relationships after admission to the Home. There are no Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 12 restrictions on visiting times. Staff are supportive of family members including them in the daily routines of the Home. A number of service users were spoken with and everyone who commented on the food said it good. The menus were viewed and found to offer variety. Lunch was sampled and was found to be well cooked, tasty and well presented. Throughout the day it was noticed that hot and cold drinks were offered to residents on a regular basis. Supplementary drinks were noted to be available where required. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed during this inspection. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): 19,26 The standard of the environment within this home is satisfactory, providing service users with a clean, attractive and homely place to live. EVIDENCE: Burlington Hall is located in the centre of Woburn Sands; it is pleasantly decorated with co-ordinating curtains and upholstery. The corridors all have handrails to assist service users if needed; the home also has two shaft lifts. The home has a variety of lounges, all of which are a good size and are decorated in a homely style. Furnishings are domestic in character and meet the needs of individual’s residents. Individual bedrooms contained personal belongings reflecting the character of the occupant. All bedrooms have en-suite facilities, the home has 14 toilets, and 7 bathrooms all have disabled bathing facilities. All windows above ground floor level have restrictors in place; the handyman regularly checks these as part of his weekly duties. Thermostatic valves have been fitted to all hot water outlets. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 15 The home was noted to be clean and tidy with no unpleasant odours noted. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): 29,30 The home has a full recruitment procedure in place, unfortunately this has not been fully complied with, therefore there is a potential for putting residents at risk. Update training has not been arranged for all staff, therefore staff are not equipped with up to date knowledge to enable them to perform their duties fully. EVIDENCE: A number of personal files were viewed, it was concerning to note that not all information as required by Standard 29 and Regulation 19(1) of The Care Homes Regulations was not available. An immediate requirement was served that staff without all the necessary checks should not be employed in the home until such a time as the checks have been undertaken. The home has a new manager in post, during the inspection the manager discussed with the inspector that she was collating all of the training information and devising a projected training profile for all staff to ensure that all mandatory training is undertaken by all staff. A number of staff are in need of mandatory training such as moving and handling updates, first aid and food safety. A requirement is served that the manager forwards the training plan for staff and makes arrangements for staff to attend the identified training. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 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): 35,38 Service users finances are not protected by the current system in use. The Health and Safety of service users is promoted and protected. EVIDENCE: The home holds small amounts of cash for service users; this is stored in individual wallets in the safe, with receipts maintained for any expenditure. It was concerning to note on closer examination that the records for service users money has not been adequately maintained, discrepancies between actual cash held and records were noted. The whole system for holding service users finances needs reviewing to ensure a clear and transparent system that is audited regularly. A requirement is made regarding the review of the service users finances. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 18 All mandatory Maintenance schedules are kept and reports written. Health and Safety checks are made training is undertaken by staff with appropriate records maintained. Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 19 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 x 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 x 17 x 18 x 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 1 x x 3 Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 20 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 OP35 Regulation 24(2) Requirement Timescale for action 15/12/05 2 OP30 10(1) The provider is required to audit the money and system in place to hold service users finances. A copy of the details of this audit is to be forwarded to the Commission by 15.12.2005 A requirement is served that the 01/02/06 manager forwards the training plan for staff and makes arrangements for staff to attend the identified mandatory training. An immediate requirement was served on the day of the inspection that staff without all the necessary employment checks should not be employed in the home until such a time as the checks have been undertaken. 10/10/05 3 OP29 19(1) Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 21 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 Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. Extracts may not be used or reproduced without the express permission of CSCI Burlington Hall Care Home DS0000015049.V263343.R01.S.doc Version 5.0 Page 23 - 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!