Inspection on 10/01/06 for Burman House

This inspection was carried out on 10th January 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

Burman House 08/11/06

Burman House 16/06/05

Burman House 08/11/04

Burman House 17/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Burman House Burman House Mill Road Terrington St John Wisbech Norfolk PE14 7SF Lead Inspector Mrs Jenny Rose Unannounced Inspection 10th January 2006 10:15 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 Burman House DS0000036214.V277199.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. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burman House Address Burman House Mill Road Terrington St John Wisbech Norfolk PE14 7SF 01945 880464 01945 881416 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) Norfolk County Council-Community Care Mrs Patricia Anne McCallum Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 29 Service Users who are Older People 3 Service Users who have a Learning Disability whose names appear in the Commission`s records may be accommodated. May accommodate one Service User who has a diagnosed dementia, who will be named in the Commission`s records. 4th July 2005 Date of last inspection Brief Description of the Service: Burman House is a care home providing care and accommodation for 32 older people. It is owned by Norfolk County Council Social Services Department. The home is located in the village of Terrington St John, which is midway between the market towns of Wisbech and King’s Lynn. Burman House is a two storey building with the accommodation for service users on the ground floor. There are some office areas and staff sleep-in facilities on the first floor. All of the bedrooms are single. Access into the building is unimpeded including access for wheelchair users. The grounds were well kept and there were seating areas outside for service users in warm weather. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection programme and took place over 6 hours on a weekday. Preparatory work had taken place in the CSCI office beforehand. Where a standard has been inspected, the complete range of sub elements, as set out in the National Minimum Standards, may not have been assessed. The score given represents those aspects viewed on the day and which are commented upon within the text of the report. There was a regular financial audit taking place at the same time of the inspection. There were 26 residents in the home on the day and the Manager; Mrs Pat McCullum was present during the inspection. A number of records, policies and care plans were examined and during the inspection 3 visitors, 2 members of staff, a group of 4 residents and 3 residents were spoken to privately. Comment cards were left for the Management, Visitors and Residents at the close of the inspection. What the service does well: What has improved since the last inspection? * Activities participated in by residents are now recorded in care plans * Medication records have photographs of residents and are more securely filed for the further protection of residents * The percentage of staff with NVQ11 qualifications is being increased. * Copies of recruitment records for staff are kept at the home. * The hot cupboard is locked when not in use for residents’ safety. * The office has been reorganised in order to give more space for staff. * The drying room has been cleared of stored furniture for health and safety of staff. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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. Burman House DS0000036214.V277199.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 Burman House DS0000036214.V277199.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): 3 There is a comprehensive pre-assessment procedure, which ensures that prospective residents can be assured that the home has the capacity to meet their needs. EVIDENCE: There is a good pre-assessment procedure, which then forms the basis of the care plan. The Care Co-ordinator described this procedure which involves a senior member of staff visiting the prospective resident to assess the resident’s needs in detail, including medical conditions, including some risk assessments for certain conditions, equipment required, together with preferences for food and all aspects of personal care. Information from other Agencies, e.g. Social Services, is also taken into account, in ascertaining whether the home can meet the prospective resident’s needs. The resident and/or their relatives can visit the home, and many residents enter the home on a permanent basis following periods of short term care, varying from a few days to a few weeks. All are given a copy of the Service Users’ Guide, before making their decision to enter the home. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 9 Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 11 There were comprehensive care plans ensuring that staff could meet the personal and social care needs of the service users. Photographs have been attached to MAR sheets, which are more securely filed, further protecting residents. The home operates a policy for the care of the dying and their relatives in a sensitive manner. EVIDENCE: There are detailed care plans based on the pre-assessment of the needs of residents and these were seen to be signed by the residents and/or their relatives. These are regularly reviewed, together with the Night Care Plans, but in several instances these contained a note that reviews had to be cancelled, because of the pressure of work, which is covered elsewhere in this report, as was the case on the last inspection. Three residents spoken to were very satisfied with the care they received, as were the visitors to the home. The Medication Standard was not fully inspected on this occasion, but the recommendation from the last report had been implemented, in that the MAR Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 11 sheets now contained photographs and also the tops of the sheets had been reinforced in order that they were more securely filed, which is important for the safety of the residents. One care plan contained a risk assessment for a resident who was choosing to self medicate. Although the care plan was reviewed regularly with the resident, there is a recommendation that this risk assessment should also be reviewed at the same time. All the staff spoken to gave good evidence that the home’s practice in the care of terminally ill residents and their relatives was delivered in a sensitive, respectful and thoughtful manner. The staff spoken to took obvious pride in this aspect of their work. Many of the care plans seen contained details of the residents’ wishes for their funeral arrangements and all the staff confirmed that relatives were involved in the resident’s care, if wished and appropriate. The Manager confirmed that the GPs and District Nurses of the Palliative Care Team were very supportive in residents’ care with the provision of equipment and advice, if appropriate, and that the wider management were responsive to the provision of extra staff at these times. One member of staff reported that there were always separate care plans for these situations. All of this is seen to be good practice. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 The home places a high priority on residents’ individual personal preferences and contact with family/friends/representatives, together with the wider community, is encouraged, which enhances the residents’ quality of life. EVIDENCE: There was evidence of good life histories and leisure interests from the care plans, with attention to particular personal details, including in one instance the name of the family dog, which visits the home, also whether individual residents wished to participate in outings or not. The recommendation from the previous report regarding the inclusion of activities in the care plans has been implemented, which is good practice. However, pressure of work once again impinged on these and the good risk assessments being regularly reviewed and there is a recommendation regarding this. There had been many activities in the home over the Christmas period, which was confirmed by residents, staff and visitors alike. There was a regular Church service in the home, for those residents who wished to attend together with activities, including outings, sometimes round the local villages, where residents used to live, and cooking. The Care Co-ordinator who organises the activities sends in a column to the local newspaper regarding the events in the Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 13 home every week and these and photographs are being made into a book for residents. This is seen as good practice. There was much evidence that this home is embedded in the community, many of the residents knowing former neighbours, the staff and their families, visitors and healthcare professionals visiting the home, which gives continuity for the residents. There were several visitors to the home on the day of the inspection, those spoken to confirmed they visit at any convenient time and in some cases, the family visited several times a week. All were very satisfied with their relatives’ care. There is evidence that residents are encouraged to exercise choice and control over their lives, this was confirmed by residents, staff and visitors spoken to. All the residents spoken to were very satisfied with the meals and the choice available. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 There has been a recent change in the complaints procedure and the home are working hard to ensure that the smaller, individual complaints are still dealt with. Residents’ legal rights are protected and staff training ensures that residents are protected from abuse. EVIDENCE: The last two inspections found a good complaints procedure in this home and the staff have taken pride in the attention and appropriate action they have given to complaints, particularly the smaller, individual complaints regarding daily living from residents. Norfolk County Council have recently introduced a new procedure which has replaced the complaints book in which these individual complaints were recorded, with another system which involves form filling. The home intends to work hard at ensuring that the smaller complaints are still dealt with under the new system. Two residents spoken to were aware of how to make a complaint, if necessary, as were all the visitors spoken to. There was evidence that residents’ rights are protected and there had been one instance of the home acting as an advocate for a resident in a family matter. At the last inspection residents had voiced concerns over the payment of their personal allowances, this had now been addressed to their satisfaction. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 15 All the staff spoken to gave a good account of their understanding of the issues of Adult Protection and have undergone training which is revisited with the NVQll qualification. The staff said they would know to whom to report this if necessary. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 The home provides residents with a safe, well-maintained, comfortable and clean environment in which to live EVIDENCE: Since the last inspection the hot cupboard is locked when not in use, for the protection of residents. There is also an on-going maintenance programme. The office has been reorganised to provide more space for staff. Visitors are able to speak to residents in confidence in various areas of the home. There were many instances in the care plans of residents wishing to have their Bedroom doors open and it was recorded that electronic door closers have been ordered for these residents, in case of fire, and these have been fitted in many cases. There had been a recent outbreak of illness in the home, appropriately reported to the CSCI, which the Manager described as being satisfactorily managed by confining designated staff to working in one area of the home to Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 17 prevent cross infection. Advice was taken from the Environmental Health Officer. Two Care Co-ordinators will attend an Infection Control Course at the end of January. All domestic staff have their NVQ1 qualification, which is seen to be good practice. One resident had asked for a replacement, specialist wheelchair for ease of independent movement and he was observed, together with the Occupational Therapist trying this out. All areas of the building on the day were seen to be clean and hygienic. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 The number of staff undertaking NVQll has increased since the last inspection. There is a good staff team and staff enjoy their work and are appreciated by the residents. EVIDENCE: “You couldn’t wish for a better staff, they are perfect” was the comment of one of the residents, who, at the same time confirmed that he would be able to complain if it were necessary. The staff spoken to reported that they felt there was a good staff team and that the managers were approachable. Staff meetings took place once a month and there was regular staff supervision. There is a keyworker system in place, which ensures that residents’ individual needs are given attention. One member of staff said that she liked working in the home as there was a ‘family atmosphere’. The overall dependency of the residents had decreased since the last inspection and staffing levels were deemed to be adequate at this inspection. Norfolk County Council have responsibility for supporting the home’s recruitment procedures, but in accordance with the recommendation from the previous reports, the home now holds copies of staff CRBs, which offers more protection for residents. Some staff files were seen and were seen to be in order. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 38 Residents are able to exercise choice and control over their lives, but a completed quality assurance procedure would further ensure that the home is run in their best interests. There are procedures in place for ensuring the health and safety of residents and staff are protected as far as possible. EVIDENCE: There is evidence from speaking to residents, their visitors and staff that residents are consulted on all aspects of their daily living and how they spend their time and the Manager has the quality assurance system ready to be implemented. There is therefore a recommendation for this. Various health and safety records were seen. There was testing for Legionella on 25 October 2005, water temperatures and flushing through the water system. Care Coordinators are responsible for designated wings for checking Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 20 through Health and Safety Audits and reporting property defects. There was to be fire training with the Fire Brigade on 12 January 2006. Recommendations from the previous inspection, such as clearing the Drying room of spare furniture for the safety of staff, had been implemented. Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 3 Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 22 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. 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 2 Refer to Standard OP7 OP33 Good Practice Recommendations It is recommended that care plans and risk assessments, particularly in regard to self medication, are regularly reviewed. It is recommended that a formal quality assurance survey is carried out to ensure continuous self monitoring of the organisation of the home Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Burman House DS0000036214.V277199.R01.S.doc Version 5.1 Page 24 - 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. 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