Inspection on 08/11/06 for Burman House

This inspection was carried out on 8th November 2006.

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

Burman House 10/01/06

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 Jacky Vugler Key Unannounced 8th November 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burman House DS0000036214.V318875.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. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 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) www.norfolk.gov.uk 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.V318875.R01.S.doc Version 5.2 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. 10th January 2006 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 Kings 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 are well kept and there are seating areas outside for service users in warm weather. Burman House DS0000036214.V318875.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 key inspection taking place over 8 hours. 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 on within the text of the report. Twenty-nine residents were accommodated on the day of inspection. The Manager, Mrs Pat McCallum was present throughout the inspection. During the day a tour of the premises was undertaken and many records were viewed. Three comment cards were received from relatives and two from healthcare professionals. Three residents and a relative were spoken with privately and six residents were spoken with in a group in the lounge. Three members of staff were spoken to privately as was a District Nurse. The comment cards received were very positive of all aspects of the home and one put forward some ideas to improve the environment especially with regard to the first floor, which is currently not used for residents. What the service does well: The home benefits from a very experienced and competent Manager and an enthusiastic, well established staff team, a lot of whom have been at the home for many years. Many positive comments were made by the healthcare professionals either by the comment cards or in person, for example, excellent, one of the best homes I go in, they really care about their residents, we have confidence as we know that whoever is here will be looked after, communication is very good, the staff are all willing and helpful, the home is well run and has a friendly atmosphere, the residents are well cared for, the home is very welcoming. The training opportunities offered are very good and the home has more than 50 of its staff qualified with an NVQ level 2 or above. The home takes all complaints seriously and act upon them, no matter how small. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burman House DS0000036214.V318875.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 Burman House DS0000036214.V318875.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): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a written contract stating the terms and conditions with the home. There is a comprehensive process in place for assessing prospective residents and they can be sure that their needs will be met. Prospective residents and their relatives and friends are encouraged to visit the home prior to admission so they can assess the suitability of the home. EVIDENCE: Each resident has a Residence Agreement which states the room number, trial period, notice period and fees, and was seen to be signed by the resident or family member. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 9 There is a good procedure in place for assessing residents prior to their admission and this assessment forms the basis of the care plan. Information is obtained from the social worker and a senior member of staff visits the prospective resident to assess their needs in detail, including medical conditions, personal care needs and personal preferences, for example, for food. The prospective resident and their family are encourage to visit the home prior to admission, although one resident spoken to said that she had been in for respite before. Comments received from residents admitted for short term care confirmed that they came to look round first. One resident spoken to said that she had received a copy of the statement of purpose, service users guide and had seen her care plan. Burman House DS0000036214.V318875.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place ensuring that staff are able to meet the individual health, personal and social care needs of residents. Residents can be confident that their health care needs are fully met. Residents are protected by the homes policies and procedures for dealing with medicines. Residents feel they are treated with respect and their right to dignity is upheld. EVIDENCE: Three care plans were looked at in detail and two others generally. The care plans are detailed and based on the pre-admission assessment of residents. They contained a photograph and details of the residents health and personal care needs. A night care plan is also in place and these are regularly reviewed Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 11 and signed by the resident. Risk assessments are in place where necessary and these are regularly reviewed. A record of falls is kept as well as a skin condition chart for pressure sores where necessary. Other healthcare professionals are involved when necessary, for example, the GP, District Nurse, the optician visits regularly and one resident has a domiciliary visit privately, the community dentist holds a clinic every six months. Two staff members are responsible for continence in the home and they attend meetings with the continence advisor, although the manager said that these meetings have recently been suspended. The dietician will visit on request and staff attended nutritional training in August 2006. Since the last inspection the risk assessment for a resident wishing to administer her own medication was reviewed and it was decided that this was no longer a safe practice. The home uses Norfolk County Council policies and procedures for medication. The medication administration records contained a photograph of the resident, their preferred name and room number, and they were well completed. There is a homely remedies policy and they are recorded separately as well as on the individual residents records. The storage of medications was clean and tidy and there was no old stock. Controlled drugs were correctly recorded. A new cabinet for the storage of controlled drugs has been obtained and will be installed when the medication room has been redecorated. A separate cupboard is in place for the storage of external preparations and dressings. The medication room and fridge temperatures are recorded. All staff administering medications have attended training and an update was carried out on 01/11/06. From observation and residents comments, it was confirmed that the staff were very polite and respectful. Burman House DS0000036214.V318875.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The regular activities provided the residents with variety and interest. Residents are able to maintain contact with family and friends, and the local community. Residents are able to exercise choice and control over their lives. Residents receive a varied, well balanced diet in pleasant surroundings. EVIDENCE: Although there is no designated activities person, a care coordinator oversees the activities and keeps a good record of those undertaken including cut outs from the local paper. Activities undertaken are also recorded in the residents daily records. A weekly activities programme is displayed and activities include a monthly exercise class to music and craft sessions conducted by two members of night staff. The residents and Manager said that the home was Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 13 full of decorations for Halloween day. Regular church services including Communion and Harvest Festival are held at the home. The home operates an open visiting policy and visitors were seen to enter freely throughout the day. One resident said visitors come and go freely. In the village is an over 60s club which two residents used to attend and a coffee morning is held in the village hall. One resident has an electric scooter and uses it to visit his daughter. Residents spoke of the many choices available to them saying, we can sit where we like, staff give lots of choices including meal times. The menus seen were varied and nutritious and indicated choices available. The dining room was pleasant with small tables seating four. A board was on the wall for displaying the menu, but it was blank. It is recommended that the menu is displayed in the dining room. On the day of inspection the lunch was roast turkey with three vegetables and pears with chocolate sauce for pudding. Evidence of choices was seen, for example pork or pizza. The kitchen was clean and tidy and all relevant information was available. The cook has achieved the Intermediate level of the Food Hygiene certificate. The cook said that she often speaks to the residents regarding alternative meals available and their preferences. She said she will also be attending the residents meeting to be held next week to discuss menus with them. Burman House DS0000036214.V318875.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 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Resident are protected from abuse. EVIDENCE: Since the last inspection one complaint was received by the home regarding the care of a resident. The records of this complaint were seen and it was found to be unsubstantiated. No further complaints have been received apart from the smaller individual complaints around daily living and the recording of these, and the action taken is good practice. Residents spoken to said that they knew how to complain and would do so if necessary. All staff have received training in the protection of vulnerable adults and all have a criminal records bureau disclosure in place except for one, which is still in the process. Staff spoken to had a good understanding of abuse awareness and said they would report any suspicions. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained environment. The home is clean and tidy. EVIDENCE: The home was generally well maintained although there were some areas needing attention, for example, wheelchair scuffs along some corridors and in some doorways; the paintwork on two bedroom doors was damaged and a patch of plaster had fallen off the wall in one bathroom. It is required that a plan of action for attending to these matters be submitted to the Commission. The window frames are in good decorative order. The home has three wings and each has its own small lounge, although they are not very often used as the residents prefer to sit in the larger lounge and Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 16 in the entrance to the home. Pictures are on the walls in the hallways; one resident used to do needlepoint, and many of her pictures are framed and displayed throughout the home as well as in her room. Flower displays are also displayed in the units. The laundry room is situated in one wing and as it is within close proximity to some bedrooms is it not possible for staff to undertake laundry duties at night. There is a room for ironing and storing clean linen, a hairdressing room and a wheelchair storage area. All bedrooms have a lock on the door and the name of the resident and room number displayed. The reception area is homely and a few residents enjoy sitting there during the day. A lot of information is displayed including a board with the names of the staff on duty during the day. The statement of purpose and the inspection report are available there as are comment cards for completion. The home was clean and tidy and free from unpleasant odours. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good enthusiastic staff team of which over 50 have achieved the NVQ level 2 or above. Residents are protected by the homes recruitment procedures, however some documents are still held at County Hall. The training opportunities are very good and training is up to date. EVIDENCE: On the day of inspection the home accommodated twenty-nine residents. A care coordinator works from 7.15am until 9.45pm with an overlap at lunchtime for hand over. Four care assistants work in the morning and three in the afternoon and evening, and these shifts include a senior where possible. There are two waking night staff. The manager said that the home has recently been allocated an additional 26.5 hours a week. The care coordinators duties are mainly around medications and administrative duties, which leaves little time for helping with care. It is therefore recommended that the Manager continues to monitor residents dependency levels to ensure that adequate staff is provided to meet their needs. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 18 As there is no dedicated laundry person available, the care staff are expected to undertake these duties and as previously stated it is not possible for the laundry to be undertaken at night. It is therefore recommended that a member of staff is dedicated to laundry duties so that these duties do not impinge on the time the care staff have available to care for the residents. The home has a key worker system and one resident said I have a good key worker, its a lot more personal. Other comments included excellent care from everyone involved, there seems to be enough staff, one relative commented, I cant praise Burnham House enough……always lovely, friendly and warm welcome. Three care coordinators have achieved NVQ level 3 and five care assistants have NVQ level 2. This equates to 57 of care staff having achieved NVQ level 2 or above. Five staff recruitment files were viewed, two in detail. Most of the information required was available, but this did vary. Norfolk County Council are responsible for the homes recruitment procedures and the manager said that the missing documents have been obtained, but are held at County Hall. It is required that the missing documents are obtained and held at the home. The training opportunities at this home are good. Each member of staff has an Evidence of Learning file, which contains evidence of training undertaken including induction and mandatory training. Other training undertaken includes, vulnerable adults at risk, dementia, effective communication, risk management, medication management, diversity and rights and many more. Questionnaires and certificates were seen where necessary. Although, the training was all up to date, it is recommended that these files are better organised in order to make it easier to monitor when updates are due. Staff said that training needs are identified in supervision and they go on the list, training opportunities are good, if you want to do anything different, they will try to help. A resident said the staff know what they are doing. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a well run home, which is managed by a person who is experienced and qualified, and able to discharge her responsibilities fully. The home is run in the best interests of its residents. Residents financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 20 The Manager has been in post at Burman House for in excess of 16 years. She therefore has considerable knowledge and skills in dealing with elderly people as well as dealing with staff. The manager has regularly undertaken updates in various training courses along with the staff group and has achieved the NVQ level 4 Registered Managers Award. The manager has a job description and there are clear lines of accountability both within and external to the home. Evidence was seen of returned surveys from residents, relatives and staff from September to October 2006. Surveys from residents indicated that the home provided a good quality provision of care, which was moving in the right direction; the relatives survey indicated a high standard is clearly being achieved and the staff survey indicated that there was lots of scope for improvement. All issues raised have been addressed by the Manager and an action plan is in place. Other surveys received from visiting professionals included comments this is the best run home I visit, Burman House is a well run home, has a friendly atmosphere and the residents are well cared for. Regular audits are conducted, for example, medication records, call bells and infection control audits, for example, the hairdressing room with an associated risk assessment and the sluice. Regular staff meetings are held and the minutes are displayed in the staff room. Regular residents meeting are held and this was confirmed by those spoken to. The residents financial records were in good order with a record kept of income and expenditure. Receipts were kept and numbered. The cash held was checked randomly for nine residents and found to be correct. The fire records seen were satisfactory, and risk assessments were in place and recently reviewed. The fire alarms, emergency lighting and fire fighting equipment were tested and serviced regularly. Fire training is up to date and a fire drill was conducted recently following a fault on the system, with a record saying efficient evacuation of the Wing. The service certificate for the call bell system was seen, and the file for Legionella, which recorded the regular tests carried out. The accident records seen were detailed and a risk assessment had been written as a result where necessary. Burman House DS0000036214.V318875.R01.S.doc Version 5.2 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 3 3 x 3 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 4 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 Burman House DS0000036214.V318875.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23 (2)(b) Requirement The Registered Person must ensure that there is a plan for doorways be repaired and redecorated. The Registered Person must ensure that the documents listed in Schedule 2 are kept at the home. (Previous recommendation). Timescale for action 28/02/07 2. OP27 19 (1)(b) Schedule 2 31/01/07 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. 3. 4. Refer to Standard OP15 OP27 OP27 OP30 Good Practice Recommendations It is recommended that the menu is displayed in the dining room. It is recommended that the Manager continues to monitor residents dependency levels in order to ensure adequate staffing is available. It is recommended that consideration be given to providing a member of staff for dedicated laundry duties. It is recommended that the staff training files are better organised. DS0000036214.V318875.R01.S.doc Version 5.2 Page 23 Burman House Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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