Inspection on 21/11/05 for Burnaby House

This inspection was carried out on 21st November 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

Burnaby House 03/11/09

Burnaby House 27/09/07

Burnaby House 06/06/05

Burnaby House 06/10/04

Burnaby House 01/07/04

Burnaby House 11/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Burnaby House Longhirst Road Pegswood Morpeth Northumberland NE61 6XF Lead Inspector Jim Lamb Announced Inspection 21st November 2005 09:30 21/11/05 Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 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 Burnaby House DS0000000514.V253896.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 Adults 18-65. 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. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burnaby House Address Longhirst Road Pegswood Morpeth Northumberland NE61 6XF 01670 - 513915 01670 - 513915 lynn.shardlow@nhs.net 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) Northgate & Prudhoe NHS Trust Miss Lynn Shardlow Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1) of places Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Burnaby House provides personal care and accommodation for 5 male service users with learning disabilities. The home is located in a residential area in the village of Pegswood. The home is close to all the village amenities and there are good transport links to Ashington, Morpeth and Newcastle. All bedrooms are single and there are communal toilets and bathrooms on each floor. The gardens are landscaped and easily accessible to all service users. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second annual announced inspection visit; it took place over 3 hours during the morning and early afternoon. Time was spent looking at the service users care records, the homes policies and procedures, taking to service users, staff and touring the home. What the service does well: What has improved since the last inspection? The bathroom on the ground floor is about to be refurbished and an assisted bath fitted. Items of new furniture have been purchased for the dining room. The manager described examples of how service users are supported to make choices for themselves regarding their lifestyle and daily activities. Burnaby House DS0000000514.V253896.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. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The homes statement of purpose and service users guide provides prospective service users with sufficient information to enable them to make an informed choice about the home. Prior to admission to the home all service users were appropriately assessed. EVIDENCE: The homes Statement of Purpose and the Service Users Guide both contained the full range of information required. One service user interviewed confirmed he had been given a copy of the guide. Two service users’ files were checked and on each were a copy of a full needs assessment. The 2 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. The service users interviewed said their needs were met and they were happy with the care offered to them. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 9 Two care plans checked stated that a range of specialist services was provided to service users. Staff had a range of relevant training and experience. Admissions to the home are very rare however; all service users were appropriately assessed prior to admission to the home. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service users health, personal and social care needs are fully met. Systems are in place to promote and protect each service users privacy, dignity, independence and risk taking. EVIDENCE: There is evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users. Each service user has an allocated key worker. Care plans are drawn up with service users. There is evidence that plans are amended and reviewed on a regular basis. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 11 Service users can access a range of external agencies that promote independence; any rights that are restricted are linked to risk assessments. Each service user receives support from staff to manage their finances. A one-service user requires an annual review of his care needs: the manager agreed to contact the placing authority to arrange a review with the service users care manager. Relatives are invited to attend these reviews. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has devised a new system to ensure that the service users recreational and social needs are fully met. The menus were nutritional and well balanced. EVIDENCE: Each service user has a practical life skills assessment carried out and this is reviewed and updated on a regular basis, all service users participate in this process and their families are invited to attend. Validated intervention treatment programmes are accessed if a need does arise. There was evidence that each service user has the opportunity to participate in community-based activities, including supported work programmes, education and training. All service users are supported to maintain close links with their families. All are able to choose who they want to see and when. One service user has holidays with his family; the other four service users Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 13 have been on holiday this year; one to Paris, one to Berwick and two to Skegness. There was evidence that daily routines promote independence, choice and freedom of movement. Service users are involved in housekeeping tasks. The inspector observed staff interacting in a sensitive and respectful manner with service users. The Home’s menus are based on the known likes and dislikes of the service users. Service users have access to the kitchen and are able to prepare snacks for themselves if they wish. The service users said that the food was very good. Nutritional assessments are routinely completed for all service users. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The physical, emotional health care needs of the service users are fully met. Systems are in place to support the safe administration, storage and disposal of medication. Staff has undertaken accredited medication training. Staff require; ageing, illness, and death training. EVIDENCE: No service users currently have any moving and handling needs. Service users require minimum help with her personal care tasks, such as bathing and dressing. Privacy and dignity are respected at all times. No service users currently have or require any technical aids or equipment. Two service users said that they felt their privacy is respected. There was evidence within the service users care records that they have access to external health care services. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 15 G.P.’s visit when necessary, and service users are referred for specialist health care if appropriate. All service users receive regular health care checks. The medication systems were examined for ordering, receiving and administering and disposal. All were well managed. Currently no controlled drugs are prescribed. All staff has undertaken medication training. The staff require; ageing, illness and death training. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has an appropriately detailed complaints procedure in place and an adult protection policy. The staff team have received the Protection of Vulnerable Adults training. The home keeps detailed records of the service users finances. EVIDENCE: The home does have a complaints procedure, which the inspector saw. It does contain details of how to contact the CSCI to make a complaint, and is written in a way to ensure that service users fully understand its contents. One service user confirmed that he had been given copies of the procedure and that staff always listened to his concerns and dealt with them fairly. The home does keep a record of complaints. During the last twelve months there has been no complaints received. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. The Home maintains detailed financial records on behalf of the service users; each has an individual bank account. There was evidence of personal spending, receipts are kept and regular finance audits are carried out. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service users live in a homely, safe and well-maintained environment, the lounge/dining room does require redecoration and a new carpet and the conservatory walls need repainting following water damage, however all other areas within the home are extremely comfortable and well-maintained. The home is clean and hygienic. EVIDENCE: On the day of the inspection the home was clean, and well maintained. One service user interviewed said the home was very comfortable. The grounds were tidy, safe, attractive and accessible. One service user has a great interest in gardening and grows a range of plants in the garden greenhouse. The fire service and the environmental health department had made visits to the home. Requirement made by these organisations had been actioned. The home does have an appropriate amount of sitting, recreational and dining space. There are sufficient rooms for a variety of activities to take place. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 18 Service users can see visitors in private in their own rooms. The dining areas are large enough to cater for all service users. There is a smoke-free sitting room. Furnishings and fittings were domestic in design and in good condition. Lighting was sufficiently bright and also domestic in design. The home does have a sufficient number of baths, showers and toilets. These were close to bedrooms, lounges and dining areas. Work will soon commence to refurbish the downstairs bathroom. Doors had privacy locks, and service users have keys to their bedrooms. Room sizes exceed the minimum required. Room dimensions were such there was space on either side of the bed when necessary to enable access for carers and specialist equipment. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Lighting levels were sufficient and there was emergency lighting throughout the home. Water is stored at over 60°C. Valves are in situ at water outlets to ensure water is provided close to 43°C to prevent scalding. Water temperature checks are carried out. The lounge/dining room carpet should be replaced as it is worn in places and rippled. This area also requires decorating. There is a large attractive conservatory to the rear of the home, water damage to the walls needs to be made good, the service users could make much better use of this area during the winter months if adequate heating was installed. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The deployment and numbers of care staff including the enablers, is sufficient to meet the needs of the service users. Appropriate recruitment procedures appear to be in place. The staff requires supervision sessions at least six times a year. EVIDENCE: Staff levels on the day of the inspection did meet the agreed level. Samples of 2 weeks’ rotas were checked and these stated the required numbers of staff were on duty: 2 staff between 8am and 9pm with one sleepin between 9pm and 8am. The home also employs two enablers who support service users in all aspects of social interests and community-based activities. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified via supervision and appraisal sessions. Staff supervisions have lapsed, due to long-term sick leave; the manager will ensure that these will now take place within the required time-scales. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 20 No staff files were available for inspection, however the manager was able to describe the homes recruitment process which includes; obtaining two written references, obtaining full employment histories and checking gaps in these, a criminal records check, medical checks, obtaining proof of ID and any qualifications. All staff receives a statement of terms and conditions are provided with a copy of the code of conduct. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is managed well; this provides guidance and direction to staff to ensure the service users receive consistent quality care. There are systems in place to promote and safeguard the health, safety and welfare of the service users. EVIDENCE: The registered manager has many years experience in senior management, in the last year all of the staff team have attended several courses to keep themselves up to date. Staff interviewed were clear about the their responsibilities and the majority of staff have worked for the Trust for many years, some have more than twenty years service. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 22 Service users are informed when inspections take place and have access to inspection reports. These are also summarised and discussed in service user/staff meetings. Copies are available for relatives/others to see The Trust has developed a range of new policies and procedures and these have been linked to the National Minimum Standards. The records inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, Health and Safey hot water checks and procedures were in place for unexplained absence from the home. There was information which verified that appropriate maintenance contracts for the home are in place. Water storage tanks, gas and electrics are checked annually. Finance records have previously been forwarded to the CSCI to verify that the home is viable. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burnaby House Score X 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000000514.V253896.R01.S.doc Version 5.0 Page 24 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 2 3 Standard YA 24 YA 24 YA 36 Regulation 23 23 18 Requirement Repaint the conservatory walls. The lounge/dining room requires decoration and a new carpet fitted. All staff require supervision sessions six times a year. Outstanding from previous report. Timescale for action 31/05/05 31/05/05 31/12/05 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 YA 35 YA 21 Good Practice Recommendations 50 of the staff team must complete NVQ level 2 training. Staff requires ageing, illness and death training. Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Burnaby House DS0000000514.V253896.R01.S.doc Version 5.0 Page 26 - 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. 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