Inspection on 27/09/07 for Burnaby House

This inspection was carried out on 27th September 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnaby House 03/11/09

Burnaby House 21/11/05

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 Key Unannounced Inspection 25th September 2007 09:30 Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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.V351463.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 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.V351463.R01.S.doc Version 5.2 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) Northumberland, Tyne & Wear 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.V351463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: Burnaby House is a large detached house set in its own grounds on the outskirts of Pegswood. It provides very attractive and comfortable accommodation on ground and first floor levels for 5 service users with a learning disability. All bedrooms are spacious and highly personalised. Currently the service users are all male. A range of shared accommodation is provided including a large conservatory and games room. The home is set within large attractive landscaped gardens that are easily accessible. Transport is available for the service users and the home is close to the village facilities and other transport links. Fees for the home range from £270 to £360. Copies of inspection reports and information about the service are available in the home. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 1.11.07 During the visit we: • • • • • • Talked with people who use the service and the staff. Looked at information about the people who use the service, this included case tracking, this tells us how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: Service users, where able, described good relationships with the staff and said they were all polite and helpful. Staff were friendly and relaxed and showed a good understanding of their needs. Arrangements for service users to maintain contact with their family and friends are good. A variety of social activities were available providing service users with varied and interesting days both inside and outside the home. Meals are varied, well balanced offering good choice and nutritious food at all meals. Those spoken to were pleased with the quality and choice available. Meals were seen as a relaxed and social occasion. Hygiene practices were good protecting the health of service users and staff. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 6 The home is well staffed with a skilled, consistent and trained staff team giving security to service users. Staff recruitment and training records were clear and concise and contained all relevant information. The vetting process helps protect service users. The staff had a good understanding of service users individual needs. More than fifty percent of staff is qualified to National Vocational Qualification in Care level 2 (NVQ) or above providing service users with a trained, skilled staff team. The service users were very complimentary about the staff. 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. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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.V351463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a contract/statement of terms and conditions. Prospective service users have enough information about the home to help them to make a choice about where to live. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. The homes Statement of Purpose and the Service Users Guide both contained the full range of information required. Two service users’ files were checked and each included a full needs assessment. They contained a range of appropriate information. The service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. The service users enjoy this, and it helps them to understand the need to keep records about them. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 9 The 2 service user plans checked by the inspector were well recorded, and listed details of the service user’s needs and actions taken by the staff to meet these needs. The service users feedback cards all showed their needs were met and they were happy with the care offered to them. Staff interviewed had very good knowledge about each service users care needs. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system is clear enough to ensure that staff has the information they need to meet the assessed needs of the service users. Service users are supported to make decisions about their lives, and take risks to promote their independence. EVIDENCE: There are comprehensive assessments in the service users’ care plans. There is also a comprehensive risk assessment of service users. These have been agreed and signed by service users and their representatives. There are advocacy arrangements, as well as family input, to represent service users. Each service user has an allocated key worker. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 11 Care plans are drawn up with service users. Plans are amended and reviewed on a regular basis. There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These involve the care managers and the service users representatives. Service users can use 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. Service users’ feedback cards all showed that they are able to make decisions for themselves, and that they are happy with all aspects of the care that they receive. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The service users have opportunities for personal development and leisure activities. They are supported to maintain very good links with the community and their relatives and friends. EVIDENCE: Each service user has a life skills assessment carried out. This is reviewed and updated on a regular basis. All service users participate in this process. This ensures that they are involved in all decisions about their lifestyle. Service users use a range of community-based services, which promotes and provides opportunities to learn and use life skills. Some attend day centres, and they also have opportunities to attend various college courses. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 13 Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, to enjoy their own interests and hobbies. The staff team continue to liaise closely with external agencies in order to monitor each service user’s progress. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. Daily routines promote independence, choice and freedom of movement. Service users are involved in housekeeping tasks, and this helps to promote their independence and daily living skills. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day, meals are viewed as a very social occasion. Service users have access to the kitchen and can prepare snacks for themselves if they wish. All those spoken to said that the meals were very good. One-service users said, “The staff are good cooks, and we often eat out, or sometimes we have a take away”. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care of the service users is met and there is good multi disciplinary working taking place. The promotion of health care needs is taken seriously. Medication systems are well managed. Personal support is always provided in the way that service users prefer. EVIDENCE: Service users need minimal help with personal care tasks, such as bathing and dressing. The staff ensure their privacy and dignity are respected at all times. Service users care records showed that they have access to external health care services. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 15 G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. All receive regular health care checks. The medication systems were examined for ordering, receiving, administering and disposal. All these are well managed. All staff had undertaken accredited medication training. Controlled drugs are not currently prescribed. Should this change; appropriate systems and procedures will be put in place. The dispensing pharmacist offers good support and advice. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good, clear, user-friendly complaints system and service user’s views are listened to and acted upon. Procedures are in place to protect service users from harm, and these are followed. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. In earlier inspections, service users said that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. The home keeps a record of complaints. Since the last inspection visit, there have been no complaints received. The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 17 The home also has a copy of the Department of Health’s document, “NO SECRETS”. The Home keeps detailed financial records on behalf of the service users. Each has an individual bank account. Receipts of personal spending are kept. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for those living there. The standard and decoration within the home is generally very good. Some areas still need to be improved. Communal areas and bedrooms are large, and meet the service users needs. All areas within the home are well maintained, clean, tidy and free from offensive odours. EVIDENCE: The home was clean, well decorated and the main house is well maintained. The home is in an attractive residential location. There are still on going concerns about the conservatory, the roof is leaking in parts and needs repairs carried out, and there is still no adequate heating. For the last two years it has been a recommendation that appropriate heating is Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 19 installed in this room, to no avail. Therefore, it is now a requirement that roof repairs are carried out and adequate heating is installed. The grounds were tidy, safe, highly attractive and accessible. One service user helps to look after the gardens, he has his own plot that he tends, and where he grows his own vegetables. The fire alarm system was being serviced on the day of the inspection. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place, including a games room. Service users can see visitors in private in their own rooms, or in the blue lounge/games room. Furnishings and fittings were domestic in design and in very good condition, and lighting was bright and domestic in design. All doors have privacy locks. Room sizes exceed the minimum required. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. Service users’ bedrooms have opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Radiators and pipes are guarded. There was emergency lighting throughout the home. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities are well organised. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 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 match of well-qualified staff offering consistency of care within the home. There are robust procedures in place for the recruitment and selection of new staff, which helps to protect service users. The staff receives supervision and this provides them with a good understanding of the service users support needs. EVIDENCE: Staff levels on the day of the inspection met the agreed level. Samples of 4 weeks’ rotas showed the required numbers of staff were on duty: 3 staff between 8am and 9pm with one sleep-in between 9pm and 8am. Staff said that staffing levels were appropriate. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 21 All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. The training programme has been reviewed to ensure it meets The National Training Organisation requirements for the first six months. Staff receive three days paid training. The Trust has a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. The three staff on duty were observed to treat service users with respect, and in a caring and sensitive way. Two service users spoke positively about the staff and the care that they receive. One said, “I like all the staff, they help me with everything, and I love going out with them to different places”. Another said, “ I had a great holiday, I went to Blackpool with the staff, and the staff are always kind to me”. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported by the Trust in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The systems for service users’ consultation are good, and service user’s views are both sought and acted upon. The health and safety of the service users is promoted. The service is aware of equality and diversity and its implications. EVIDENCE: The manager has many years experience in senior management, and has the necessary qualifications to manage the home, she is also a qualified nurse. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 23 Staff were all clear about their responsibilities and the service users care needs. Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives and others to see. Easy read summary reports are also provided for service users. Service users can deposit cash for safe keeping in the home’s safe and records are kept of accounts. A sample of personal finances records was examined. Transactions were appropriately recorded and had two signatures for each entry. There was plenty of evidence of personal spending. Receipts are obtained for purchases and numbered to cross-reference to the transaction. Daily checks of balances and cash are carried out. There is a health and safety policy and range of associated procedures. Staff receive training in health and safety and safe working practices, fire safety, moving and handling, first aid, food hygiene, and infection control. Servicing and maintenance agreements are in place for facilities and equipment. Risks in the environment and tasks, including safe working practices are assessed and reviewed. All fire safety checks; tests and instructions to staff are conducted at the required frequency and recorded. Accident reporting was suitably recorded and analysis of accidents is carried out. Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA28 Regulation 23 Requirement Repaint the conservatory walls. Outstanding since the last inspection visit. The conservatory roof must be repaired, and adequate heating must also be installed. Timescale for action 27/09/08 2. YA28 23 27/09/08 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 Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. Extracts may not be used or reproduced without the express permission of CSCI Burnaby House DS0000000514.V351463.R01.S.doc Version 5.2 Page 27 - 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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