Inspection on 17/01/06 for Burnham

This inspection was carried out on 17th 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnham 28/10/06

Burnham 23/06/05

Burnham 17/11/04

Burnham 08/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Burnham 19 Julian Road Folkestone Kent CT19 5HW Lead Inspector Mrs June Davies Unannounced Inspection 17th January 2006 12:00 Burnham DS0000023122.V251249.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 Burnham DS0000023122.V251249.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. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burnham Address 19 Julian Road Folkestone Kent CT19 5HW 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) MNP Complete Care Group Miss Debbie Beer Care Home 5 Category(ies) of Physical disability (5) registration, with number of places Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person with Physical Disability whose date of birth is 20/7/1939. Date of last inspection 23/06/05 Brief Description of the Service: Burnham is a large detached Victorian-style building, and it is situated in a pleasant residential area of Folkestone. The home is near to a public park, a leisure centre, the town, shops and the sea. Burnham is owned by the company MNP Complete Care Group, who are experienced providers for residents with physical and learning disabilities. They have several other care homes in this area, and one of these is within a few minutes walking distance of Burnham. There is a good rapport between these two homes, and this provides the opportunity for residents to share in a wider range of activities, and to get to know a wider range of people. Accommodation is provided on 2 floors, in 5 single bedrooms. All of these have en-suite toilet and shower or bathing facilities. @Access to the first floor is via a passenger lift, which was newly installed in 2003. One of the bedrooms has it’s own front and rear access to the building. All rooms are fitted with call bells. A variation on the registration was agreed with CSCI for one resident who has lived at the home for several years, and is now aged over 65 years. It has been agreed that the home remains a suitable venue for him at this time. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection with commenced at 12.00 p.m. and was concluded at 4.00 p.m. The inspector included a tour of the premises, but not all of the residents bedrooms, only one residents bedroom was viewed. The inspector also looked at documentation, discussed issues with the acting manager, and was able to talk to two residents who were in the home at the time of the inspection and two members of staff. One resident was out in the community on his own, and a risk assessment had been carried out for this, another resident was in his bedroom and did not wish to have a visitor, and another resident was away from the home for two days. The residents spoken to conveyed that they were happy in the home. What the service does well: What has improved since the last inspection? Since the last inspection one of the residents can now open a ground floor window in his bedroom, and another resident has had his own shower chair purchased for him. All MAR sheets now have a divider between each resident, this divider has a photograph of the resident and also highlights any allergies. Each resident now had an infantry of their main items of clothing. Burnham DS0000023122.V251249.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. Burnham DS0000023122.V251249.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 Burnham DS0000023122.V251249.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): 2 and 5 The home ensure that good pre-admission assessments are available as a basis on which to assess if the home can meet the residents needs and on which to base an individual care plan. Each resident is aware of his or her role and responsibilities within the home. EVIDENCE: The inspector was able to view the pre admission assessments for two of the residents in the home; all assessments had been appropriately completed, with good assessments of the residents personal and social care needs. These pre admission assessments had been completed by the residents individual care managers and by the previous registered manager of Burnham. Two statements of terms and conditions were viewed by the Inspector and while giving appropriate information, the inspector noted that neither copy of the statement of terms and conditions had been signed either by the resident, their representative or a representative of the company, therefore the inspector has made a requirement that these documents are signed appropriately at the time of the resident coming to live in the home. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 9 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): 6, 7, 8, 9 and 10 Residents know that their personal goals are reflected in their individual care plans and that potential risks are managed, but residents must know that their views are listened to. Resident’s records are kept securely, maintaining confidentiality. EVIDENCE: The inspector viewed the individual care plans for two residents living in the home, both care plans were detailed in content, and gave good holistic evidence as to the care requirements of each resident. The inspector did notice however that regular reviews had not been recorded within the care plan and has therefore made a requirement that reviews are carried out for each resident in the home at least twice a year and more often if deemed necessary. Residents in the home are encouraged to make decisions and this is recorded in each individual resident’s care plan. Staff are able to communicate in a language relevant to each resident, and therefore request residents to make decisions regarding the daily lives on a day-to-day basis. Residents are encouraged to become involved in the day-to-day running of the home, such as the time they have their meals, what shopping is required. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 10 Residents also make choices in relation to colours when new decorations are required, and are able to meet with potential new members of staff. Each resident’s care plan has detailed risk assessments in place relating to personal and day-to-day activities. Residents are encouraged to be involved in their own risk assessments to ensure they have a good understanding while restrictions have been place to keep themselves and others at minimum risk. The staff are aware that they need to respect the confidentiality of the residents in the home. Care plans are kept in the office and only the manager and care staff have access to these care plans. Any other confidential information is kept under lock and key. Should an issue arise where a resident asks a member of staff to keep information confidential, this would depend on the nature of the information, but if it was obvious that this information should be shared with others, this would be explained in an appropriate language to the resident in the first place. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 11 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): 12, 13, 14, 15 and 17 The residents have good links with the community, which support and enrich the resident’s social and educational opportunities. The meals in the home are good offering both choice and variety and catering for special diets. EVIDENCE: At the present time only one resident in the home has chosen to attend college for I.T. Another resident attends the Barry Shaw trust for basic life skills. The inspector was able to ascertain that out of the five residents in the home two are able to go out on their own, and two other residents need to be escorted by members of staff, one resident has chosen not to go out in the community. Residents are able to go to local shops, and have got to know neighbours in the locality. The residents also attend theatrical shows that are of interest to them as a group and with residents from other homes in the group, they enjoy bowling, and are hoping to start sessions at the local hydrotherapy pool in the near future. Evidence was available within the residents individual care plan and by confirmation of the acting manager that residents are able to pursue leisure activities of their choice such as gardening, musical interests, DVD’s, reading, board games, baking and shopping. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 12 The residents have good regular contact with their relatives and friends, almost on a daily basis. Residents are given choice daily on what they would like to eat at meal times, and the inspector was able to view menus, which showed that residents are offered well balanced, varied and nutritious food. At the present time only one resident requires to have a high calorie diet, and this is closely monitored via his care manager, and dietician. No other specialised diets are required in the home. One resident is weighed weekly but there was no evidence within the care plans that the other four residents in the home are weighed regularly, and the inspector has made a requirement that residents have their weight checked and recorded. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 13 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): 18, 19, and 20 Personal care is offered in a way to protect the residents’ privacy and dignity and promote independence. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The administration of medication in the home is fairly good but mid week medication needs to be properly signed in. EVIDENCE: Personal support is outlined in each residents care plan, and gives staff sufficient knowledge at to what assistance residents need with their personal hygiene. All aspects of personal hygiene carried out on a daily basis are recorded on the daily report sheet for each resident. The inspector witnessed on the day of the visit, that staff dealt with personal hygiene needs sensitively, while at the same time respecting the privacy and dignity of the resident. Residents in the home are able to choose when to go to bed and rise in the morning. The inspector noted that all residents dressed individually according to their own taste, and during discussion with the acting manager it was confirmed that residents go into the town with staff members to do their own clothes shopping. None of the residents require psychiatric input, but one resident has input from the NHS psychologist and attends out patient appointment at the local hospital. The home has good working relationships with G.P’s and other multi disciplinary health groups in the community. At the present time and a physiotherapist attends the home to give a regular exercise Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 14 programme for one of the residents, and also leaves exercise sheets for staff to carry out a daily exercise programme with this resident. All residents visit their own optician, the chiropodist visits the home as and when required and the same is true of the dentist, all visits are recorded in each residents individual care plan. The inspector carried out an audit of the medication in the home and noted that all residents MAR sheet now have a separator, the separator has a resident photograph attached and also gives details of any allergies that the resident may have. The inspector did note that where a medication has been prescribed mid week the MAR should show recording of the amount of medication who received it and the date it was received, therefore a requirement has been made to ensure that this takes place in the future. The care plans have homely remedies permissions from the residents G.P’s, the inspector also saw that a signature sheet was included at the back of the MAR sheet folder, showing the signatures of staff who have undertaken medication training, and who now administer medication within the home. The acting manager has recently introduced a stock control sheet, and this monitors all medication in the home as well as liquid medication. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 15 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): 22 and 23 Residents know that their complaints will be listened to and acted upon. Staff have a good knowledge and understanding of adult protection issues, which protects the residents from abuse. EVIDENCE: The inspector was shown a complaint made to the home and was able to verify that this had been appropriately recorded, investigated and resolved within the timescale set out by the homes complaints policy and procedure. All staff in the home have access to the POVA policies and procedures, and have undertaken POVA training. The home also has the most recent copy of the KCC guidelines for POVA. The inspector also witnessed that the home has an up to date policy and procedure for whistle blowing. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 16 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): 24, 26, 27, and 30 The standard of the environment both internally and externally is good providing the residents with an attractive and homely place to live. The awareness of health and safety issues in the home is good, giving the residents a safe environment in which to live. EVIDENCE: The inspector was able to view the communal areas of the home and one of the resident’s bedrooms; all decorations and furnishings were of a high standard. Residents had been given choice of colour regarding the decoration of their own bedrooms and communal rooms. The kitchen is due for refurbishment and this is to take place in early April 2006. The home was clean tidy and free from any offensive odours. One resident was able to show me his bedroom; this room had been decorated to the choice of the resident. The bedroom reflected the resident’s interests and hobbies, and family photographs were displayed on the walls and furniture. All bedrooms have been fitted with new locks on the doors. Four of the residents’ bedrooms have en-suite facilities consisting of wet rooms, to make personal hygiene easier for the disabled residents. The inspector noted that a recommendation from the previous inspection had been Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 17 purchased and now all residents who require a shower chair now have one. One first floor bedroom has a bathroom and toilet situated adjacent to the bedroom and the resident occupying this bedroom has sole use of this bathroom. The rear garden of the home is well maintained, and the acting manager and a member of staff on duty, confirmed that residents enjoy the garden when the weather is nice. The garden has the provision of a patio area with a brick built barbeque. The laundry room is situated on the first floor, and is fitted with a domestic washing machine and tumble drier, which is adequate for the needs of the home. At the time of the inspection the laundry was clean and tidy. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 18 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): 32, 33,34 and 35 The home needs to improve on the staff work related qualifications to ensure, that staff have a good understanding of the support needs of the residents living in the home. The standard of vetting and recruitment practices is good therefore reducing an element of risk to the residents. EVIDENCE: The inspector was able to discuss staff qualification and training with the acting manager, and was also able to view the training matrix for the home. Only 28 of the care staff have an NVQ qualification and the inspector has made a requirement that staff continue to be trained and complete NVQ level 2 to enable at least 50 of staff to be qualified to NVQ level 2. The inspector was able to view two of the staff personnel files and this confirmed that CRB checks had been completed, and the at least two references had been obtained prior to the member of staff being employed in the home. Both files also contained the following documents, application form, terms and conditions, contract, appraisal, absence form and supervision forms. The inspector noted that formal supervisions are not carried out at regular intervals and a requirement has been made that staff receive at least six formal supervisions per year. The training matrix showed that the majority of staff have completed mandatory training, and the acting manager assured the inspector that further Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 19 mandatory training has been organised to ensure that all staff have completed their mandatory training. Evidence was available on staff personnel files to show that all staff have completed induction training within the first six week of their employment. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 20 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): EVIDENCE: The acting manager is in the process of completing her NVQ Level 4 and RMA. She has had experience of working at senior level in one of the companies other homes. The inspector witnessed that staff on duty were able to approach the manager with any queries. During the inspection there was an incident with a staff member coming on duty, which at the time did not affect any of the residents in the home, and the inspector witnessed that the acting manager dealt with this issue, in a sensitive and appropriate manner, ensuring that all actions were recorded in writing. The inspector was able to view the policies and procedures file, and this gave clear evidence that all the policies and procedures have been reviewed in the last year. Staff are required to read policies and procedures as part of their induction programme. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 21 The inspector was shown that date valid certificates were in place for all equipment used in the home and this included, the shaft lift, fire alarm system, circuit testing, PAT testing, gas boiler, fire cylinders, and Legionella. The homes insurance certificate was in date. There was a recent requirement from the environmental health officer, and the company is dealing with this. The inspector did note that a bowl of prawns had been placed in the fridge, and while it was appropriately covered, and named, it did not have the date written on the label and a recommendation is being made that all food being stored in the refrigerator should be dated at the time of storage. All rooms have now been fitted with window restrictors, and environmental risk assessments are carried out on a regular basis. At the previous inspection there was a recommendation that a side-opening window in a ground floor bedroom should be adjusted to enable the resident to open it, and this has now been carried out. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 22 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 X 3 X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burnham Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 3 X DS0000023122.V251249.R01.S.doc Version 5.0 Page 23 No 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 YA5 Regulation 5 (c) Requirement Statements of terms and conditions are signed by the resident/residents representative and representative of the company. Care plans are reviewed every six months and more frequently if required or requested by the resident. Residents should be weighed on a regular basis, their weight should be recorded and any cause of concern reported to G.P. immediately All medications including those received mid week into the home should have quantity, initials of receiver and date placed onto MAR sheet. At least 50 of care staff working in the home achieve NVQ level 2. Staff receive at least six formal supervisions per year. Timescale for action 01/03/06 2. YA6 15 (2) 01/03/06 3 YA17 13 (5) 20/01/06 4. YA20 13 (2) 17 20/01/06 5 6 YA32 YA36 18 (1) (a) 12 (5) 18 (2) 30/03/06 01/03/06 Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 24 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 Refer to Standard YA42 Good Practice Recommendations Food labelled and stored in the refrigerator should also be dated on the day of opening and storage. Burnham DS0000023122.V251249.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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