Inspection on 12/01/06 for Burnham House

This inspection was carried out on 12th January 2006.

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

Burnham House 20/04/09

Burnham House 21/10/08

Burnham House 18/02/08

Burnham House 05/11/07

Burnham House 09/04/07

Burnham House 09/06/06

Burnham House 12/05/05

Burnham House 06/01/05

Burnham House 06/09/04

Burnham House 10/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Lady Astor Court Nursing Home Burlington Avenue Slough Berkshire SL1 2LD Lead Inspector Julie Willis Unannounced Inspection 12th January 2006 09:40 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 DS0000010999.V275410.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000010999.V275410.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lady Astor Court Nursing Home Address Burlington Avenue Slough Berkshire SL1 2LD 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) 01753 517789 01753 522899 ladyastor@schealthcare.co.uk Southern Cross Healthcare Services Limited Ms Wendy Elizabeth Bristow Care Home 72 Category(ies) of Dementia (39), Dementia - over 65 years of age registration, with number (39), Old age, not falling within any other of places category (33), Physical disability (33) DS0000010999.V275410.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users in category PD not to be admitted under the age of 60 years. Service users in category DE not to be admitted under the age of 55 years. 12th May 2005 Date of last inspection Brief Description of the Service: The home is private and run by a national company, Southern Cross Health Care. The house is purpose built in the centre of a busy town. There is access to the shops and local resources. The home has a garden surrounding it, part of which is accessible by the residents on the first floor. There are three lounge and dining areas on each floor. Most of the bedrooms are single and of good size with en-suite facilities. There is one double room with en-suite facilities on each floor. DS0000010999.V275410.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.40 a.m. and 3.15 p.m. on a weekday morning and afternoon. The inspector visited all the occupied parts of the home, spoke to staff, residents and relatives and examined 3 care plans, 5 staff files, financial and health & safety records. The inspector spoke to 11 service users at length and others in small groups in various parts of the home. The inspector also spoke to 3 relatives that were visiting at the time of inspection. There were no requirements outstanding from the previous inspection and only two requirements and one recommendation were made as a result of this inspection. What the service does well: Staff appear well trained and committed and there is enough staff on duty at the home to meet the needs of residents effectively. Visitors to the home are encouraged to visit any time and offered hospitality during their visits. Relatives are kept well informed of any changes to the users health or welfare. Written records are good and provide staff with enough information to give good quality care. Medication is administered safely by well-trained and competent staff. DS0000010999.V275410.R01.S.doc Version 5.1 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. DS0000010999.V275410.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000010999.V275410.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected fully on this occasion. EVIDENCE: None of the above standards were inspected fully on this occasion. DS0000010999.V275410.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 Service users personal and healthcare needs are fully met in a manner, which maintains their dignity, privacy and independence. A new service user plan has been developed which ensures service users needs are viewed holistically and are fully met by well-informed staff. The system for the administration of medication is good with clear and comprehensive arrangements in place to ensure the safety of users. EVIDENCE: The written records were well-documented and provided staff with sufficient information to enable them to offer the appropriate level of care to users of the service. Southern Cross has recently developed and introduced a new comprehensive care plan and risk assessment tool into all of its homes to aide clarity and continuity across the country. All staff will receive the necessary training to assist in the documents effective completion. Clinical tools were being used routinely to assess the risks associated with manual handling, nutrition, skin integrity and use of restraint devices such as cot sides. Where a risk was identified there were effective risk reduction measures in place. DS0000010999.V275410.R01.S.doc Version 5.1 Page 10 The homes manager has also introduced a new way of reporting and recording any injuries that occur to users. This new form will ensure all injuries however, minor are recorded, photographed (where deemed necessary) and fully documented. Observation of care practice concluded that users, particularly those with mental frailty, were encouraged to remain as independent as possible by providing appropriate levels of support to maintain their privacy, dignity and independence. Service users confirmed that they were provided with access to health and social care professionals when required and were seen in the privacy of their own bedrooms. Routine screening and preventative treatments are offered routinely and a number of service users confirmed that they had been offered a flu vaccination by their GP and are in receipt of regular chiropody and eye tests. From examination of the medication administration system and discussion with senior nurses it is clear that the home follows best practice guidance when administering drugs. The nurses have been trained in the administration of medication and are regularly in receipt of refresher training. A monitored dosage system is in operation at the home and medication is delivered to the home on a monthly basis. The storage systems for medication are effective and disposal systems are safe. The ‘Doom box’ system has been adopted by the home for the disposal of waste medication. Two signatures are required when administering any controlled drugs and these drugs are stored separately as legislation requires. A controlled drug check carried out by the inspector and senior nurse evidenced that medication was being accounted for effectively. DS0000010999.V275410.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Service users are encouraged to maintain contact with the local community, their friends and relatives. EVIDENCE: The inspector had the opportunity to meet 3 visitors to the home during the course of the inspection. The relatives were able to confirm that the home operates an ‘open door policy’ and does not restrict visiting to certain times of the day. They said that they could meet their relative in privacy if they wanted to but several said that they often spent time in the communal areas where they could meet other residents and staff members. One relative said that she “felt like part of the team, as staff greeted her in an informal way and made her most welcome at every visit” Relatives confirmed that staff are always warm and welcoming and offer them appropriate hospitality during their visits. A number of social events are held throughout the year, which promote community involvement and which provide residents families with the opportunity to engage with the staff and users on an informal and regular basis. DS0000010999.V275410.R01.S.doc Version 5.1 Page 12 Relatives confirmed that they are kept well informed about the health and welfare of the users. They said that staff keep them regularly updated in person or by telephone should the user become unwell or if their condition changes at any time. Relatives said that “they felt involved and included” in the care provided to users. DS0000010999.V275410.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff have received training in adult protection to ensure that service users are safe from exploitation and abuse. EVIDENCE: As a result of recent incidents and complaints to the home all staff have received refresher training in the abuse of vulnerable adults. It has been mandatory training and all staff, including night workers, have attended a course on the subject. The training is well documented in staff files and staff have received certificates as proof of attendance. All newly employed staff receive training in adult protection as part of their formal induction and NVQ training in which it forms a core module. Refresher training is also offered regularly to staff by the homes management team as part of routine refresher training and team development. There are plans to include adult protection as a standing item on all future staff meeting agendas to keep staff focused on this important issue. Discussion with the staff on duty demonstrated that they were aware of the homes abuse of vulnerable adults and whistle-blowing policy. It is not clear however, if all staff were clear about their responsibilities in relation to whistleblowing prior to the most recent adult protection training session as an investigation into an incident is currently being undertaken by Management. DS0000010999.V275410.R01.S.doc Version 5.1 Page 14 The inspector had the opportunity to speak to 11 service users in various parts of the home. All confirmed that they felt safe and secure at the home and appeared confident that their needs were being met effectively. DS0000010999.V275410.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the premises standards were fully inspected on this occasion. EVIDENCE: None of the premises standards were fully inspected on this occasion. DS0000010999.V275410.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff individually and collectively were able to demonstrate that they have the necessary skills and experience to effectively meet the needs of service users in their care. Staff recruitment procedures are robust and transparent and protect service users from harm. Staffing levels are sufficient to meet the needs of users of the service. EVIDENCE: At the time of inspection there were sufficient care and nursing staff on duty in all parts of the home to meet the needs of users. The home has a full complement of permanent staff and does not currently employ agency workers to cover gaps in the staff roster. This helps to provide continuity of care through a system of lead nurses and key workers that are knowledgeable about the specific needs of individual users. Sickness and holidays are covered by staff working over time whenever possible. Examination of the recruitment files for 6 employees indicated that all necessary checks are undertaken on prospective staff to ensure the safety and protection of service users. Records were well kept and met the required standard. All staff have a Criminal Records Bureau check and POVA check before starting work at the home. DS0000010999.V275410.R01.S.doc Version 5.1 Page 17 There was evidence in the files that all new staff are provided with induction and foundation training to Sector Skills Council standard. All staff receive ongoing support and are formally supervised at least six times a year. All staff on the dementia unit have been formally supervised by the Registered Manager in January 2006 including all of the night workers. From discussion with staff and nurses it was evident that staff understood how their individual role benefits the work of the team. The staff including ancillary workers and activity co-ordinators were able to demonstrate to the inspector that they had a thorough knowledge of the key values that underpin their work with service users. Staff are offered opportunities to gain qualifications to further enhance their knowledge and skills such as National Vocational Qualifications at level 2 & 3. All staff are provided with refresher training at regular intervals, in core skills such as fire safety awareness, health & safety, first aid, manual handling and infection control to ensure service user safety. Service users and their relatives were complimentary about the qualities of the staff who they said were “friendly and caring”. DS0000010999.V275410.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 The policies and procedures regarding service user finances safeguard the interests of residents. On-going monitoring of performance against the homes stated aims and objectives is carried out by senior management. Information gathered is used to improve outcomes for service users. EVIDENCE: Southern Cross Healthcare requires its managers to undertake regular audits of all facilities and services. The inspector was shown the monthly validation audit, which assesses the homes compliance with the National Minimum Standards. Managers are also required to carry out a pressure sore audit, a monthly medication audit, a facility and catering monthly audit, accident analysis and housekeeping audit. Part of the auditing process is to gauge customer satisfaction. The Registered Manager and Deputy Manager engage DS0000010999.V275410.R01.S.doc Version 5.1 Page 19 with users of the service and visitors to the home on a daily basis and use the information gathered to improve the quality of services offered. The Activity Organisers are responsible for holding residents meetings although minutes of these meetings are not always taken. They encourage users to attend, by holding informal coffee mornings where they assist users to complete a quality assurance questionnaire. The Registered Manager also frequently works out of office hours and will complete an audit sheet to monitor care practice and quality standards early morning, late evening or during the night. It would be helpful if the home could collate the results of satisfaction surveys to produce an overview of the level of satisfaction with the service that could be shared with users, their friends and family and other interested parties such as the Local Authority and the CSCI. This would help the Organisation to measure its success against its stated aims and objectives. The inspector had the opportunity to discuss the procedure for administering resident’s cash accounts and to examine financial records held on computer in the home. The majority of users take advantage of the ‘residents cash account system’ for managing their personal finances and paying local bills such as hairdressing, chiropody and purchasing newspapers. The system operated seems relatively simple, open and transparent. A safe system is in operation for the safe deposit or withdrawal of resident’s money, records of which are held on the computer. Head office is able to audit the accounts at any time by accessing the homes accounts on line. The administrator and Registered Manager are the only people who have access to the accounts system. Receipts are kept of all cash spent. Most service users have family members that deal with their financial affairs and only small amounts of cash are deposited within the home. DS0000010999.V275410.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 x x x DS0000010999.V275410.R01.S.doc Version 5.1 Page 21 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 OP18 Regulation 13 (6) Requirement Ensure that all staff are fully aware of their responsibilities in relation to whistle-blowing and adult protection. Information gathered from quality assurance questionnaires and audits should be collated to measure the homes success in meeting its stated aims and objectives Timescale for action 12/04/06 2 OP33 24 12/04/06 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 OP12 Good Practice Recommendations Consideration should be given to recording the minutes of residents meetings. DS0000010999.V275410.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 DS0000010999.V275410.R01.S.doc Version 5.1 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!