CARE HOMES FOR OLDER PEOPLE
Burntwood Hall Moor Lane Brierley Common Barnsley S75 9HB Lead Inspector
Steve Vessey Unannounced 21 June 2005 09:40am 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 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. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Burntwood Hall Address Moor Lane Brierley Common Barnsley S72 9HB 01226 780222 01226 713645 Not known Guardian Care Homes UK Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Angela King PC Care Home Only 42 Category(ies) of OP Old age - 42 registration, with number of places Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 3 February 2005 Brief Description of the Service: Burntwood Hall is registered as a care home to provide personal care for older people. Care is provided on a long term or short term basis. The home accommodates both male and female residents. Accommodation is provided in single and double rooms at ground floor and first floor levels, with views over the open countryside and landscaped gardens. A passengser lift serves the first floor. Guardian Care Homes (UK) Ltd are the proprietors and the administration office is based in Wolverhampton. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours from 09:40 to 16:40 The process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with, the manager, staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to seven staff, six residents and relatives in detail. What the service does well: What has improved since the last inspection?
Information given to prospective residents had been improved with the addition of contact details for the Commission for Social Care Inspection. Appropriate checks were carried out before staff were employed. An audit of the environment had taken place and a plan of refurbishment had been sent to the managers of the organisation for consideration. Residents at risk of injury due to the temperature of radiators have been identified and some action had been taken to reduce the risk to them. The manager has plans in place should the number of residents increase and additional dining space be required. Catering staff were undertaking a course in nutrition and the manager had made some progress in working towards her management qualification. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 standard(s) 1 and 3, standard 6 was not applicable at the home Prospective residents have the information they need to make an informed choice about where to live. Residents had a detailed assessment of their needs carried out prior to admission to the home. EVIDENCE: The manager stated that the telephone number of the local area office of the Commission for Social Care Inspection (CSCI) had been included in the complaints policy within the Service User Guide. Contact details for the CSCI office were displayed on the notice board and included on the copy of the complaints procedure displayed. Four care plans contained an assessment undertaken by the home before admission. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 standard(s) 7, 8, and 9 Residents had a detailed up to date care plan including the actions needed by staff to meet their needs, however these could be improved by the addition of more information detailing the arrangements for the administration of residents medication. Resident’s health care needs were met. Medication was well managed and securely stored. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Four care plans checked included detailed information as to the actions required from staff to meet the needs of the individual residents and were reviewed regularly by staff. Risk assessments were in place for, development of pressure areas, moving and handling, falls and nutrition and information was included about visiting professionals involved in resident care. One care plan identified the level of assistance needed by the resident with medication administration, however residents identified as being able to administer some of their own medication, for example inhalers, did not have a risk assessment recorded in their care plan. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved, relatives confirmed that residents were well cared for. Records were kept of medication being received into and leaving the home. There were medication administration records for residents, which were completed appropriately. Staff administering medication confirmed that they had received training on the safe administration of medication. All medication was stored appropriately and securely, maintaining the health safety and welfare of residents. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 standard(s) 12,13 and 15 Residents are given choice in many aspects of their lives and a variety of activities are provided, however some residents said that they would like the opportunity to go out more. Relatives are encouraged to visit and can visit residents in private. Residents receive a choice of food, which is of good quality and can choose where they eat. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 12 EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed and could spend time in their room when they want to, maintaining their choice and independence. There is a designated room for activities and an activities co-ordinator who provides activities for residents. Staff stated that a wide range of activities takes place. Staff were observed spending time with residents, talking to them and giving manicures. Staff stated that residents do not go out as much as they used to because the home does not have a bus now. Some residents stated that they would like to go out more. Some residents stated that they did not participate in the activities on offer but stated that they preferred to relax or spend time in their room. A hairdresser and an aromatherapist visit weekly to provide a service to residents. Relatives were observed visiting throughout the day. Residents and relatives stated that visits can take place at any reasonable time and that they are always welcomed into the home by staff, comments included “my relatives can visit me in my room”. Residents stated that they have a choice of food and that on the whole they are satisfied with the quality and quantity of food provided. Comments included “The food is good, we get plenty to eat”, “We can have a cooked breakfast” and “The stew and dumplings were nice today”. Residents confirmed that they are offered snacks and supper. Residents eat in a pleasant dining area or in their own room if they wish, maintaining their choice and independence. Lunch was served in two sittings, meals were served in an unhurried manner and staff were observed assisting residents to eat and drink in an appropriate and sensitive way, sitting and interacting with residents in the dining room, maintaining their dignity. The manager discussed the options available for additional dining space and stated that if resident numbers increased additional space would be made available for dining on the first floor. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Residents were aware how to complain and thought that their complaints would be listened to and dealt with, however some relatives stated that they were not aware of the complaints procedure. Staff were aware of the policies and procedures in place to protect residents from abuse and had received training. EVIDENCE: A copy of the complaints procedure was displayed on the notice board. Residents stated that they would tell staff if they were not happy and they thought that staff would sort it out, but also stated that they had nothing to complain about. Some relatives stated that they were not aware of the homes complaints procedure. Residents are protected by policies and procedures relating to recognising and reporting of abuse including whistleblowing, staff receiving protection of vulnerable adult training and a copy of the local authority adult protection policies and procedures being available and accessible to staff. Residents spoken to stated that they felt they felt that the home was safe. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 21, 24 and 26 The home was in need of some major refurbishment and redecoration work to improve the living environment for residents, as it is currently detracting from the character of the home and the quality of care received by residents. Some bathroom floor covering was stained. Residents were happy and comfortable in their rooms, however some rooms were in need of redecoration and new furniture. The home was in the main clean, pleasant and hygienic, however staff stated that they need another vacuum cleaner to be able to maintain this. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 15 EVIDENCE: Areas of the home checked were clean and odour free. However communal areas and some bedrooms were showing signs of needing redecoration and refurbishment, skirting boards, door frames and doors were damaged and carpets on corridors were showing signs of wear. The woodwork on the outside of the building was also in need of repainting. The surrounding gardens were very pleasant but had only recently received the basic maintenance. The manager stated that she had recently developed a plan of refurbishment, which had been forwarded to the owners for consideration; a copy of the finalised plan should be forwarded to the Commission for Social Care Inspection. The stained flooring in the laundry had not been replaced, however as it was intact, not presenting a safety hazard and not affecting residents, following discussion with the manager, it was decided that the requirement to replace the floor covering would be removed. The bathroom flooring with a similar stain will need to be replaced to improve the living environment for residents. Residents, relatives and staff spoken to stated that the home was always very clean and that they were happy and comfortable in their rooms, bedding checked was clean ensuring the comfort of residents. However staff stated that they were having some difficulty maintaining the cleanliness of the home because there was only one vacuum cleaner. A relative thought that the bedroom accommodating their relative was in need of redecoration and new bedroom furniture. Residents stated that in the main they were happy with the standard of the laundry service. Policies and procedures were in place for control of infection, and staff reported that they had sufficient provision of protective clothing. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 An assessment of the current staffing levels is needed to ensure resident’s needs are met. A robust recruitment procedure was in place, protecting residents. Staff receive induction training and opportunities for further training are good. EVIDENCE: The manager was on duty, there was also a senior care assistant, two care assistants, two domestic staff, and a cook on duty. Some staff spoken to stated that there was sufficient staff on duty to meet the needs of the residents. Some residents stated that they thought more staff were needed to meet their needs, this was confirmed by some staff, however residents stated that they were happy with the care that they receive but that they sometimes have to wait for a member of staff to assist them. Three staff files contained CRB disclosures; files for staff that had been employed recently contained appropriate recruitment information. Staff spoken to stated that they had received induction training and there were opportunities for other training; residents stated that staff are very good at their jobs. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, and 38 The manager is experienced and competent to run the home, however she needs to continue with her management qualification. Residents feel that the home is safe, however there were some gaps in health and safety procedures, training and records. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 18 EVIDENCE: The registered manager was continuing with her management qualification. Staff stated that they had received fire and moving and handling training and records indicated that staff taking charge of the building had carried out a fire drill. Records indicated that not all staff had received fire training within the last six months; the manager stated that fire training was planned. Servicing of electrical systems, portable appliances, the lift and hoists had taken place and the hot water temperature tested was around 43 degrees centigrade. The health safety and welfare of residents is not fully protected as the hot water temperatures were not monitored and recorded in all areas of the building. Radiators are not of a guaranteed low surface temperature type and do not have guards fitted. The manager stated that quotes for providing guards had been obtained and forwarded to head office. The manager stated that risk assessments had been carried out and where residents were at risk, some measures to reduce that risk had been taken. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 1 x 2 x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x x x 2 Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 7 Regulation 15 Requirement The residents care plan must include information relating to arrangments for medication administration, including a risk assessment when residents administer their own medication. Residents must be consulted about outings they wish to undertake Any carpets showing signs of wear must be replaced. (Previous timescale of 06.06.05 not met). The identified woodwork on the outside of the home must be repainted. (Previous timescale of 06.06.05 not met). The damaged skirting boards, door frames and doors must be repaired and repainted. A programme of renewal and maintenance of the premises (with timescales) must be produced and sent to the Commission for Social Care Inspection. (Previous timescale of 06.06.05 not met). The identified bathroom floor covering must be replaced. Timescale for action 21/08/05 2. 3. 12 19 16 23 21/08/05 21/09/05 4. 19 23 21/09/05 5. 6. 19 19 23 23 21/09/05 21/09/05 7. 21 23 21/09/05 Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 21 8. 24 23 9. 27 18 10. 11. 12. 38 38 38 13 13 13 13. 18 22 A ongoing plan for the decoration of bedrooms and the replacement of bedroom furniture must be produced. An assessment of the current staffing levels must be carried out to ensure adequate numbers of staff are available to meet the needs of the residents. All staff must receive fire training. A system must be implemented for the monitoring and recording of hot water temperatures. All radiators must have either guaranteed low surface temperatures, or a programme for fitting guards in order or priority (previous timescale of 11.04.05 not met). Residents relatives and representatives must be provided with a copy of the homes complaints procedure. 21/08/05 21/08/05 21/08/05 21/08/05 21/08/05 21/08/05 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 26 31 Good Practice Recommendations Sufficient equipment should be provided to enable staff to maintain the cleanliness of the home. The registered manager should ensure that she has obtained NVQ level 4 in management by 2005. Burntwood Hall J51 S58048 Burntwood Hall V230029 21.06.05 UI Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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