Inspection on 24/10/06 for Burntwood Hall

This inspection was carried out on 24th October 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burntwood Hall 19/01/09

Burntwood Hall 24/10/07

Burntwood Hall 29/11/05

Burntwood Hall 21/06/05

Burntwood Hall 03/02/05

Burntwood Hall 16/06/04

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

CARE HOMES FOR OLDER PEOPLE Burntwood Hall Moor Lane Brierley Common Barnsley South Yorkshire S72 9HB Lead Inspector Christine Rolt Key Unannounced Inspection 24th October 2006 10:00 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 Burntwood Hall DS0000058048.V304407.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 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 DS0000058048.V304407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burntwood Hall Address Moor Lane Brierley Common Barnsley South Yorkshire S72 9HB 01226 780222 01226 713645 none www.guardian-care.com Guardian Care Homes (UK) Limited 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) Miss Angela King Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Burntwood Hall is situated on the South Yorkshire/West Yorkshire border. The home is a detached property within its own grounds and is in open countryside. Village amenities are approximately five minutes drive from the home. The home is registered to provide personal care for older people on a long term or short-term basis. 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 passenger lift serves the first floor. Information supplied in the Pre-Inspection Questionnaire dated June 2006 stated that the weekly fee was from £315 to £400. Hairdressing and chiropody were not included in the weekly fee and were charged separately. There was no Service User Guide or Inspection Report on display and residents did not have copies of the Service User Guide. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. a random inspection was carried out on 1st September 2006 following an anonymous complaint relating mainly to medication and care practices. Some aspects of the allegations were not upheld but an immediate requirement was issued relating to medication procedures. The home has improved the issues. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9:20 am to 6.25 pm on 25th October 2006. The registered manager, Ms. Angela King was present and provided assistance throughout the site visit. The majority of the residents were seen throughout the day. Four residents and four relatives were asked detailed questions about their opinions of the home. Comment cards were received from four relatives and eight residents and two social workers were asked for their opinions. Three residents were tracked throughout the inspection. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, residents and relatives for their assistance and co-operation. What the service does well: The staff were praised highly for their dedication and all comments were positive. Comments were, “If you want ‘owt’ or want to talk to them, they’re there”, “All are angels”, “Staff are perfect and can have a good banter” “The workers are marvellous”, and “Good insight into residents needs”. Residents liked the meals and said that they were “Very good”, “Very nice”, “Mum loves it” and “Get variety”. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 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. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 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 Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 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): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Prospective residents did not have full information they needed to make an informed choice about the home. Residents had their needs assessed before moving into the home but were not assured that their needs would be met. The home does not provide intermediate care. EVIDENCE: The manager said that prospective residents and their relatives could visit the home at any time and they would be given a tour of the home. They would be provided with verbal information and questions would be answered. However, there was no Service User Guide or Inspection Report on display and the manager said that residents did not have copies of the Service User Guide. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 9 Residents had their needs assessed and copies of the assessments were on residents’ files. However, it was noted that the home has a high percentage of residents who are confused. The residents must be within the category of registration. The manager needs to liaise with placing local authorities and care managers to determine whether the home can meet all the needs, including emotional and social needs, and confirm this in writing to the residents. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 10 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, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ health, personal and social care needs were set out in individual care plans but daily recording did not reflect care needs. Residents’ health care needs were partially met. Medication procedures ensured that residents were protected. Residents considered that they were treated with respect but their rights to privacy were not always upheld (See also Environment). EVIDENCE: Care plans provided a good range of information including risk assessments but the daily records did not reflect this information. The records seen used the repetitive phrase ““All day cares given. Good diet and fluids taken” without reference to the care plan, therefore there was no individuality relating to care needs. Some files contained information of accidents/incidents but there was no information of how the residents had been monitored to determine if any injuries were sustained. One file contained updated information that the resident’s mobility had deteriorated but there was no Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 11 information of whether referral had been made for the resident to have their own wheelchair. The manager confirmed that referral had not been made. Care plans and risk assessments were reviewed monthly but there was no indication of consultation with the residents or their representatives. The senior carers dealt with residents’ medication. The home used a monitored dosage system and had recently changed pharmacists. Medication was checked on a sample basis and there were no discrepancies. The correct procedure was being used for the receipt and recording of medication administration. Medication that required refrigeration was stored at the correct temperature and temperatures were monitored. Residents and relatives considered that residents were treated with respect and dignity and all comments were positive about the staff and the care given and included “Lovely lasses”, “Wonderful”, “Staff are perfect”, “I wasn’t very well last week, but I was looked after well” and “100 ”. Some residents’ rights to privacy could not be assured because in one part of the home, doors were not fitted with locks and some residents did not have lockable facilities. (See section on Environment) Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ lifestyle in the home did not always match their expectations and preferences. They were encouraged to maintain contact with their family and friends and had some choice and control over their lives. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: There were no activities taking place during the site visit. Residents sat in the lounge without any stimulation. The television was on but no-one was watching it. Some residents considered that they were “too old” to take part in activities and one resident’s comment was that they “Would like to see more activities arranged”. Care plans provided information of residents’ interests but these were not implemented. The need to provide stimulation through individual and group activities was discussed with the manager. The manager said that the home was advertising for an activities co-ordinator. The PreInspection Questionnaire provided information that occasional trips were organised. However on questioning the manager, there was no means of Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 13 transport and therefore this happened rarely. Residents said that it was their families who took them out. There were no local amenities within safe walking distance of the home. Residents said that they could get up, go to bed and use their rooms when they wanted. Records on residents care plans verified the times that residents liked to get up and go to bed, but choices of how they spent their day was limited because there were no activities. Residents and visitors comments about the meals were positive - “Very good”, “Very nice”, “Get variety” and “Love it”. There were choices at all meals but the option of a cooked breakfast had to be requested. The manager was advised to offer this as a positive choice at breakfast because it was unclear as to whether all residents were aware of this option. The dining room was pleasant. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Residents and their relatives are confident that their complaints would be listened to and acted upon. Residents were not fully protected from abuse. EVIDENCE: The complaints procedure was displayed on the notice board. The Commission for Social Care Inspection received an anonymous complaint relating mainly to medication and care practices, and a random inspection was carried out in September 2006. Some aspects of the allegations were not upheld but an immediate requirement was issued relating to medication procedures. The home has improved the issues. See Section on Health and Personal Care. Staff who were interviewed during the site visit said that they would report any allegation of abuse to the manager. However, only the manager and six members of staff have undertaken any adult protection training. The need for all staff to undertake this training was discussed with the manager. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 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): 19, 20, 22, 23, 24 and 26 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service Residents did not have access to all communal areas. Residents did not have safe access to the grounds. Some specialist equipment was not accessible. Some bedrooms did not meet residents’ needs. The home was clean and hygienic. EVIDENCE: There were potholes in the drive leading up to the home and this issue was raised with the manager regarding the health and safety of residents, staff and visitors to the home. A relative of a resident also mentioned that he was concerned about the damage that the potholes could do to cars. There was no signage to inform visitors of the direction of the main entrance. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 16 On the patio outside the main lounge, old furniture including padded armchairs was stacked up. The Pre-Inspection Questionnaire stated that activities took place in the large recreational therapy room however, at the time of the site visit, the room was not fit for purpose because it was being used to store old furniture. The home’s electric hoist was also stored in this room and was not immediately accessible. During a check of the environment, it was noted that some bedrooms were well furnished and comfortable whilst others needed work to bring them up to standard. Some bedrooms had no lockable facilities and on one wing of the home, the bedroom doors were not fitted with locks therefore residents’ privacy was not assured. The manager said that the home was undergoing refurbishment. She was advised to audit the environment as part of her Quality Assurance programme. There were no offensive odours noted during the site visit and both residents and relatives considered that home was clean and hygienic Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Residents were supported and protected by the home’s recruitment practices. They were in safe hands at all times and their needs were met by the numbers and skill mix of staff, but the home needs to consider the risks associated with senior carers working continuous long hours. Staff were trained and competent to do their jobs. EVIDENCE: At the random inspection in September 2006, it was noted that the home had only two senior carers to cover the day shifts and they were working twelvehour shifts. The dangers associated with working continuous long hours and overtiredness were discussed with the manager, who said that more senior carers would be employed. This has not happened. The manager said that the two members of staff she intended to promote have since left and as an interim measure a senior carer who normally works nights was assisting to ensure that all shifts are covered. The Pre-Inspection Questionnaire stated that 56 of staff had National Vocational Qualification Level 2 or above, which is above the minimum requirement. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 18 The files for two members of staff were checked. The files contained all the relevant recruitment documentation to ensure that residents were protected. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service The home was run and managed by a person who was fit to be in charge, of good character and able to discharge her responsibilities fully. Improvements could be made to ensure that the home is run in the best interests of residents. Residents’ financial interests were safeguarded. The health, safety and welfare of residents and staff were promoted and protected. EVIDENCE: The registered manager spoke about the training she had undertaken this year to ensure her skills were kept up to date. She was also undertaking the Registered Managers Award. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 20 The Commission for Social Care Inspection received copies of reports on visits to the home by the owner’s representative (as required by Regulation 26 of the Care Home Regulations). The manager said that residents, relatives and stakeholders in the community were asked for their opinions of the home, but there was no format or system to determine the collation and outcome. Advice was given on the various methods for improving quality monitoring and assurance through checks of the environment, health and safety checks, audits of systems and records within the home, observations of practices and planned meetings with residents and their relatives. The home’s Certificate of Registration was displayed. date insurance cover. The home had up to The home had safe storage for residents’ personal allowances. A sample of these was checked. All entries were signed and the manager carried out regular audits. All monies tallied with the records. Receipts for purchases on behalf of residents were available. Staff training, including mandatory health and safety training, was ongoing, and records were available of the training undertaken by staff. The Pre-Inspection Questionnaire provided information of the dates that equipment and systems within the home had been serviced and maintained. Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 21 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X 2 2 2 X 3 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 3 X 2 X 3 X X 3 Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5, 17 Timescale for action A service user guide, that 19/12/06 includes all the required information must be provided for each resident and a copy must be available for anyone who wishes to see it. Each resident must be informed 19/12/06 in writing that all their needs have been assessed and the home is suitable to meet all of his or her needs Daily care records must be more 19/12/06 detailed to reflect the individual physical, emotional and social needs of residents. It must be demonstrated in the 19/12/06 care plan/daily records that where a resident has had a fall or an accident, the appropriate action was taken and the resident monitored to determine that no injury was sustained. Care plans must be reviewed in 19/12/06 consultation with the resident or their representative. Residents must be consulted 19/12/06 about outings they wish to DS0000058048.V304407.R01.S.doc Version 5.2 Page 23 Requirement 2 OP3 14 3 OP7 15 4 OP8 12 5 6 OP7 OP12 15 16 Burntwood Hall 7 9 OP12 OP18 16 13 10 OP19 23 11 12 13 14 OP19 23, 13 23 13 12, 16 OP20 OP22 OP23 15 16 OP24 OP33 23 24 undertake. (Requirement outstanding from 21st August 05) A programme of activities, suited to the needs of the residents, must be implemented. All staff must undertake adult protection training to ensure that they are aware of what constitutes abuse Arrangements must be made for all disused and damaged equipment and furniture to be removed. External grounds must be made safe and maintained, particularly the driveway Designated rooms must be fit for purpose, i.e. activities room Aids for moving and handling residents must be accessible at all times. Residents’ bedrooms must be provided with locks to doors and lockable facilities to ensure privacy. The ongoing refurbishment of the home, especially bedrooms, must continue. The quality assurance and monitoring programme must ensure that the home is run in the best interest of residents. 19/12/06 19/12/06 19/12/06 19/12/06 19/12/06 19/12/06 19/12/06 22/02/07 19/12/06 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 OP1 Good Practice Recommendations Copies of the Service User Guide should be issued to all prospective residents or their relatives to ensure that they can make an informed choice. DS0000058048.V304407.R01.S.doc Version 5.2 Page 24 Burntwood Hall Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Burntwood Hall DS0000058048.V304407.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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