Inspection on 24/10/07 for Burntwood Hall

This inspection was carried out on 24th October 2007.

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 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 24/10/06

Burntwood Hall 29/11/05

Burntwood Hall 21/06/05

Burntwood Hall 03/02/05

Burntwood Hall 16/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 2007 09:35 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.V349713.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.V349713.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 None 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 Dementia (42), Old age, not falling within any registration, with number other category (42) of places Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 42 2. Date of last inspection 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. Since the last inspection, a unit to cater for the needs of 15 people with dementia had been opened on the first floor. A passenger lift serves the first floor. Accommodation is provided in single and double rooms at ground floor and first floor levels, with views over the open countryside and landscaped gardens. The fees ranged from £341.50 for residential care to £381.00 for dementia care for people placed by local authorities. Self-funding fees were from £380.00 for residential care to £400.00 for dementia care. Items not covered by the fees include toiletries, hairdressing, chiropody, aromatherapy, private taxis, dry cleaning and newspapers. The manager supplied this information during the site visit on 24th October 2007. The Service User Guide, Statement of Purpose and last Inspection Report were on display. People living at the home had been issued with copies of the Service User Guide. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.35 am to 4.50 pm on 24th October 2007. The manager completed an Annual Quality Assurance Assessment before the site visit. This document gave the manager the opportunity to say what she thought they did well, what needed to improve and how they planned to do this. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the manager. The majority of people living at the home were seen throughout the day and chatted to. The care provided for three people was checked against their records to determine if their individual needs were being met. Questionnaires were sent to six relatives and five health/social care professionals. Completed questionnaires were received from five relatives, and five health/social care professionals. The inspector wishes to thank the manager who came in at lunchtime on her day off, members of staff, people living at the home, relatives and health and social care professionals for their assistance and co-operation. What the service does well: What has improved since the last inspection? Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 6 Since the last inspection, a unit for people with dementia had opened. Comments about this new service were positive. “The new dementia unit will be of extreme value to the service users in the local area,” and “The dementia unit which has just opened looks promising as a valuable resource to residents and the local area.” Staff considered that staffing levels had improved and that they now had more time to meet people’s needs. Activities were now being provided but there were still no outings into the community. Daily records had shown some improvement with information of people’s well being. This could be improved further. See section below. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burntwood Hall DS0000058048.V349713.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.V349713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessments were carried out to ensure that the home could meet people’s needs. People did not have the full information needed to make an informed choice. This home does not provide intermediate care. EVIDENCE: A copy of the statement of purpose, the service user guide and the last inspection report were displayed on the notice board. The manager said that all people living at the home had been given copies of the Service User Guide. The home had undergone alteration to the upper floor to provide a unit for people with dementia. The statement of purpose and the service user guide made reference to people with dementia but did not contain information of this unit or the facilities provided. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 9 People considered that they always or usually had sufficient information about the home. However, their comments belied this. “A complete fact sheet could be given out when a person enters the home e.g. I received a letter showing us to be in debt as I didn’t know that we had to leave a ‘float’ for incidental also took a month to find out how to pay the standing order. (My parents are self-funding) A fact sheet would answer all these questions.” Another person commented “Not your concern but annoying when told the fees are at local authority rates and then increased by 37 in two years. Can’t move elderly people elsewhere once they are settled so there’s nothing you can do about it. Could outline ongoing fee policy rather than do what they like once they have you”. These comments signified that there was not sufficient information in the statement of purpose and the service user guide. The service user guide did not include a copy of the terms and conditions, details of total fees payable and arrangements for paying additional services. The need for this information to be included in these documents was discussed with the manager. People living at the home were assessed prior to admission to the home and copies of the assessments were seen on their files. They contained a good range of information of their individual needs and wishes. One person commented, “Before placements are agreed, Burntwood Hall always insist on gathering accurate information regarding the service user’s needs” Burntwood Hall DS0000058048.V349713.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were treated with respect, but their personal care needs were not reflected in their care plans. Health needs were generally met but could be improved. Medication procedures were generally sufficient to ensure that people were protected. On receipt of verbal feedback regarding this inspection, the regional manager immediately put in place an improvement plan and a performance management plan. These have been taken into account when making this judgement. However, areas of care in this evidence require rapid and sustained improvement. EVIDENCE: People living in the home looked clean and well dressed but there were comments about people’s needs not being met. One person said, “Because Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 11 (parent) doesn’t want to be seen as ‘demanding’…doesn’t make …needs known. (Parent) only had one bath in the first three weeks. told me and I requested that (parent) be bathed” and another person said, “There is, at times, a lack of understanding concerning the use of (parent’s) hearing aid. (Parent) is 96 years of age and totally deaf without it. There has been occasion when I have had to change the battery because the staff have failed to recognise the problem.” The files for three people who live at the home were checked. To assist the staff, the company had produced pre-printed care needs sheets. These provided the basis for care planning. Each care need sheet was broad based with a list of items that might or might not be relevant to the particular person. The intention was that staff chose the ones that were considered relevant to the person and also added, in the space provided, any other specific care or additional information. If completed correctly, the care needs sheets produced a person centred care plan. However, in practice this was not happening. Information supplied in the assessments was not always transferred to these sheets, which left gaps in the care plan e.g. sensory needs. On one of the files, there was duplication of one of the needs (Nos. 1 and 8 of identified needs), but with different handwritten notes added. The care plan index listed the care needs sheets that were included but on two of the three files, some of these sheets were missing. This was brought to the attention of the manager who was able to explain why some were missing from one file but not the other. Files also contained a range of assessments for dependency, moving and handling pressure sore, nutrition, falls, continence, bed rails and issuing of keys. On one file, the pressure sore assessment numerical score had risen and put the person in the high-risk category but there were no instructions of what actions or effect this had on the person’s care needs. There was no review or alteration to the care plan. The manager said that she was aware of the Malnutrition Universal Screening Tool (MUST) but had not yet implemented this. The ‘issuing of key’ assessment, would if written/typed properly, have provided a good guide but there were errors which gave conflicting instruction. None of the three people was weighed monthly as the records indicated they should be. One had been weighed only twice (January and February 2007) and another only four times this year. The assessments for these three people stated that they wished to have a bath once or twice per week. The bath charts in the files indicated that people were not receiving regular baths. The manager said that a bath book was Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 12 also used for recording baths and this information had probably not been transferred onto people’s files. In fact there were two bath books and the information and dates from these together with the information and dates from the bath charts verified that people were not having two baths per week as they preferred. In some instances they had not had baths for over a month. Records of people’s belongings, where available on file, were out of date and did not provide sufficient information to identify the items. On the leisure assessment for one resident, the member of staff had written “No hobbies due to visual impairment”. This brought into question the staff member’s awareness when dealing with people with sensory disabilities. Daily records had improved and provided information of emotional well-being and issues of note, but could be improved further. Specifying the physical care needs that had been met instead of using the all-encompassing phrases “All day cares maintained” and “All day cares given” would highlight any gaps in care provision i.e. bathing, weighing and specific sensory care needs. It was also recommended that information of involvement in social activities, social interactions and personal pursuits also be recorded. During discussions with carers, it came to light that senior staff wrote the daily care records and that carers did not use the care plans to determine people’s care needs. It is recommended that carers use the care plans as working documents and record the care they have provided for each person. There were no accident forms on people’s files. The manager said that these were removed from the accident book but then placed together again in another file. Placing accident forms on people’s individual files would inform staff of the accident and also show the frequency of falls. The home used 72 hour monitoring sheets to monitor people who’d had accidents or falls, but they were not used consistently. There was a 72-hour monitoring sheet on only one of the files seen and this had been used for only one day. To ensure the speedy identification of injuries not apparent at the time of an accident, these documents need to be used consistently and for the full 72-hours. This was discussed with the manager. This was a previous requirement. Care plans were not consistently reviewed at least once per month. They were not consistently reviewed following accidents or following changes to dependency scores e.g. pressure sore assessment. Therefore they were not amended accordingly if the person’s needs changed. Neither was there any information to suggest that the person or their representative was consulted or notified about reviews. This was a previous requirement. Medication was stored safely. Medication that required refrigeration was stored in a temperature controlled medication refrigerator. The temperature was monitored and written records were kept. The Controlled Drugs Register Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 13 was checked and this showed that the correct procedure was being followed with two signatures and a reducing total. Staff who dealt with medication had received medication training. A member of staff was observed administering medication and the correct procedure was being followed. One medication required the person to have their pulse rate checked to determine whether the medication should be given. The member of staff was asked about the availability of written instructions of when the medication should not be given. There were no written instructions and information was passed on verbally. The manager was informed that written instructions must be provided. Following the site visit, further advice was sought from the CSCI Pharmacist who said that this medication would normally be administered by a registered health care professional e.g. district nurse, therefore would not be included in the medication training. This procedure could be delegated to staff but training would have to be given, and the trainer, i.e. district nurse would need to ensure staff competency in administration of the medication and use of the pulse rate monitor. The trainer would also need to provide written instructions and monitor the situation. The day after the site visit, this information was discussed with the manager who said that she would deal with it immediately. People were treated with dignity and respect. It was noted that they answered people’s questions and gave them information in a kind and calm manner. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Meals were good quality with variety and choice. Personal choices and control were not fully promoted. The lifestyle within the home generally matched people’s expectations and preferences but could be improved. EVIDENCE: The manager said that an activities co-ordinator was employed during the week but because of personal problems was not working set hours at the time of this site visit. The home had also recently employed a weekend activity coordinator. The activity co-ordinators worked on both floors. An aromatherapist and a hairdresser also attended weekly and their fees were displayed on the notice board. The manager was asked about activities in the community but admitted that these did not happen. This was a previous requirement. In the lounge on the dementia unit there was a selection of books relating to the past, some with photographs. Staff were in the process of taking people Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 15 through to the dining room for tea but one person was very interested in one book and spoke about the people in the photographs. On the ground floor staff had organised a quiz and games of dominoes. No visitors were seen during the site visit. The service user guide stated that visitors were welcome to visit at any time. Relatives, in the main, considered that people were always or usually supported to make choices. However, one comment was “Has a keyboard he would like to play but legs prevent him moving about. One member of staff has helped in time past but generally don’t seem to care.” This problem would be overcome if care plans were formulated correctly and daily records identified the needs that were met including people’s social needs. (See previous section). Breakfast and lunch were seen. At breakfast some people had chosen cereal, others were enjoying a full cooked breakfast and others were eating toasted teacakes. At lunch there was a choice of liver and bacon or chicken casserole. The carer said that if people didn’t want either of these then they could have whatever they wanted. Dessert was a hot pudding, yoghurt or ice cream. Menus were displayed but were not conspicuous. It was recommended that these be enlarged, particular the one on the dementia unit. Special diets were catered for. The dining room door on the dementia unit was colourful and identified the room as the dining room. However, the dining room itself was bland. The manager said that this was still in the process of being finished and colourful pictures and information would be provided throughout the unit. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service were not protected from abuse. They and their relatives and friends were not always confident that their complaints would be dealt with appropriately. EVIDENCE: The home’s complaints procedure was displayed. Complaints were recorded. Relatives considered that the home always or usually responded appropriately to complaints. One comment was “The incident was investigated thoroughly when I raised my concern. I was told that appropriate staff training was ongoing”. There was one outstanding complaint. The complainant was not happy with the manager’s response and the CSCI had referred the complaint to the company who was dealing with it. Since the last inspection, the home had been involved in an adult protection case. A relative felt that the home was not to blame and commented, “…….Hospital staff recently made ill founded and ill considered accusations about my mother’s care which caused her untold stress and the care home much distress. I would like to see my views on that situation reflected in any reports on the matter. In my opinion Burntwood Hall was absolutely blameless”. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 17 The adult protection issue related to the delay in seeking medical attention. Adult protection multi-disciplinary team meetings were held and recommendations were made. One of the concerns raised by the hospital staff and the social services was that this person was sent to hospital without an escort. The home was responsible for this person, said that it could meet their needs and had a duty of care. This was not the first time that this had occurred and following the last incident, the manager had been told to provide a contingency plan. This had not been done. When a person is ill, in pain, distressed and probably confused, comfort and reassurance from a person they recognise and trust is particularly important. Only six of the 28 staff including 19 carers had undertaken adult protection training. This was a previous requirement. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was well maintained and safe but was not pleasant and hygienic. EVIDENCE: Since the last inspection, the driveway had been repaired. However, there was still no signage to direct visitors to the main entrance. The landscaped gardens were neat and tidy. The entrance hall was hot, stuffy and airless. There was the odour of stale urine in the downstairs lounge and a strong odour of stale urine on one of the upstairs corridor. There was also an unidentified odour in one of the unoccupied bedrooms. It transpired that there were no cleaners working that day. It was noted that staff were attempting to keep the home tidy. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 19 Since the last inspection, alterations had been made to the upper floor to accommodate the dementia unit. The manager said that all bedrooms now had lockable doors. New furniture had been purchased. No hazards were noted and mobility aids were available. There were some aids to orientation on the dementia unit e.g. directions to bedrooms and a very colourful dining room door but the lounge and the dining room on this unit were bland and would benefit from pictures and means of orientation and stimulation for people with dementia. The manager said that it was intended to supply these and was already being discussed. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were supported and protected by the homes recruitment procedures. The staff levels of care staff met their needs but ancillary staffing did not. Specific training would enhance care staff’s skills and competence. EVIDENCE: Opinions were that care staff provided the support and care that people needed but one person commented, “I have some concerns regarding staffing levels”. On the day of this site visit, there were sufficient numbers of care staff on duty. The manager said that since the opening of the dementia unit and changes to the staffing levels the home was much calmer. Staff confirmed this and said that they now had more time to deal with people’s needs. There were no cleaning staff on duty during this site visit. One person considered that “The manager and staff have a reputation of being very caring people. They all appear to have good insight into the needs of older people. The manager in particular is very experienced in working with Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 21 older people and her compassion and support is evident.” However, not all staff had undertaken dementia training and the training given was limited to less than half a day. To enable greater insight and empathy for people with dementia, staff need to undertake more in depth training in dementia. A comment from a relative reinforced this need for training. They said, “On the day that (parent) moved there…became agitated and hit a carer…has never done this before or since. As an Alzheimer’s sufferer I wonder whether lack of skill or experience may have made the situation worse rather than calming (parent) down. No one has ever known (parent) raise a hand to anyone…” Some people had a visual or hearing impairment but staff had not received any sensory awareness training. The need for this training was reinforced by a statement in a care plan that the person had “No hobbies due to visual impairment”, which showed the staff member’s lack of awareness and a relative’s comment that, “There is, at times, a lack of understanding concerning the use of my (parent’s) hearing aid.” The manager said that 61 of staff had attained National Vocational Qualification (NVQ) Level 2 or above in care and the remaining staff were enrolled for this qualification. The recruitment files for four members of staff were checked. the relevant checks and information. All contained Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s financial interests were safeguarded. Their health, safety and welfare were not fully promoted and the home was not fully run and managed in the best interests of people living at the home. On receipt of verbal feedback regarding this inspection, the regional manager immediately put in place an improvement plan and a performance management plan. These have been taken into account when making this judgement. However, areas of evidence require rapid and sustained improvement. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager had worked at this home for several years. She had the relevant qualifications and experience and ensured that she was up to date with current practices. However, her office was in a quiet part of the home, which meant that she was not a visible presence in the home and did not see the daily routines. On the day of this site visit, staff did not know her whereabouts and a member of staff had to go and check that she was not in her office. It is recommended that she be a more visible presence to enable her to oversee the day to day running of the home and be more accessible to people living in the home, staff and visitors. The home’s quality assurance monitoring file contained completed questionnaires. The information had not been collated to determine satisfaction ratings and highlight any action that needed to be taken. The same situation was seen at the previous inspection and advice had been given on the collation of this information and various checks that could be carried out to improve the quality assurance system. There was no other information on the quality assurance file to demonstrate any improvement. This was a previous requirement. The area manager carried out monthly visits and produced written reports, copies of which were sent to the CSCI. Secure storage was provided for money held on behalf of people living at the home. The administrator dealt with this and the area manager carried out audits of these personal allowances during her visits to the home. A sample of these allowances was checked and the cash tallied with the records. Advice was given on numbering receipts and providing a column in the records for cross-referencing receipts to items bought on people’s behalf. A relative commented, “I received a letter showing us to be in debt as I didn’t know that we had to leave a ‘float’ for incidentals. My mother had cash but the hairdresser wouldn’t take it”. The manager was advised to include clear information about people’s personal allowances and facilities available in the statement of purpose and service user guide. (See Choice Section) Equipment and systems were serviced and maintained within the regulated timescales and certificates and records were available as verification. Fire safety checks and fire awareness training were carried out and records were seen. Mandatory health and safety training was not being provided for all care staff. The training graphs showed that very few staff had received any training in food hygiene, infection control, first aid or emergency aid and adult protection, therefore people were not being protected. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 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 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 25 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 Requirement Timescale for action 20/12/07 2 3 OP7 OP7 12 12 4 OP7 15 The service user guide must include: • terms and conditions • details of fees and how these are to be paid • additional services and how these are to be paid. Care plans must include all 20/12/07 needs and preferences as identified in the assessments. 22/11/07 Daily recordings must provide: • More specific information of the physical care needs that have been met to ensure that no needs are missed e.g. bathing and weighing. • Information of how people’s social needs were met. This information will provide a more person centre approach Care plans must be reviewed and 22/11/07 amended as necessary: • after any incident or accident that affects the person’s wellbeing • if a person’s needs have DS0000058048.V349713.R01.S.doc Version 5.2 Burntwood Hall Page 26 changed e.g. risk assessment scores • at least once per month. to ensure that people’s needs are being met consistently. Care plans must be reviewed in consultation with the resident or their representative. (Previous timescale of 19th Dec 06 not met) It must be demonstrated in the 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. (Previous timescale of 19th Dec 06 not met) Staff who deal with medication must receive training in the administration of Digoxin and use of the pulse monitor. Training must be checked to ensure competency and written instructions must be available. (Previous timescales of 21st August 05 and 19th Dec 06 not met) Make proper provision for people’s health and welfare by ensuring they are protected and cared for at all times both inside and outside the home i.e. escorting to hospital. All staff must undertake adult protection training to ensure that they are aware of what constitutes abuse. (Previous timescale of 19th Dec 06 not met) The home must be kept free from offensive odours Sufficient domestic staff must be available to ensure that the home is kept clean and free from DS0000058048.V349713.R01.S.doc 5 OP8 12 22/11/07 6 OP9 13 31/10/07 7 OP12 16 20/12/07 8 OP18 12 22/11/07 9 OP18 13 20/12/07 10 11 OP26 OP27 16 18 31/10/07 31/10/07 Burntwood Hall Version 5.2 Page 27 12 OP30 12 13 OP33 24 14 OP38 13 offensive odours. Staff need training to have a 17/01/08 greater understanding of people with: • Dementia • Sensory disabilities to ensure that the individual needs of people living at the home can be met. 20/12/07 The quality assurance and monitoring programme must ensure that the home is run in the best interest of residents. (Previous timescale of 19th Dec 06 not met) All staff must undertake 17/01/08 mandatory health and safety training including food hygiene, infection control and emergency or first aid to ensure they have the relevant skills and knowledge and that people are protected from harm. 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 3 4 5 Refer to Standard OP1 OP1 OP7 OP7 OP7 Good Practice Recommendations The statement of purpose should contain information of the facilities and services provided for people with dementia. Include information in the service user guide of the facilities available for looking after people’s personal monies. Involving carers in people’s care plans, including writing care needs that they have met would raise awareness and highlight any gaps in care provision. Amend the ‘issuing of key’ assessment to provide clear information The inclusion of instructions on risk assessments would DS0000058048.V349713.R01.S.doc Version 5.2 Page 28 Burntwood Hall 6 OP7 7 8 9 10 11 12 13 14 OP8 OP8 OP12 OP15 OP19 OP19 OP31 OP35 trigger the actions that staff needed to take if the numerical scores showed deterioration in health. This would ensure that the risk assessments were used effectively and that people’s needs were met promptly. An up to date inventory of each person’s personal furniture, equipment and other belongings should be recorded on their personal file. The inventory should provide sufficient information to enable identification of the items. The provision and implementation of the Malnutrition Universal Screening Tool (MUST) would highlight people at risk. Placing accident forms on people’s individual files would ensure that staff were aware of people’s accidents and also provide a quick reference of the frequency of falls. Residents should be consulted about outings they wish to undertake. Provide more conspicuous menu boards in larger print Provide pictures and visual stimulation and means of orientation to time and place to assist people with dementia Provide signage to direct visitors to the main entrance The manager’s presence should be more visible to enable her to oversee the day-to-day running of the home. As a sign of good practice, the numbering of receipts and provision of a column for receipt numbers in the records, would enable cross referencing of items bought on people’s behalf. Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burntwood Hall DS0000058048.V349713.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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