CARE HOMES FOR OLDER PEOPLE
Burntwood Hall Moor Lane Brierley Common Barnsley South Yorkshire S72 9HB Lead Inspector
Jayne Barnett-Middleton Unannounced Inspection 29th November 2005 9:30 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.V261365.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V261365.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Burntwood Hall Address Moor Lane Brierley Common Barnsley South Yorkshire S72 9HB 01226 780222 01226 713645 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) Guardian Care Homes (UK) Limited 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.V261365.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st June 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 passenger lift serves the first floor. Guardian Care Homes (UK) Ltd are the proprietors and the administration office is based in Wolverhampton. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 am to 3.30 pm. Most of the service users were seen during the inspection. Five service users, six staff and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well:
There was a welcoming atmosphere within the home. The staff were friendly, approachable and relaxed to talk about the care that they provided. All service users spoke positively about the staff team and described them as “patient”, “very good” and “brilliant”. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. It was evident that service users who required help to wash and dress had been offered this to a good standard. Service users spoke positively about the attitude of the staff team. One commented “I have confidence in them all”. The daily routines within the home were flexible. Service users said that they could get up and go to bed as they wished and confirmed that the staff respected their choices. There was a good choice of menu provided and special dietary needs were catered for. All service users confirmed that they were happy with the choice provided and described the food as “lovely”, “very nice” and “we are always offered a choice”. Service users and their representatives were regularly surveyed to enable them to comment about the service that was provided and to give them the opportunity to suggest areas of improvement. Positive comments from recent surveys included “the staff are always polite and efficient” and “the home is always clean”. The home was clean, tidy and odour free, which promoted a comfortable and homely environment. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Care plans were in place for all service users. However they had not been reviewed on a regular basis and did not clearly evidence that the healthcare needs of service users had been monitored. Controlled drugs were not being stored appropriately and extra care was needed to ensure that all medication administered was signed for. A previous requirement to ensure that all relatives were aware of the complaints procedure had not been met. Some previous requirements in relation to the environment had not been carried out. However, the manager confirmed that all areas throughout the home were included in the refurbishment programme.
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 7 Staff files required some amendments to ensure that they included the required information. 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.V261365.R01.S.doc Version 5.0 Page 8 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.V261365.R01.S.doc Version 5.0 Page 9 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): 3 and 5. Service users were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. Service users and their relatives were given the opportunity to visit the home prior to their admission. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission. Staff from the home also visited prospective service users prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. Service users and their relatives were invited to visit the home prior to their admission, to assess the quality, facilities and suitability of the home. Several service users confirmed that they had visited the home prior to their admission. The home does not provide an intermediate care service.
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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. Care plans were in place for all service users. However they had not been reviewed on a regular basis and did not clearly evidence that the healthcare needs of service users had been monitored. Controlled drugs were not being stored appropriately and extra care was needed to ensure that all medication administered was signed for. Service users were cared for in a manner that respected their dignity and privacy. EVIDENCE: Three care plans were checked. One care plan was only partially completed. The needs of the service user had been identified; however there was no specific detail to ensure that the care needs of the service users could be met. Nutritional screening was undertaken for service users on admission. Weight monitoring records were in place. However, records demonstrated that the
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 11 service users had not been weighed on a regular basis to ensure that any potential health problems could be identified and subsequently monitored. Risk assessments had been completed. They clearly identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live as independently as possible. The moving and handling risk assessment in one care plan checked did not clearly identify the equipment and techniques required to safely care for the service user. One service users plan of care and risk assessments had not been reviewed on a monthly basis to reflect their changing healthcare needs. Service users said that their healthcare needs were met One service user described the help that she needed with regards to a health problem and commented “The staff always make sure that I am ok”. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. Two medication administration records checked did not clearly record the amount of stock that had been received, and it was difficult to track the specific medication and amount that had been received. Medication had been administered to one service user. A record (signature) to confirm the administration had not been made. Controlled drugs were not being stored in a metal cupboard to comply with the Misuse of Drugs Act. All staff responsible for administering medication had received accredited training. Throughout the day staff were observed to treat service users with dignity and respect. It was evident that service users who required help to wash and dress had been assisted with this and all service users were clean and appropriately dressed. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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. Routines with the home were flexible and service users were encouraged to spend their day as they wished. A programme of activities was in place that was appropriate for the needs of service users. Service users were able to receive visitors at any reasonable time. A good choice of menu was offered and specific dietary needs were catered for. EVIDENCE: There was a relaxed atmosphere within the home. Service users were observed to be following their preferred routines. Several service users were sitting in the lounges socialising with other service users whilst others had chosen to spend time in the privacy of their bedroom. There was a designated room for activities and a wide range of activities took place. Throughout the day staff were observed to be spending time talking to service users and giving manicures.
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 13 The daily routines within the home were flexible. Service users said that they could spend the day as they wished and confirmed that the staff respected their choices. Service users were encouraged to maintain links with their family and friends. Service users confirmed that their relatives were welcome to visit them at anytime. There was a good choice of menu provided and special dietary needs were catered for. The cook had recently been employed at the home. She confirmed that she had settled into her new job very well and that the staff had ensured that she was aware of service users dietary requirements. All service users confirmed that they were happy with the choice provided and described the food as “lovely”, “very nice” and “we are always offered a choice”. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. A previous requirement to ensure that all relatives were aware of the complaints procedure had not been met. However the manager confirmed that she was in the process of ensuring that this information was circulated to all relatives. Service users stated that they were satisfied with the care provided and they had no complaints. Service users felt that they could voice any concerns that they may have and described the manager and staff as “always approachable, polite and friendly”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. All staff had received Adult Protection training to enable them to identify and report any allegations or incidents of abuse to service users. Service users spoke positively about the attitude of the staff team. One commented “I have confidence in them all”.
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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, 23, 24, 25 and 26. A refurbishment/redecoration programme has commenced at the home. Areas completed had been refurbished to a very good standard. The home was clean, comfortable and generally well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: A refurbishment programme had recently commenced at the home. The dining room had been redecorated and new furniture provided. The upstairs corridor had been redecorated and a new carpet provided. New armchairs of a good quality had been provided for the lounge and activity room and ten bedrooms had been refurbished. All areas had been completed to a very good standard and presented a bright and welcoming environment. Some previous requirements in relation to the environment had not been carried out. However, the manager confirmed that all areas throughout the
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 16 home were included in the refurbishment programme. The manager, staff and service users were positive about the improvements that had been achieved. One service user commented that the new bedrooms were “lovely” and that they had been given the option to move to one of the recently decorated bedrooms if they wished. Several bedrooms were checked and all were clean and tidy. Service users confirmed that on their admission they had been encouraged to personalize their rooms with small items of furniture and mementoes. The home was clean, tidy and odour free, which promoted a comfortable and homely environment. The grounds were well maintained and seating was provided. Service users said that they enjoyed sitting outside when the weather was warm. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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. Sufficient and experienced staff was provided that met the assessed needs of service users. A training and development programme was in place. Staff received regular training to update their knowledge and competence. Staff files required some amendments to ensure that they included the required information. EVIDENCE: Staff rotas checked, demonstrated that the agreed staffing levels were being met to meet the individual needs of service users. The manager said that since the last inspection the majority of staff vacancies had been recruited to, and that this had improved the staffing levels. The Staff were friendly, approachable and relaxed to talk about the care that they provided. All service users spoke positively about the staff team and described them as “patient”, “very good” and “brilliant. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Discussions with staff and records checked demonstrated that staff had received a good range of training that included Moving and Handling, First Aid and health and safety.
Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 18 One staff that had recently commenced employment at the home confirmed that they had received the appropriate induction training to enable them to safely care for service users. Six members of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of residents. The manager confirmed that the remaining staff was in the process of working towards an NVQ qualification. A recruitment policy and procedure was in place. Two files checked contained a range of information including two references, declaration of health and qualifications/training. The files did not contain a full employment history or a recent photograph of the employee. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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, 32, 33, 35 and 38. Service users and staff benefited from the ethos, leadership and management approach. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager had experience within the caring profession that enabled her to contribute to the care of service users and communicate a clear sense of leadership to staff. She was in the process of undertaking a NVQ level four qualification. All staff and service users said that the manager was “approachable” and were confident in her abilities to manage the home. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 20 Staff meetings were held on a frequent basis to enable them to contribute to the development of the service. Staff said that the meetings were “useful” and commented that any general issues would always be resolved. Service users and their representatives were regularly surveyed to enable them to comment about the service that was provided and to give them the opportunity to suggest areas of improvement. Positive comments from recent surveys included “the staff are always polite and efficient” and “The home is always clean”. Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. A recommendation for two staff to check finances on a regular basis was made, to promote the protection of service users. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 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 2 Standard OP7 OP7 Regulation 12,15 12 Requirement Care plans must include specific details of the service users care needs. Care staff in consultation with the service user (where practical) must review service users care plans at least once per month. Service users must be weighed on a regular basis. Records of weight loss/gain must be maintained and appropriate action must be taken. Moving and handling assessments must clearly demonstrate the action required by staff to safely care for the service user. Risk assessments must be reviewed on a regular basis. Records of medication administered to service users must be maintained. Records of medication in stock at the home must be maintained. Controlled drugs must be stored in compliance with the Misuse of Drugs (safe Custody) Regulations 1973.
DS0000058048.V261365.R01.S.doc Timescale for action 31/01/06 31/01/06 3 OP8 12,13 01/01/06 4 OP8 13,15 01/01/06 5 6 7 8 OP8 OP9 OP9 OP8 13,15 13 13 13 01/01/06 01/01/06 01/01/06 01/01/06 Burntwood Hall Version 5.0 Page 23 9 OP19 23 10 OP19 23 11 12 OP19 OP19 23 23 13 14 OP29 OP29 19 19 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). Staff files must include proof of the person’s identity, including a recent photograph. Staff files must include the full employment history of the employee and any gaps in employment must be accounted for. 01/03/06 01/03/06 01/03/06 31/01/06 01/02/06 01/02/06 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. 2. 3. Refer to Standard OP9 OP31 OP35 Good Practice Recommendations A record of temazepam administered should be maintained in the controlled drugs register and witnessed by another member of staff. The registered manager should obtain a NVQ level 4 in management. Two staff should check service users finances on a monthly basis. Burntwood Hall DS0000058048.V261365.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office 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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