Inspection on 19/01/06 for Burntwood Lodge

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burntwood Lodge 08/07/08

Burntwood Lodge 09/07/07

Burntwood Lodge 07/08/06

Burntwood Lodge 21/04/05

Burntwood Lodge 16/11/04

Burntwood Lodge 26/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Burntwood Lodge Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA Lead Inspector Kenneth Dunn Unannounced Inspection 19th January 2006 10:00 Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 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 Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burntwood Lodge Address Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA 01883 330525 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) Mr Abdulha Aziz Coowar Miss Wendy Louise Coowar Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Two (2) named resident may also fall into category PD(E) (Physical Disability - over 65) One (1) named resident may also fall into category MD (Mental Disorder) Two (2) named residents may also fall into category SI (Sensory Impairment) The age range of those accommodated shall be 43 - 65 years of age and 1 resident over 65 years of age 21st April 2005 Date of last inspection Brief Description of the Service: Burntwood Lodge is a registered care home, providing care and accommodation for up to six adults with learning difficulties. The home is set in a quiet residential area, with shops and other amenities a short drive away. All six rooms were occupied, one single room with ensuite facilities, one double shared room, and four single rooms. Communal rooms comprise a spacious lounge, dining room, kitchen and bath/shower room. The area to the rear of the main house has a patio area and a large garden. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an unannounced visit, which meant that staff and residents were unaware that it was due to happen. The atmosphere in the home is warm and friendly; this helps the service users to know and understand that this is their home. The Inspector was informed that service users are supported in a positive way to make choices and enjoy their chosen activities. Routines in the home are flexible and Service users make choices about how they wish to spend their time. There has been a new manager appointed to the home since the last inspection. The manager has been in post since November 2005 and has embarked on a process of audit and review of the services delivered to the residents and the policies and procedures operated within Burntwood Lodge. This process is not complete but has proved a valuable tool in highlighting areas where future development is needed. However there were still requirements outstanding from the previous inspection report. It is the responsibility of the registered provider to ensure that all requirements made in regards to this service are fully actioned and completed within the dates established within the inspection reports. What the service does well: What has improved since the last inspection? What they could do better: The provider must ensure that all requirements from this report and all previous reports are fully actioned and completed. The provider must also provide evidence that the requirements are fully completed in line with the agreed dates established within the inspection reports. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 6 The manager must ensure that she has a good working knowledge understanding of the National Minimum Standards and the Surrey Multi Agency Vulnerable Adults Procedures. 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 Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service continues to meet the core standard please refer to the previous inspection report dated 21 April 2005. EVIDENCE: Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service continues to meet the core standard please refer to the previous inspection report dated 21 April 2005. EVIDENCE: Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 There is good documentary evidence retained by the staff to indicate and to demonstrate that residents were encouraged and supported to lead as independent and fulfilling life as they were able. EVIDENCE: The manger stated that the residents are encouraged and supported to be as independent as they were able to be. On the day of this inspection the some of the service users had already left for their day care activities the remaining residents were at home engaging in their own chosen activities, jig saws, drawing and relaxing in front of the TV. On the whole the residents appeared to lead busy and interesting lives, which included attending, day care, leisure activities, shopping and home time for life skills development. A review of individual service users care plans confirmed that they each had a programme of activity. The care plans were individual and clearly designed around a specific service user, they are developed using prior knowledge of their known likes and dislikes and potential new and challenging experiences. The new home manager was in the process of completing a full review of all care plans and risk assessments to ensure that the documents are up-to-date and reflect as accurate a picture of the individual as possible. The home has its own transport for residents to enable them to go out into the surrounding community. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 11 Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service continues to meet the core standard please refer to the previous inspection report dated 21 April 2005. EVIDENCE: Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a satisfactory set of policies and procedures in place for dealing with concerns, complaints and the protection of the service users. EVIDENCE: The new manager is systematically reviewing all policies and procedures in an effort to ensure they are user friendliness. The complaints procedure is comprehensive and complies fully with the National Minimum Standards. However when reviewing the policy and in general discussions with the manager and staff it was apparent that the procedures was not accessible to the service users. The manager must develop a system to enable the service users to be able to understand and action the policy and the concept of making a complaint. In line with a requirement from the previous inspection report a complaints log has been started unfortunately it was still considered inadequate. The log must be open to everyone and to be effective it must be checked frequently to ensure that the service users live in an environment, which safeguards and protects them from abuse inside and outside the home. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 The standard of the environment within this home was generally good and meets the needs of the residents, providing an attractive and homely place to live. However there were areas where the décor was unsatisfactory. EVIDENCE: All of the resident’s bedrooms were viewed during this inspection. They contained many personal items there were various soft toys sitting around on the beds, photographs of family members and other items relating to holidays and specific interests of the residents. The rooms appeared comfortable, warm, and the overall quality of the furniture and decoration was good. The main sitting room and dining room were comfortable. The manager stated that the organisation is now looking into the possibility of continuing the refurbishment of areas within the home that fall below the standards of the rooms already redecorated. In line with a requirement made during the previous inspection the rear garden has been cleared and now offers the service users an additional and appropriate area to access and enjoy. The home was clean and no odours were present. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 34, 35 & 36 The new manager has attempted to ensure that the National Minimum Standards are met ensuring that the service users receive an appropriate level of care. EVIDENCE: The new manager stated that since she was appointed into post (4th of November 2005) and is still to be registered by the CSCI. The manager has conducted a review of all aspect of staffing within the home. The manager has established a programme of review and audit to ensure that all of the elements required by the National Minimum Standards are in place. It was apparent that there are still areas where the service is not effectively meeting the National Minimum Standards and these gaps where highlighted and discussed with the manager, specifically staff files. All staff files have been audited and the gaps highlighted are gradually being filled, at the time of this inspection the majority of staff files were complete however there were some significant omissions. There is written evidence of the request the manager has made to members of staff to produce the missing documents and the manager is updating this information daily. The manager informed the inspector that by the 31st of January 2006 all documents would be in place. The manager has started to offer supervision to staff however there is still gaps within this system. The manger must ensure that all staff receive appropriate supervision and appraisals as per the National Minimum Standards. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 The new manager is fully aware of the needs of the Service Users in the home. The manager has reinstated a system of regular staff meetings and individual supervision sessions since her appointment in November 2005. EVIDENCE: A new manager was appointed to this service in November 2005, she has conducted a full review of the homes procedures and was working towards completing some of the highlighted areas of concern. However prior to this appointment the service has failed to comply with requirements made during the previous inspection 21st April 2005. The registered provider must ensure that all requirements made in regards to this service are fully actioned and completed within the dates established within the inspection reports. Failure to comply with requirements could result in further enforcement action being taken. Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 2 2 2 2 2 X Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 18 No Are there any outstanding requirements from the last inspection? 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 YA22 & 23 Regulation 22 Schedule 4.11 Requirement Timescale for action 19/01/06 2 YA24 3 YA34 4 YA36 5 YA37-42 6 YA37-42 The manager must ensure that a full log of complaints is appropriately kept. The log must also be reviewed daily. 16 & 23 The process of redecoration must be completed throughout the home. 19 Schedule 4.6 The manager must ensure that the homes recruitment procedures meet the National Minimum Standards. 18 All staff must receive regular supervision in line with the National Minimum Standards. 9,10,12,13,17,23&25 The provider must ensure that all requirements from this report and all previous reports are fully actioned and completed. 9,10,12,13,17,23&25 The provider must provide evidence that all requirements are fully completed in line with the agreed dates DS0000013582.V276081.R01.S.doc 19/03/06 19/01/06 19/01/06 19/01/06 19/01/06 Burntwood Lodge Version 5.1 Page 19 established within the inspection reports. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burntwood Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Lodge DS0000013582.V276081.R01.S.doc Version 5.1 Page 21 - 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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