Inspection on 16/08/06 for Burnworthy House

This inspection was carried out on 16th August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burnworthy House 14/08/07

Burnworthy House 25/01/06

Burnworthy House 04/10/05

Burnworthy House 07/01/05

Burnworthy House 26/05/04

Burnworthy House 27/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Burnworthy House South Street South Petherton Somerset TA13 5AD Lead Inspector John Hurley Key Unannounced Inspection 16th August 2006 09:30 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 Burnworthy House DS0000016077.V308383.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. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnworthy House Address South Street South Petherton Somerset TA13 5AD 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) 01460 240116 01460 241729 claire.smith@somersetcare.co.uk Somerset Care Limited Mrs Claire Smith Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Burnworthy House is operated by Somerset Care Limited, a not for profit organisation. The home provides care and support for up to 37 older people. It is situated in South Petherton, with good proximity to the shops and other amenities in this large, south Somerset village. The home comprises of 31 single bedrooms, (14 of these having en-suite facilities) and 3 double bedrooms (also with en-suite facilities). Double rooms are used as doubles exclusively for married couples or close relatives who choose to share. There are 5 communal rooms and service users also have access to the gardens at the rear of the property. Day to day management of the home is under the direction of the manager and her deputy, who was appointed in January 2006. Both have many years experience working in the care sector. The home has a number of locally based volunteers who visit the home on a regular basis. The home is fully engaged with the local community and service users are encouraged and supported to maintain links with families and friends. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over five hours. The inspector spoke with a number of service users during the visit and observed the interactions between them and the staff. The inspector also spoke with the staff both formally and informally. The management of the service assisted the inspector in carrying out the inspection by way of ensuring all information requested was available promptly and efficiently. The inspector toured the premises on an accompanied and unaccompanied basis, looking at most areas of the main building. The inspector sampled the service users documentation, some of the organisational policies and some staff records. Prior to the inspection comment cards were sent to service users, relatives and other stakeholders requesting comment on how they felt the home was performing. The 16 responses that were received all commented positively with regards to the environment, staffing and management of the home. What the service does well: People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. Service users appear to have a relaxed lifestyle supported by staff that are knowledgeable with regards to their individual needs. The home provides a range of activities for those that choose to participate. The home continues to involve service users in the home by way of service user meetings and continual feed back from the individuals and other stakeholders. The management ensure all staff are appropriately supervised and continue to be proactive with regards securing training opportunities for those who require it. The storage and records relating to medication continues to be in good order, as do the records kept relating to the individual service users. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burnworthy House DS0000016077.V308383.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 Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 People who use this service have good information about the home in order to make an informed decision about whether the service is right for them Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The manager informed the inspector that they, their deputy or senior career would visit a prospective service user prior to admission to Burnworthy. The reason for these visits are to ensure that through the assessment process the home is able to meet the personal care and social care needs each service user. Two-pre admission assessments were seen which provided information of the service users care needs. The manager informed the inspector that they will gain information from relatives and any other agencies who are currently Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 9 involved with the care of the service user as part of the an assessment process. The manager informed the inspector that the home does not intermediate care. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The home is proactive in assessing the needs of the service user, keeping these needs under review and taking action to address emerging needs. The storage and administration of medication is good. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The inspector observed staff being kind and caring towards residents. Staff spoken with demonstrated a good awareness of how to meet resident’s needs. Service users comments included ‘staff couldn’t be kinder or more friendly’ and ‘the staff are very good’. The Inspector spoke with a relative who confirmed that their relative was “well looked after”. The health care needs of the service users are monitored. By sampling the daily statements written in the care records, it was evident that any changes in health care needs were promptly addressed by contacting the GP to arrange a visit to the home. The community nursing team addresses any nursing care Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 11 needs, as the home is not registered to provide nursing care. All service users are registered with a local GP practice that visits the home on a regular basis. Appropriate pressure reliving equipment had been provided where required. Service users have their weight monitored monthly. The medication procedure was seen with a medication trolley used to support safe administration of medications. Medications were stored correctly with limited stock available. The medication administration records were up to date. An up to date medication reference manual is provided to ensure that the staff are able to reference medications. Where a service user wishes to self medicate, this is supported by a self -medication risk assessment. The inspector was able to visit with many of the service users some of which by choice spent some of their time in the privacy of the own rooms. These service users expressed how much they appreciated that the care staff fully respected their privacy and dignity and that they were not made to do anything they did not wish to, such as attending activities or having meals in the dining room. Service users confirmed that all personal care was provided in the privacy of their bedrooms or bathrooms. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Individuals continue to enjoy the relaxed lifestyle offered at this home. The menu available demonstrates that a balance diet is available to the service user. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: Residents confirmed that they could spend their time as they want to and that they are given choices. Resident’s rooms are personalised with their own possessions. Residents can access their personal records on request in accordance with the Data Protection Act 1998. Service users spoken with were satisfied with the activities provided, and advised that staff had asked them to suggest places to visit during the summer months. Activities records are maintained and audited on a monthly basis, to ensure that all service users are provided with regular opportunities to participate. Visitors are welcomed at the home. The home has a six-week menu. The day’s menu is displayed on a board in each unit and in the reception area. The service users spoken with knew what Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 13 they were having for dinner. Service users further confirmed that the food is good, home cooked and plentiful. Service user also confirmed that they are offered a choice. The dining room was pleasant. The tables were attractively laid with tablecloths. Some service users commented that they had some concerns over the new menus, as they did not recognise the names of the food being offered such as Normandy chicken. The registered manager informed the inspector that a new corporate menu had been recently introduced. Through discussion with staff and service users the inspector established that there had not been any consultation with the users of the service in the compilation of these menus, it would have been helpful if the organisation had consulted on this issue. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a complaints procedure that is available to residents and staff. Residents are protected from the risk of harm. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: The home has a complaints procedure. This is displayed on the home’s notice board. The home had received a complaint since the last inspection. The records that were viewed evidence that the matter was dealt with in accordance with the organisations stated policy. Service users confirmed that they knew who to speak to if they had any concerns. There was good evidence to say that staff support service user in raising issues in an objective manner Four staff files viewed contained POVA first checks and completed CRB disclosure checks. The home has policies relating to whistleblowing and abuse. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23,26 The home has been decorated and furnished to a good standard. There are sufficient communal areas and bathroom facilities to meet service users needs. Service users rooms are personalised to reflect their individual tastes. The main bathroom area is now showing signs of wear and will need to be refitted in the near future. The laundry area is suitable equipped but the facilities need to used in line with their stated purpose. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting an unannounced visit to this service. EVIDENCE: Service user accommodation is provided over two floors. There is a passenger lift, assisted bathroom and call system available to service users. Communal areas comprise of lounges and two dining rooms. The communal areas are domestic in nature providing comfortable seating and dining facilities. The corridors are well illuminated with a number of prints and Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 16 original art works. There are a number of seats discreetly placed in recesses of the corridors allowing individuals to rest if needed, handrails are also provided to aid independence around the home. Service users are able to bring personal possessions with them into the home. Service user rooms seen had been personalised with pictures, furniture and photographs. During the tour of the building the inspector noted that in the laundry area commode pots were being disinfected in a sink designated for hand washing clothes. The area designated for this activity was not being used. The manager accepted that this undermined the infection control policies and agreed to ensure that staff use the designated area. Although there are sufficient bathrooms to provide for the service users the main bathroom is now showing signs of wear. The inspector considers it would be helpful if the organisation made clear its intentions with regards to the refitting of this area in the near future. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staff team are well trained and knowledgeable with regards to the service users needs and aspirations. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting an unannounced visit to this service. EVIDENCE: The registered manager confirmed there is enough staff on each shift to meet the service users needs. This was also confirmed by service users who commented that staff were always available to help and were very attentive. The home does have vacancies, which for the overall smooth running in the longer term need to be filled. Newly appointed staff confirmed that they had undergone a thorough recruitment and selection process by way of a formal interview and statutory checks to establish their suitability to work in the home. All new staff receives a comprehensive induction when they start at the home, one staff member has responsibility for supporting each of them through this process. All elements of the induction process are signed by both parties to confirm the element has been completed and understood. In addition to this new staff complete the mandatory training required by the regulations. This induction process is excellent as it ensures that new staff have the skills required to start supporting people at the service. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 18 Staff receive regular supervision, and appraisals are completed on an annual basis. Staff stated that they enjoyed working at the home, and received appropriate support. Staff have undertaken mandatory training such as Fire Awareness, Moving and Handling, Food Hygiene and Infection control. Some staff has also attended various day courses. Some care staff has undertaken the NVQ Award in Care. The registered manager informed the inspector that all night care staff work at least one day shift per month. This ensures that all staff can be assessed in their working practices and allows for supervision by line management if required. The deputy manager works shifts and so also ensures the staff are working to the agreed minimum standard. Both of these approaches represent good practice as it allows for a good communication between senior staff and other shift workers. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The Registered Manager provides effective leadership to the staff team. There are appropriate systems in place to obtain the views of service users. Records relating to service users are stored securely. Health and safety records have been appropriately maintained. Quality in this outcome area is judged to be good. This judgement has been made by evaluating the available evidence and conducting a unannounced visit to this service. EVIDENCE: There was a relaxed atmosphere within the home. Staff spoke highly of the Registered Manager, and stated that they are approachable. Further development has taken place to the quality control assessments with service users meetings regularly being held, providing an opportunity for service users to express any concerns or improvements they would like to see to the service provided by the home. Service users surveys had been conducted gaining the Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 20 views and the opinions of the service users. Opportunities for other stakeholders to express their opinions are available through both formal and informal consultation. The home will keep money for service users who wish them to. Records are maintained of all transactions involving service users finances, and are supported by staff signatures and receipts. Records relating to service users are stored securely. The home displays appropriate Employers Liability Insurance. Fire safety equipment has been serviced and tested as required. Staff have been provided with regular fire safety training. Equipment servicing records have been appropriately maintained. The management needs to consider how it implements its quality audit systems to ensure that issues relating to infection control are robust and matters identified are dealt with. Hazardous substances are stored securely and are not accessible to service users. Accidents are recorded and reported as required. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 3 X 3 3 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 22 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 OP38 OP26 Regulation 13(3-6) Requirement The registered manager must ensure that all infection control measures are robustly applied and maintained. Timescale for action 16/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations The responsible individual should consider making arrangements for the refitting of the main communal bathroom. Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Burnworthy House DS0000016077.V308383.R01.S.doc Version 5.2 Page 24 - 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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