Inspection on 25/01/06 for Burnworthy House

This inspection was carried out on 25th January 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 16/08/06

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 Unannounced Inspection 25th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burnworthy House DS0000016077.V279877.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 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.V279877.R01.S.doc Version 5.1 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.V279877.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 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 worked at Burnworthy House for a many years. The majority of staff employed at the home live locally. Many of the service users have known both staff and other service users, within village life, for many years. 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.V279877.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over five hours. The inspector spoke with five service users joining two more for lunch. The inspector also spoke with staff and management of the service. The inspector toured the premises when first entering the home and looked at most areas of the main building. The inspector sampled the service users documentation, some of the organisational policies and some staff records. What the service does well: What has improved since the last inspection? What they could do better: The management must ensure that hygiene practices in and around the kitchen are observed. For example staff must were aprons when entering the kitchen. Similarly the management must ensure there are sufficient and appropriate means to collect laundry and distribute and collect commode pots. The management must ensure that all key contract documentation is signed by the most appropriate person and when necessary establish who has power of attorney to act on the service users behalf. The management further need to consider recording the individuals weight when they first enter the home, it would also be helpful if they maintained the daily records relating to what a person has eaten. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 6 Whilst the inspector considers that the new induction material is good it would be further enhanced by the inclusion of the companies vulnerable adults and whistle blowing policies. 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.V279877.R01.S.doc Version 5.1 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.V279877.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Individuals have sufficient information on the home to make decisions. The management must ensure that either the service user or their advocate as appropriate sign all significant documents. EVIDENCE: The inspector looked at the documents relating to the last two service users to take up residence within the home. One had been as an emergency, self funded placement the other was planned but at short notice, again this individual was self funded. The information available for the emergency placement was still being collected so as to build up a profile of this individual’s needs and wish’s. The basic information was available, such as contact numbers for the individual’s doctor and next of kin details along with a date of birth and some general likes, dislikes and basic health screen. The inspector spoke with the individual who informed them they were happy with the information that was being made available to them and whilst there was a degree of apprehension relating to the home they felt that they were safe and that they were being listened too. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 9 The other individuals documentation, who had a planned placement, was missing some key detail and the contract for the placement had not been signed by the service user. There appeared to be some involvement in the placement by friends of the service user and the service user’s solicitor. The home had obtained some social history relating to the individual and again was in the process of building up a profile of this service user individual needs. The initial assessment had been carried out by the home with the service user and the service user friends. This registered manager acknowledged that the service user did not sign some key documentation and agreed to attend to this. The registered manager further acknowledged that it would be helpful to establish if this service user has given any individual power of attorney to make decisions on their behalf. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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): 7,9,11 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. EVIDENCE: The inspector sampled the care plans of the last two service users to take up residency. These documents generally reflected the initial assessment of need. They further evidenced that the home was building up a profile of the individual’s requirements and assessing how best the emerging needs could be met. The inspector considers it would be helpful to ensure that the service users weight was recorded on admission and at planned intervals thereafter. The documentation available demonstrated that once all sections were completed the home would have gained a holistic persons centred view of the individual. Through reading other service user documentation it is reasonably clear that the care plan is kept under review and health care interventions are on an as and when basis as well as annual health care screening. One service user confirmed that they had received a recent appraisal of their needs and as a Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 11 result a standing frame and other aids were being made available so that they could have a greater degree of independence within the home. The inspector looked at the homes medication policy and carried out a random check of the medication kept at the home. The policy appears to be in line with good practice guidelines, the Per Required Needs (PRN) procedures are based on the individual service users circumstances and give clear instructions. In general terms the home dispenses all medication except for one individual whom has retained the responsibility to administer their own medication. Appropriate risk assessments are in place, the home provides safe storage arrangements for this individual so that they can maintain control over their own medication routine. The homes storage arrangements for all other medication are good and the random audit of medication held evidenced that the home accounts for the medication well. The recording documentation relating to the receiving, administration and returns of unused medication is similarly good. The inspector spoke with the registered manager with regards how the staff deals with bereavement of service users. The registered manager informed the inspector that the staff have training relating to this issue and in general terms ensures that those more experienced staff care for service users who have a terminal illness. The registered manager also acknowledged the impact on staff and other service users when there was an unexpected death, informing the inspector that the organisation has the services of a counsellor if needed. The inspector considers that it would be helpful if the organisation gave contact details of the counselling service in the induction material. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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): 12,14,15 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. EVIDENCE: The inspector spoke with several service users throughout the inspection. They all informed them that they enjoyed living at the home and felt safe there. One individual who had recently taken up residence told the inspector that at first they did not know what to expect as the arrangements for their stay had been made in emergency circumstances. They did however confirm that they felt safe and considered the staff and other service users had made them welcome. They went on to say that they had been made aware of the activities on offer but did not wish to join in at this particular moment in time. This individual had struck up a friendship with a service user who had been at the home for a number of years, the inspector was informed that they were now “being shown the ropes”. Both of these individuals considered it was a good home to live in. Unfortunately the main oven was out of commission on the day of the unannounced inspection but this did not appear to effect the meal time arrangements. The management confirmed that service engineers had been called to address the issue, they were in attendance just after lunch time . Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 13 As mentioned previously the inspector joined the service users for lunch. The service users informed them that the food was to their liking. The food was served with the meat on the plate, with a choice of vegetables placed on the table for individuals to help themselves. The staff ensure that those who may require assistance to serve their own vegetables had it at the point the meat was served. The meal-time was an unhurried affair and it appeared that most enjoyed this social occasion. The staff informed the inspector that service users can choose where to eat, either in their own room or one of the two dinner rooms. Service users confirmed that they had their established routines of where and when they choose to eat. The inspector noted that the dinner room was well laid out with table clothes and flowers on the table. Service users were offered either a soft or alcoholic drink with their meal and a cup of tea or coffee after the pudding. The service users confirmed that this was normal practice. The kitchens and associated storage arrangements were inspected. The kitchen area was clean and hygienic as were the storage areas and associated equipment, fridges, freezers etc. There was found to be a good balance between fresh, tinned and frozen food stuffs demonstrating that the home could deliver the planned menus. The inspector noted that a daily record was kept detailing who had had what for their meals; unfortunately this record was not always kept up to date, it would be helpful if it was. Appropriate risk assessments were in place for the kitchen area as well as associated signage for example, advice on the Control of Substances Hazardous to Health (COSHH) safe handling of food advice. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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): 16,17,18 The home has an open approach to complaints and deals with them fairly and promptly. The manager needs to record who has Power of Attorney to make significant decisions on behalf of the service user. The organisation policies and procedures are sufficiently applied to protect service users from abuse. EVIDENCE: The service maintains a complaints log that details any issues that are brought to the attention of the organisation or management. The inspector noted that in some cases staff had enabled service users to make complaints by taking their verbal comments and putting them into writing. The complaints that were noted had been dealt with in line with the corporate policy and time scales. The inspector considered that the outcomes records appeared to be fair and demonstrated an open approach to service user comments. As mentioned earlier the legal status of individuals who appear to be acting on behalf of the service users needs to be formerly established as soon as it becomes apparent that they are making significant decision on behalf of the service user. The organisation has a corporate policy with regards to vulnerable adults and whistle blowing. These documents provide part of the basis for ensuring that Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 15 the service user are protected from abuse, the comprehensive recruitment procedure and induction period forms another part of the organisations approach to protecting the individual from abuse. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 16 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): 19,20,21,22,24,26 The home is maintained in good order, management address issues in a timely fashion. EVIDENCE: At the time of the unannounced inspection the home was found to be clean and comfortable. The service users rooms are personalised to reflect their individual tastes and preferences. The service users confirmed that they are able to bring in personal effects, all of the individuals spoken to was happy with the standard of personal and communal space. The communal areas are domestic in nature providing comfortable seating and dining facilities. The corridors are well illuminated with a number of prints and 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. There is a lift between the two floors. The outside patio area has had the required maintenance and should provide an extra outside area in the summer months. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 17 The facilities available for bathing are maintained in good order with appropriate aids and adaptations to enable the safe lifting of service users if required. The day before the unannounced inspection the commercial tumble dryer was deemed to be beyond repair. There was sufficient evidence to say that a new machine had already been sourced and was awaiting delivery and commissioning later that week. The management had made arrangements to have the laundry dried at another of the organisations homes in the intervening period. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 18 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): 27,30 The staff team are well trained and knowledgeable with regards to the service users needs and aspirations. EVIDENCE: All of the staff the inspector spoke with were knowledgeable with regards to the service users needs and the part they play in ensuring these needs are met. The rotas viewed indicate that there is sufficient staff on duty to meet the service users needs. A senior member of staff confirmed to the inspector that they had recently undergone medication training. The staff records set out their training needs. These range from industry standards such as health and safety and manual handling through to more targeted training. One member of staff considered that there are good training opportunities at the home The inspector viewed the new induction material that is being introduced for new members of staff. The inspector considered that the material was both informative and relevant allowing the management to evaluate progress. The inspector considered that it would be helpful if the organisation included an introduction to its vulnerable adults and whistle blowing policy within this documentation. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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): 31,34,38 The home continues to be managed well, management and staff work with other professions to deliver a needs led service. The infection control policy could be undermined through lack of appropriate equipment and poor practice. EVIDENCE: The inspector viewed a number of key documents during the inspection ranging from care plans to staffing records; these documents were well laid out and in good order. The small amount of money held on behalf of the service users was randomly audited. The amounts tallied up, the records again being kept in good order. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 20 The staff the inspector spoke with said that the manager was approachable and fair, often working with them and the service users. The further confirmed that they have supervision on a regular basis. During the tour of the building the inspector noted that the laundry bin, which should have been placed under the laundry shute, was being used to deliver clean commode pots. On closer inspection of the laundry area the inspector found dirty laundry at the bottom of the shute on the floor. The manager accepted that this undermined the infection control policies and agreed to ensure that alternative arrangements were made with regards to the distribution of commode pots. The inspector further noted that staff entered the kitchen area during the lunch period without the appropriate aprons, again this could undermine the infection control measures in place. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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 3 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x 3 x x x 2 Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 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 OP2 Regulation 5(1)(b)(c) Sch 4.1 Requirement The registered manager must ensure that key contract documentation is signed by the most appropriate person and when necessary establish who has power of attorney to act on the service users behalf The registered manager must ensure that all infection control measures are robustly applied and maintained Timescale for action 20/02/06 2 OP38 13(3-6) 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 OP15 OP3 Refer to Standard OP18 Good Practice Recommendations The responsible individual should consider including the organisations vulnerable adults and whistle blowing policy in the staffs induction material. The registered manager should consider accurately maintaining the daily records relating to meals taken by service users The registered manager should consider recording the DS0000016077.V279877.R01.S.doc Version 5.1 Page 23 Burnworthy House weight of any new service users who takes up residency. Burnworthy House DS0000016077.V279877.R01.S.doc Version 5.1 Page 24 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. 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