Inspection on 20/06/05 for Burrell Mead

This inspection was carried out on 20th June 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burrell Mead 06/09/07

Burrell Mead 06/07/06

Burrell Mead 27/01/06

Burrell Mead 29/12/04

Burrell Mead 06/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Burrell Mead 47 & 49 Beckenham Road West Wickham Kent BR4 0QS Lead Inspector Wendy Owen Announced 20/06/05 10:00am 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 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. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burrell Mead Address 47 & 49 Beckenham Road West Wickham Kent Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8776 0455 020 8776 0585 Westwood Housing Association Ltd June Parke CRH 22 Category(ies) of OP 22 registration, with number of places Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 22 Elderly persons of either sex Date of last inspection 29th December 2004 Brief Description of the Service: Burrell Mead is owned by Westwood Housing Association (founded by West Croydon Baptist Church) and is run on a Christian ethos. The Home is located in a residential area of West Wickham, close to the town centre and public transport links. It provides 24-hour care to 22 older service users of either sex. Accommodation is provided in two buildings, one of which is a bungalow and provides accommodation for six service users, who are more active. The main house is set over two floors and provides accommodation for sixteen service users. The Home has nineteen single rooms and one double room. It is set in its own grounds with attractive gardens which are accessible to service users by a ramp. There is limited off road parking. There have been recent changes to the environment which includes enlarging the kitchen and storage area, the provision of a managers office and new bathroom and two single rooms with en-suite facilities. The home is staffed by a manager, care staff and ancillary staff. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first inspection of the year 2005-2006. The inspection took place over 5 hours and included an inspection of the recent environmental changes, viewing of some records and discussions with three residents, one visitor and the manager. Written feedback regarding the quality of the care was also received from eleven relatives. What the service does well: What has improved since the last inspection? Since the last inspection the home has reduced the number of double rooms and improved the office, kitchen space and number of bathrooms. All the work has been completed to a high standard. The home has also introduced a quality assurance system and provided training to care staff in bereavement and the care of those who are poorly. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 6 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. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 standard(s) 2,3,4 & 5 Assessments are completed prior to any residents’ admission which enables the home to make a decision on whether they are able to meet the individual’s needs. Whilst contracts have been developed they do not always provide the full information required to ensure residents or their relatives can be assured of the terms and conditions of residency. There was good evidence that the home is able to meet the residents needs to ensure their well-being. EVIDENCE: The home has an admission procedure which includes the home’s assessment and whenever possible, an assessment completed by another professional, such as the Care Manager. Part of this process includes a visit by the prospective resident where they can view the home, speak to the resident and staff and the home can undertake an assessment. This was evident from the file of the last resident when viewed. Contracts have been developed but have not been issued to two new residents. Residents or their families also need to be made aware of the contract prior to admission, not many weeks later as is the case. The contract also has a trial period of four weeks and then states reasonable notice to be given during this time. This relies on the same Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 9 interpretation of reasonable notice by both parties and may give rise to disagreement. Actual timescale would mean that this would not be interpreted differently by either party. Once residents stay in the home on a permanent basis four weeks notice is required. Fees are reviewed annually, although there is an issue where fees have been increased with little notice. Discussions with the manager showed that this is due to the different price bandings, where a resident may become more or less dependent and therefore move through the bandings. This has not been made as open and transparent as it could be and could lead to disgruntlement and disagreement and is not fair to residents. The contracts must include such information and how a review of an individual’s needs take place (including discussions with representatives.) The contract does not include an area for individuals involved to sign which is especially crucial especially where top up fees are to be paid. The home must look at reviewing and amending the contracts to ensure they are fair and reasonable. (See requirement 1) There is clear evidence that the home is able to meet the needs of the residents within their admissions criteria and statement of purpose with many positive comments about the good standard of care received and the warm and friendly approach of the staff. One relative said “I am confident and comfortable that they know her needs” and a visitor said they would have no doubt about their family member living at Burrell Mead. Whilst a resident told the inspector that staff are very “tolerant and considerate”. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 standard(s) 7,8,10 & 11 Care plans have progressed very little over the last year and still do not provide the information required to ensure staff are fully aware of the individual’s needs. This presents a potential risk to residents where an identified need may not have been recorded and no appropriate action taken by staff. However, the praise for the standard of care was high and shows that residents and relatives are happy with the care provided. EVIDENCE: Individual care plans are developed but are not as detailed as they need to be and at times contain little information on what the needs of the individuals are and what actions the home is taking to meet these needs. In the two files viewed health needs were not recorded even though the manager was aware of these needs. Although there is evidence that needs are being met the lack of appropriate information or guidance means word of mouth is relied upon. This may put residents at risk where certain needs have not been passed on or recorded. A long discussion between the manager and inspector was held to try and resolve where the problems lie. It is also clear from the feedback that, residents and relatives are rarely involved in any discussions or review of the care plans. (See requirement 2) Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 11 Since the last inspection the manager has provided training for some care staff in the care of the dying and how staff manage the death of residents, in order that staff continue to understand the needs of residents. It is clear from observations, feedback and discussions with individuals that residents and family believe privacy respect and dignity are central to the provision of care and well promoted by the home. One relative stated that their family member is “ never forced to do anything ” whilst another said that they were “treated like a family member”. Another relative spoke of the kind and considerate approach by the staff and that “birthdays are not only remembered but celebrated”. Residents looked well presented and well groomed with suitable attire for the time of year and temperature of the home. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 standard(s) 12,13, 15 Meeting the needs of residents regarding social activities and preferred routines is mixed and shows that some residents prefer more stimulation and external activity to make their stay more fulfilling. Meals are well-balanced and nutritious and offer a varied diet for residents. EVIDENCE: The feedback regarding the provision of activities was quite mixed. For some residents this could be improved upon whilst for others it is adequate. One resident said they did not want to join in the activities whilst another said “I would like to go out more”. The home should try and balance their approach to activities to be more individual based. This also includes the bathing routine which for some is regimented to one bath per week whilst they would prefer more. (See requirement 3) The food provided is good and there were choices on the menu of main courses and desserts although one resident stated only diabetics have alternatives. The menu provided by the home does show that there is a choice of desserts on offer although sometimes this may be a fruit alternative. Mealtimes are relaxed and food well- presented with tables laid in a pleasant way. It was positive to note that home-made cakes are made by the kitchen staff. Residents are not involved in planning the actual menus and this should be looked at to ensure residents are included in decision making on such Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 13 matters. Three residents spoken to thought very little of the dessert for that day which was jelly with fruit. However, they also spoke of plenty of refreshments on offer each day, especially over the last week- end where temperatures were very high with one resident quite delighted to have had icecream and ice pops provided to cool residents down. (See recommendation1) Visitors are made very welcome and continue to play an important part of a resident’s life in the home. One resident told the inspector of how their daughter visited regularly and took her out and also undertook some of the laundry tasks at her request but was also quick to point out that this was not due to any criticism of the home’s laundry process. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 standard(s) 16 The home has an open approach to complaints with complaints listened to and acted upon in an informal manner. EVIDENCE: The home has a complaints procedure detailing how complaints will be investigated. This is on display in the reception area. Discussions with resident showed that the home operates an open and informal approach to resolving issues. Individual’s feel they are able to discuss concerns and believe they are listened to and acted upon. Residents are also able to raise concerns in a more formal way, through the complaints procedure. However, those spoken to did not understand the system in any great detail. One said they would not want to “worry the manager” as she has “a lot to do”. There have been no formal complaints raised since the last inspection, although there is a more informal record of comments made both positive and negative, which the manager reviews regularly and discusses with individuals. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 standard(s) 19,20,21,23, 25 & 26 The home is well-maintained, well decorated, clean and tidy and provides a warm and welcoming environment for the residents and their visitors. EVIDENCE: There has been a great deal of change to the environment over the last six months. One of the double rooms has been made to a single with en-suite; another single with en-suite added and a new bathroom, all in the main building. This has been done to a high standard. This leaves the home with 18 single rooms, 2 with en-suite, 1 double room, 8 wcs and 3 bathrooms and 1 shower. Other work includes a larger refurbished kitchen and internal storage area and a new manager’s office which now leaves the staff room as a staff room. However, many records and the medication still remain in this area and so staff do not fully benefit from having a separate area. There was evidence that that residents were not disturbed during the completion of the work and that staff did a good job at this time in ensuring their lives were not affected. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 16 Many residents and relatives provided comments on the high standard of cleanliness in the home. Many care staff have undertaken infection control training and the inspector has recommended that this good practice be expanded to include domestic staff. (See recommendation 2) Three residents spoken to were very happy with their individual rooms and the way they were decorated with one saying that the room was “ very suitable for my needs”. Discussions with residents show that when staff are summoned they are quick to attend to the call. The rear garden looked a pleasant area which was well furnished with garden furniture and a small covering for shade. The areas of the home viewed by the inspector looked well -maintained, clean, tidy and well decorated as well as having no unpleasant odours. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Whilst the staffing levels and competency of staff provide a good standard of care the recruitment procedures are not robust enough to fully ensure residents are protected. EVIDENCE: Staffing levels appear to be appropriate with only one feedback, stating that there are occasions, at weekends, when there are less staff. Staffing is consistent, with very low staff turnover and many staff having been working in the home for a number of years. Residents and relatives spoke highly of the staff who worked in the home with one resident saying that “nothing is too much for them” and praising them for their patience and tolerance. The inspector was concerned with how the two separate sites were being staffed. However, many of the residents who reside in the bungalow spend the majority of the day in the main building. The manager needs to ensure the residents who live in the bungalow are not too dependent and have regular checks made. The manager, deputy and senior staff support care staff and ancillary staff throughout the day and night. The recruitment procedures still require improvement with the two files checked containing some, but not all of the information required under Schedule 2 of the Care Home Regulations 2001. Criminal records Bureau Checks were in place for both members of staff. (See requirement 4) It is positive to see how much training has been undertaken with 10 of the 17 care staff with NVQ 2 and all new staff completing the induction programme. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 & 38 The home is being well managed with residents’ health, safety and welfare promoted at all times. The implementation of a quality assurance system which includes the views of others is welcomed and provides residents and their relatives with a voice on how care can be improved. EVIDENCE: The manager has been in post for a number of years with experience of caring for this client group spanning a long period of time. She has, over the last year, been successful in achieving the Registered Manager’s Award to add to her previous qualifications. The last reports raised concerns that the informal approach to finding out what residents wanted and how care could be improved needed to be more formalised. It is pleasing to note that a quality assurance system is now in place and a recent review undertaken. This included consultation via relatives and provided information on a number of areas. The manager is aware that Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 19 this information must be collated to provide a report on the quality of care and what actions the home needs to take to improve. It is also positive that the outcome of the review reflected the feedback from the inspection process. The recent changes in the office space and re-organisation of records means the manager is unable to locate some of the health and safety information. The inspector agreed that the information could be provided within seven days and was duly sent. Fire records were all in order, including fire drills and moving and handling equipment has been serviced within the last six months. The home has progressed well with health and safety training with 12 of 17 staff trained in First Aid and many care staff trained moving and handling. However, kitchen and domestic staff should also receive training in infection control and moving and handling. (See recommendation 2). Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 x 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 Standard No 16 17 18 Score 3 x x 3 x 3 x x x x 3 Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 21 yes 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 2 Regulation 5 Requirement Timescale for action 01/09/05 2. 6 3. 12 4. 29 The registered person must review the contracts to ensure they are complete, accurante and provide all the information required by individuals moving into the home. The contracts must be made available to residents or their representatives prior to admission. 15 The registered person must 01/09/05 ensure care plans reflect all aspects of the individuals health and social care needs to ensure clear guidance is avaialbel for staff to provide the appropriate care. The plans must be kept under review with changes to care recorded. Care plans must be developed in consultation with residents and /or their representatives. Previous timescale has expired. 16 The registered person must 01/09/05 ensure routines and activities are provided according to individual choices and needs. 17, 18, 19 The regostered person must 01/08/05 ensure recruitment procedures are robust and ensure the required documentation is in place. Version 1.30 G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Page 22 Burrell Mead 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. Refer to Standard 15 38 & 26 Good Practice Recommendations Residents should be consulted on what is to be included on the menu. The manager should provide infection control and moving and handling taining to domestic and kitchen staff appropriate to their roles. Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent DA14 5 RH 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 Burrell Mead G51G01s6939BurrellMeadv221351.20.6.05stage4.doc Version 1.30 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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