Inspection on 27/01/06 for Burrell Mead

This inspection was carried out on 27th 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

Burrell Mead 06/09/07

Burrell Mead 06/07/06

Burrell Mead 20/06/05

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 Burrell Mead 47 & 49 Beckenham Road West Wickham Kent BR4 0QS Lead Inspector Wendy Owen Unannounced Inspection 27th January 2006 12:00 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 Burrell Mead DS0000006939.V275284.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. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burrell Mead Address Burrell Mead 47 & 49 Beckenham Road West Wickham Kent BR4 0QS 020 8776 0455 020 8776 0858 andrewgking@btopenworld.com 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) Westwood Housing Association Limited Mrs June Parke Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 Elderly persons of either sex Date of last inspection 21st June 2005 Brief Description of the Service: Burrell mead is owned by Westwood Housing Association 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. All are single rooms, two of which are en-suite. It is set in its own grounds with attractive gardens which are accessible to service users by a ramp. Off road parking is limited. Recent changes have included enlarging the kitchen and storage area; provisions of a Manager’s office; new bathroom and two single rooms with ensuite facilities. The home is staffed by a Manager,care and ancillary staff. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one afternoon with the Manager providing assistance with the inspection process. The inspection included discussions with residents and the Manager: viewing of records and an audit of medication procedures What the service does well: What has improved since the last inspection? What they could do better: Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 6 It was positive to note that the home has implemented a quality assurance system which requires the Manager to audit procedures within the home. However, there needs to be evidence of the audit, detailing identified shortfalls together with actions for improvement. Whilst there has been an improvement in the care planning to reflect individual care needs this must be supported by the required risk assessments. These must be reviewed regularly. Medication procedures require improvement to ensure that residents are fully protected from potential risks and that their health needs are being met. There is also a need to undertake a review of the aids, adaptations and equipment required to meet the physical needs of individuals within the home. The home should also investigate how the social and leisure needs of individuals can be more fully met. 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 DS0000006939.V275284.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 Burrell Mead DS0000006939.V275284.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): 2,3 & 4 The admission and assessment procedures provide staff with adequate information to care for the individual resident’s needs. EVIDENCE: The pre admission procedure requires the home to assess prospective residents prior to admission. Two files were viewed and both contained the assessment of capabilities, an assessment used to determine whether the home is able to meet the individual’s needs. Whilst this is adequate it would benefit from more detail of how the needs are to be met. The care plan is developed from this assessment. The Manager stated that the requirement raised at the last inspection in relation to improving the contracts for residents has now been implemented. A copy has since been received by the Commission. The inspector talked to three resident who were very positive about the quality of care provided and felt that they were “well cared for” by staff who are “brilliant”. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 9 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 There has been progress in the records required to ensure the needs of residents are being met. This progress should be continued. However, certain medication practices place residents’ health and welfare, potentially at risk. EVIDENCE: Care plans are developed from the assessments undertaken by the home. The last inspection highlighted areas which need to be addressed, to ensure they accurately reflect the resident’s needs. Two care plans were viewed and found, in the one case, to be much improved with good details about the care required ensuring the individual’s needs are being met. Both contained a description of the routine for the day for each resident, which has proved to be very beneficial for staff and gives good information about the residents’ needs. The care plans would benefit from clearer information regarding the healthcare needs of the resident and more details about how personal care needs are met. For instance: how may staff provide the care? (See recommendation 1) Moving and handling risk assessments are completed for all residents to identify their needs in this area and were found to contain the information Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 10 required. The home must, however, remember to review these regularly. (See requirement 1) The home weighs each resident regularly and makes a record of these, although the resident’s weight is not recorded on arrival at the home. Nor does the home undertake any form of nutritional assessment either at the preadmission assessment or upon arrival in the home. This should be undertaken, as a matter of course, to ensure the nutritional needs of the residents are met. (See recommendation 2) The home keeps good records relating to healthcare needs and appointments kept by residents and visits made by the GP or other healthcare professional and any prescribed treatment. The daily records also provide information on how the individual’s needs are being met. An audit of the medication practices showed medication records to be completed fully including whether the resident had allergies or not or if they were not known. Photographs of each resident are also in place. Each medication is recorded into the home by hand and these were recorded in full, with the exception of short-term medication. During discussions with the Manager and a member of staff, the inspector found that some medication, including warfarin, is being re-dispensed from the original container to a nomad tray by a member of staff. This must stop immediately and medication must be administered from the original container. The records maintained also were not as clear as they should be and could lead to mistakes in administration, leading to potential risks to service users. (See requirement 2) Medication requiring storage at lower temperatures are kept in a lockable fridge and the temperature is recorded daily. One of the medications kept in the fridge required disposal with twenty-eight days of opening. This had been opened but no date of opening recorded and therefore the twenty-eight days expiry date not clear. (See requirement 2) All medication no longer required is recorded and taken to the pharmacy for disposal. It was clear from observations and discussions with residents that privacy and dignity is paramount in the provision of care. The inspector noted, in some records whether, keys to rooms are kept by the residents. Residents appeared to be well groomed and well presented with regular appointments with the hairdresser, particularly important to some residents. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 11 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 Residents are able to make basic choices on how they wish to spend their days and how they wish the home to be run. This involvement should be expanded further to ensure residents are able to control more areas of their lives within the home. EVIDENCE: The Manager explained that residents are involved in certain decisions within the home. One example of this involved discussions with residents regarding the menus, resulting in the menu being changed. This should be recorded more formally, whenever possible. (See recommendation 3) Residents are able to bring personal possessions into the home, including furniture, as long as the heath and safety of the home is not compromised. Discussions on the day also showed that residents are able to come and go as they please with the home balancing risks along with promoting independence. Details of advocacy services are available if the resident wishes to have such support. The report previously mentions the good information recorded on the daily routines for each individual enabling staff to provide care and support as the resident wishes. The last inspection required improvements, for some, in the activities offered and provided. The Manager felt that provision of more activities would not be possible with the current staffing levels and that care staff had a number of Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 12 other duties, which would be compromised. The inspector suggested that the Manager recruit a designated person to undertake activities and also investigate the use of day centres or day clubs in the West Wickham area, as a resource. This was agreed. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 13 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): 17 & 18 Residents feel that they are able to voice their concerns and that these concerns are listened to and acted upon. There are procedures in place to ensure residents feel safe and protected from harm. EVIDENCE: All residents, with the exception of the last two admitted, have been placed on the electoral register. Most residents use the postal system whilst a small number are escorted to the local polling booth. The home has developed adult protection procedures. It is positive to note that 11 of the 13 staff have NVQ 2 or above especially as adult abuse awareness is one of the core units in the achievement of this qualification. The home also requires staff to watch a video regarding adult abuse and the protection of vulnerable adults. This should be extended to domestic staff. The Manager stated that this is also discussed during induction. There have been no issues raised since the last inspection, either through the home’s procedures or through any external agency. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 14 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): 22 There is a need to ensure the home has the specialist equipment to enable residents to maintain their independence and to ensure their safety EVIDENCE: These standards were inspected at the last inspection with no requirements raised at that time. The inspector did recommend that domestic staff be provided with infection control training. This has yet to be implemented. (See recommendation 4) Discussions with one resident raised a concern regarding the lack of aids in the ground floor shower room. On viewing the shower area, the inspector found that there was no grab of hand-rail in place, although it did have a seat fitted. The Manager must undertake a full inspection of the aids and adaptations in all areas of the home to ensure residents are able to utilise areas safely. This should be completed in consultation with an Occupational Therapist. (See requirement 3) Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 15 Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 16 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 Staff are well trained and qualified to ensure residents care needs are being et to a consistently good standard. However, the staffing mix of the home, whilst adequate could be improved upon to ensure residents have greater access to social and leisure interests. EVIDENCE: The staffing levels within the home are adequate. However, the inspector has previously commented on the lack of activities (for some residents) and suggested that the home the recruit a designated activity person who would be able to focus on this aspect of care. (See recommendation 5) There continues to be a consistent and stable workforce with very little staff turnover. This provides for a continuity of care and staff understanding of individual’s care needs. The home has worked very well over the last few years to ensure the majority of staff are qualified to NVQ 2 standard. Currently only two members of care staff do not have this qualification. All senior staff and the Assistant Manager are now progressing to NVQ 3. This home is to be congratulated on its commitment to such training. The last inspection required improvements in the recruitment procedures. The recruitment record of the last person to be employed was viewed. It was found to be in order and, since the last inspection, systems have been introduced to ensure the home undertakes the checks required by the Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 17 Commission. The Manager should, as part of robust recruitment procedures, ensure that reasonable steps are taken to ensure legitimacy of the references. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 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 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 The home is being managed well with staff provided with leadership, support and guidance to ensure residents receive good care. This could be further improved by ensuring the system in place for monitoring and reviewing the quality of care has a more formal approach. EVIDENCE: Discussions with the Manager demonstrated how the changes within the home and staff roster have enabled the Manager to manage more effectively. The delegation of tasks to the Assistant Manager and administrator, have also had a positive impact. The Manager is now able to undertake more monitoring and consultation with residents. The last report identified the need for the home to implement a quality assurance system. Progress has been made with the Manager purchasing a new quality assurance system with a corresponding set of procedures. The Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 19 Manager said that she has begun the auditing required by the system but unfortunately has not made any records of these. In order for the system to be effective and to ensure there is evidence relating to such audits a more formal recording system must be implemented. This should identify what has been audit the evidence from the audit, any non-compliance and action to be taken to ensure the standard is complied with. (See requirement 4) The home maintains the personal monies of individual residents. These are kept safe with a record maintained of all transactions. Relatives or representatives regular supplement the monies to ensure there is sufficient for any spending. Whilst a record is maintained of any incoming monies and signed by a staff member, there is no corresponding signature of the individual providing the monies. The inspector suggests that the relative sign the record of allowance. The monies of two residents were audited and found to be correct. There were records of transactions, sometime signed by the resident. The home has, as required, at a previous inspection, asked that receipts be provided of all expenditure. This has now been implemented, although the inspector suggested that receipts for hairdressing and chiropody be signed by the individuals, providing the service. The home is insured to a satisfactory amount for the keeping of individual monies. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X 2 X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X x Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? no 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 OP8 Regulation 13 Requirement The Registered Person must ensure that all risk assessments are kept under regular review. Specifically, the moving and handling risk assessments must be reviewed to ensure they accurately reflect the resident’s identified need. The Registered Person must ensure that medication is not redispensed by staff within the home. Any medication having a date of expiry for its use must have a date of opening recorded to ensure the timeframe is not exceeded. The Registered Person must ensure that the home has suitable aids, equipment and adaptations to promote independence and to ensure the safety of residents and staff. The Registered Person must ensure that all auditing and monitoring of the service provided is recorded. Any review undertaken on the quality of care must be supported by a report identifying actions for DS0000006939.V275284.R01.S.doc Timescale for action 01/04/06 2 OP9 13 01/02/06 3 OP22 23 01/04/06 4 OP33 24 01/04/06 Burrell Mead Version 5.1 Page 22 improvement, if any. 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 4 5 Refer to Standard OP7 OP8 OP14 OP26 OP27 Good Practice Recommendations Care plans should be further elaborated to ensure staff have clear guidance on how the individual’s identified needs are to be met. Nutritional assessments should be undertaken to ensure any risks to residents are identified and appropriate action or interventions made. The home should record any meetings held with residents. This will show how residents are able to make choices and decisions on how they wish to live. Domestic staff should be provided with infection control training. The Manger should investigate the recruitment of an activity organiser to enable residents to follow their interests and activities. Burrell Mead DS0000006939.V275284.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000006939.V275284.R01.S.doc Version 5.1 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. 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