Inspection on 06/07/06 for Burrell Mead

This inspection was carried out on 6th July 2006.

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

The inspector found 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 27/01/06

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 Key Unannounced Inspection 6th July 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 Burrell Mead DS0000006939.V296164.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. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 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.V296164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 Elderly persons of either sex Date of last inspection 27th January 2006 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 21 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 twenty- one single rooms, two of which are en-suite. There are six toilets and three bathrooms and one shower 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, a new bathroom and two single rooms with en-suite facilities. The home is staffed by a manager, care staff and ancillary staff. The current scale of charges range from £445-£470 for long stay and £525 for short stay and trial periods. The fees include accommodation, food and staffing. The charges do not include toiletries, clothing or personal expenditure such as hairdressing or chiropody. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one and a half days. The visit included a tour of the home, discussions with three residents, a relative, three staff, a healthcare professional and the Manager. Written feedback was received from relatives and residents. The visit also included observation of practices and viewing of records. What the service does well: The very positive feedback from residents and relatives demonstrate that the Manager and staff of Burrell Mead provide a warm, safe and caring environment which respects the privacy and dignity of the residents. The attitude of the staff and Manager was commented on by many of the individuals who provided feedback. One resident wrote that Burrell Mead has “A very happy atmosphere, everyone has a caring attitude.” Another resident wrote, “I am quite independent but the staff are always there when I need them.” One relative wrote “Mostly I am very impressed with the staff and their caring attitude in particular the home manager, who goes out of her way to ensure that users feel they are at home.” As regards staff “They are very committed, many long term and very versatile. They are continuing to take training and qualifications. They are caring with clients and know them well - treating them with dignity.” Healthcare needs of the residents are met through the home accessing appropriate services. The home has an open door policy to visiting and visitors are warmly welcomed by staff. All residents are entered onto the electoral register to ensure they exercise their rights to the voting process. Residents spoken to were happy and content in the home. The décor and furnishings are of a good standard and provide a very comfortable and homely place to live. One resident spoke of how pleased she was to have a large room Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 6 in a separate building which gives her independence and a very comfortable space overlooking the garden. “The home is also kept in good repair and improvements made on a regular basis” wrote one relative The Inspector received extremely positive feedback in relation to the standard of cleanliness with many stating that it was “excellent”. The residents also spoke of the good quality of food and meals provided which are taken in a very pleasant and well-laid dining room. Residents enjoyed the social occasion of the meal times. Well over half of the staff are trained to NVQ 2 or above with one member of staff recently being praised for achieving the award even with her advancing years. Much of the feedback praised the Manager for her listening skills and how approachable she is to residents and relatives. The home has a low incidence of complaints due to her approach and the informal way in which she manages any issues or concerns. The Manager ensures that the health and safety of residents of staff is maintained through regular checks on the home’s equipment and plant used and care practices. Residents’ finances are managed well and revenue and expenditure accounted for. What has improved since the last inspection? Since the last inspection last inspection the home has ceased re-dispensing medication. Moving and handling risk assessments have been completed and an Occupational and Physiotherapist referral has been made to ensure residents have the aids and adaptations required. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 7 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 DS0000006939.V296164.R01.S.doc Version 5.2 Page 8 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.V296164.R01.S.doc Version 5.2 Page 9 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): 2,3,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 needs are identified and planned for. EVIDENCE: In all placements in the home a referral is made to the home and screening completed before any assessment undertaken. Residents and their families are invited to view the home, although in many cases it is the relatives who undertake this task on their relatives’ behalf. All residents are assessed by the home to ensure their suitability and appropriateness of the placement. Most residents are privately funded and where the Local Authority wishes to place in the home the Care Manager’s assessment of need is obtained. All residents are provided with a contract which is currently being reviewed and updated. There is a trial period, for which, the charges are slightly higher than when the placement is reviewed and a permanent place offered. Either side is able to Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 10 give notice of one week during the trial period. The contract gives details of what is included in the fees. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans have improved, although some core details have not been recorded. Staff know residents well and understand their needs. Medication practices require improvement as they currently place residents potentially at risk. EVIDENCE: Care plans have improved since the last inspection with further progress being made by development of a new care planning system. This may make it easier for staff to understand and complete. The system requires an assessment followed by an individual care plan where needs are identified. Viewing of the current care plans showed that these are still of a variable standard of completion and whilst a number of areas were identified as needs, there were a number of gaps, including health needs. Examples of the gaps include lack of detail over individual interventions for assistance with personal care, decreasing appetite and loss of weight, need for food supplements, pressure care assistance and support and aggression. There was evidence of moving Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 12 and handling and falls risk assessment. However, in one case where there were particular difficulties in handling a resident, the assessment did not detail how to do this. This was also evident from the observations made by the Occupational Therapist. (See requirement 1 & 2 and recommendation1) The detailing at the front of the care plan of the routines of the day for each resident is good practice. Whilst care plans viewed showed that the residents had signed the care plan the verbal feedback was conflicting. The written feedback from relatives also showed that very few were involved in the development of care plans or reviewing the care. Although, all said that they were kept up to date verbally with the care needs of their relative and those viewed appeared to have been recently reviewed. (See requirement 1) Residents looked well presented and well groomed and a relative spoken to felt that this was the usual standard of care. Assistance and support required is varied with some requiring minimal assistance and support whilst others require a good deal. Residents stated that staff provided assistance according to their needs. On the day of the inspection the Occupational Therapist (OT) was visiting the home assessing three residents after referral by the home. The OT was a little concerned that whilst the member of staff on duty was aware of the visit she was not aware of the residents due to be seen. The OT assessed the residents and, where necessary, requested specific aids or made a referral to the physiotherapist. Feedback from the residents showed that all the residents felt that their medical needs were met. Daily records showed regular two weekly GP visits and details of the treatment provided. The home also accesses a visiting optician (or residents use their own in the area). The NHS chiropodist visits infrequently but the home has to a private chiropodist. One relative was unaware of how to access these and therefore the Manager should provide residents and relatives with information on how the home accesses services. There was evidence of a recent visit for one resident from an audiologist. Each resident had an assessment for eating and nutrition with residents weighed and recorded each month. The last inspection identified some improvements required around medication practices. This included re-dispensing of medication. The staff have stopped this practice. However, observation of the administration of medication at lunch-time identified more bad practices. Medication was transferred from the nomad by hand to dispensing pots with two residents medication dispensed at the same time and medication signed before it was given to the residents. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 13 This is unsafe practice and would have continued unless highlighted by the inspector. Records viewed were satisfactory, although photos were missing for residents (these were on care plans). Medication records continue to be handwritten and there is evidence of medication being received into the home. There are two signatures on the record book however the inspector suggests that the medication administration record themselves record two signatures to ensure accuracy of the transcription. In one case the label on one medication stated one or two to be taken. However, the medication administration record (MAR) recorded “one to be taken” with the staff making the decision regarding the amount. There must be accurate transcription of the script onto the medication records and where there are variable doses the staff should sign the actual number administered on the MAR. Where medication is “as required” guidelines are needed detailing administration. Staff who administer medication have undertaken safe handling of medication training and senior staff have also been provided with more training relevant to their role eg monitoring of medication practices. However, as the senior was the staff member administering on the day, there are issues with the implementation of the procedures into practice. (See requirement 3 and recommendation 2) Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals and mealtimes are relaxed and provide residents with an enjoyable part of their day. Routines within the home are flexible to suit individual needs. Activities offered are limited. This suits some residents whilst others would prefer more choices. EVIDENCE: It is positive to note that the home records the daily routine for each individual. Routines are flexible with one resident spoken to said that they got up when they wanted, had breakfast in their room and then got dressed at their leisure. They joined residents for other meals in dining room and this suits them. The residents enjoyed her time in her own room reading her books and listening to the radio and whilst she went out occasionally she does like large groups prefers one to one. Other residents were observed reading in the lounge, reading, having a nap and others were in their rooms. Activities include exercise class each week and religious services. The Manager has also started a newsletter about what’s going on in the home. Those residents with accommodation in the bungalow lead a more independent lifestyle, joining in with residents in main house when they choose. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 15 The written feedback from residents in relation to activities showed 5 always felt there were activities offered, 5 usually and 3 sometimes. When relatives feedback one said: “This is my only concern about the home-the shortage of activities. It would be nice if something small happened every day-something to look forward to-if only for half an hour.” Another resident said that they felt that there were not enough outings. (See recommendation 3) Meals are taken in pleasant surroundings in the dining room in a relaxed and convivial manner. Prayers are said before meals. Residents who provided written feedback showed that 7 residents always enjoyed the food; 5 usually and 1 never. On the day there was no choice on offer as the cook stated that all the residents enjoyed the roast. However, when the meal was served staff did not ask residents if they wanted seconds as the reason provided was that the residents did not really eat much meat! However, residents spoken to were satisfied with the meal provided Some residents prefer to take meals in their rooms on trays whilst one other required assistance and was served later. The kitchen has a clean food award and staff working in the area have food hygiene qualifications. Food temperatures are taken prior to transferring food to the hot trolley. It is recommended that the staff take the temperature of the last meal served during the sitting to ensure the required temperature continue to be maintained. (See recommendation 4) Burrell Mead warmly welcomes relatives and visitors. One relative when asked the question does the home make you welcome -said “Very much so. I always feel very welcome.” Whilst another said “It’s a very nice home, all staff take trouble to attend to the residents, and make a special effort on high days, holidays and birthdays.” The inspector spoke to one relative who was spending time with her mother whom she visits regularly. The comments received were positive and observations of them and other residents sitting on the front porch enjoying the sunshine showed a relaxed approach by the home. Residents are able to bring in possessions and furniture into the home, taking into consideration size and safety aspects. This makes their private accommodation more homely. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to. However formal processes need to be further developed so that the home’s procedures are available, understood and consistently applied. EVIDENCE: The complaints procedure in place is on display in the hallway. It meets the Care Homes Regulations 2001 and included the CSCI details and timescales. The feedback from residents showed that they all knew to whom to complain or express concerns to if they were not happy. There have been no complaints made to the home, since the last inspection. Nor have the Commission or social services department received any concerns about the home. One relative spoken to said the Manager was very approachable and that “….you only had to mention something and it was sorted” so there is no need for the formal complaints system All residents are entered onto the electoral register with some residents using the postal voting system whilst others are escorted to the polling booth. Adult protection procedures are also in place, including Whistle-Blowing. Staff spoken to had a basic understanding of types of abuse and the action they would take if such incidents occurred. However, both required prompting and neither had received training. Senior staff should have a greater understanding Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 17 of adult abuse and the role of other agencies in the protection of adults from abuse, especially as they are often left in charge of the home. There was a limited knowledge of Whistle-Blowing and the meaning of this to them. There has been no adult protection incidents or allegations over the last six months. (See requirement 4) Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 18 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, 23,24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a safe, well-maintained and comfortable environment to residents which is kept fresh and clean. EVIDENCE: Burrell Mead is a home which has two separate residences. One building is the main house with a bungalow also set in close proximity to the front of the grounds. The premises are well maintained, well decorated and furnished. The main house comprises a number of bedrooms on the ground and first floor; lounge, dining room, conservatory, main kitchen and laundry. Bedrooms viewed were all well decorated and personalised with individual furniture items and mementoes giving the rooms a homely feel. The bungalow contains bedrooms and bathrooms and toilets but no communal areas. Residents take meals and other activities in the main house. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 19 The gardens are also well-maintained and filled with shrubs, perennials and annual flowers. The lawns are well kept with garden furniture situated throughout. The home benefits from a compact laundry which has hand washing facilities and appropriate laundry equipment. It is too small to separate clean and dirty laundry. The clinical waste bin is located here and may well be better located away from clean laundry. A disinfector is located on the first floor. Some care staff have had infection control training. However, the domestic spoken to had not received specific training but guidance from the Manager. She had a fair understanding of the reasons for keeping the home clean and good practices. However she would benefit, as stated at the last inspection, from specific training especially as the DH guidelines on hygiene control have now been produced. (See recommendation 5) The home is clean and fresh and without fail all residents and relatives who provided feedback said that the home was of a good standard of cleanliness. “Excellent” was used to describe the standard in many cases with one relatives saying “spick and span.” Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has provided considerable training to staff which has helped them provide consistent care to the residents. However, some of the knowledge and understanding of safe practice and protection of residents needs to be improved. The recruitment procedures must be improved to ensure the safety of residents. EVIDENCE: The inspector received good feedback from resident and relatives regarding staff understanding of the residents’ needs and ensuring they are cared for. One relative said; “In my opinion is that the staff are very well trained, competent and well motivated and do their jobs with unfailing cheerfulness.” The home has progressed well with majority of the staff having undertaken NVQ 2 in Care with a number of staff going on to Register for NVQ 3. This is good practice. The roster shows the Manager and her Deputy undertaking shifts in the home. It is positive that the Manager and Deputy are around during the evenings and weekends but consideration should be given to how much management time is required in ensuring there is adequate time for administration and management tasks. The staffing rosters show that there are an adequate number of care staff on duty with domestics and kitchen staff undertaking required tasks. Care staff Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 21 are responsible for undertaking laundry tasks and whilst staff cope with these duties the inspector refers back to the comments regarding activities in the home. Staff also informed the inspector that they have received guidance from the Parkinson’s Disease Nurse on the needs of a particular resident and how the home can meet their needs. The home has an in - house induction programme for all new staff. However, viewing of the files showed there to be a lack of induction records regarding a domestic and care staff member. (See requirement 5) Recruitment procedures were audited through the checking of the most recect members of staff to be recruited. The home has recently recruited an administrator and “handy-man”. The inspector was told that neither had received a Criminal Records Bureau Check or POVA but both had commenced their roles in the home and their work brought them into contact with residents, sometimes in isolation. The Provider was required to ensure POVA checks were completed by the second day of the inspection and this was done. Two staff files were viewed - one for a domestic and one related to a member of care staff. They both contained an application form; two references (both personal in respect of the domestic as no employment noted in the UK. However, there was a discrepancy as a residential home had been noted elsewhere in records.) The files contained proof of identity and one contained an interview schedule; some certificates but no verification of previous employment in the care sector. This area requires further improvement and the inspector sent a copy of a report on recruitment recently produced by the Commission. This gives advice on the recruitment checks required and good practice. (See requirement 6) Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the needs of the service, and the home offers consistent good quality care to residents. EVIDENCE: The Registered Manager is experienced and qualified with a number of years managing the home. The Manager is approachable and deals with any issues without delay and in a pleasant and reasonable manner, often resolving issues before formal procedures are invoked. The Manager has purchased a quality assurance system and auditing tool. However, it is not currently being used as effectively or as it should be. The system does not identify what has been audited, the evidence and findings and where there are areas of non-compliance or what action is required to address the non-compliance (See recommendation 6) Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 23 Since the last inspection the Providers have regularly undertaken the monthly visits required and supplied the Commission with the report on their findings. The last review consisted of service users questionnaires and took place in 2005 with a new survey due this year. The Manager was reminded of the need to ensure the feedback is collated, analysed and a report on the outcome produced which identifies the strengths and weaknesses and action plan to address shortfalls. She was also reminded of the need to include consultation with relatives and stakeholders. A number of service contracts were viewed and cross referenced with the preinspection questionnaire information. Areas including hoists (01/06) environmental health officer visit (12/05), lift (04/06), legionellas (06), PAT (06/06), fire extinguishers (10/05) and gas (06/06). All were appropriate and up to date. The home audits fire safety each week with the last one undertaken on 4/7/06. Whilst there have been issues with the hot water temperatures this has now been resolved. Discussions with staff show that moving and handling training has lapsed; not all staff have received adult protection training or guidance and whilst some staff have received infection control training, this is not true of domestics. Food hygiene training is required for all staff involved in the preparation and serving of food. The majority of the staff have received First Aid training ensuring there is always a qualified person on duty. (See requirement 7) 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. The monies of two residents were audited and found to be correct. There were records of transactions which had taken place. The home is insured to a satisfactory amount for the keeping of individual monies. Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 24 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 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 Requirement The Registered Person must ensure care plans reflect the health, social and physical care needs of the individual. Residents and relatives must be consulted when reviewing the care. 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. This is a repeated requirement Timescale expired 1/4/06 The Registered Person must ensure that the practices for the dispensing, administration and recording of medication are safe. The Registered Person must ensure that all staff are provided with training or guidance in the protection of vulnerable adults and whistle-blowing procedures. The Registered Person must ensure that there is a record of DS0000006939.V296164.R01.S.doc Timescale for action 01/10/06 2 OP8 13 01/10/06 3 OP9 13 01/08/06 4 OP18 13 01/11/06 5 OP30 18 01/10/06 Burrell Mead Version 5.2 Page 26 6 OP29 17 & 18 7 OP38 13 all training completed including induction training. The Registered Person must ensure that the recruitment procedures and practices are robust and the required checks made to safeguard residents. The Registered Person must ensure that all staff are provided with updated moving and handling training and that the practices are monitored. 01/08/06 01/11/06 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 OP7 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. The home should ensure that there are guidelines on how staff are to administer “as required” medication. The medication records should record the dose administered where the scripts require variable dose. The Manager should investigate the recruitment of an activity organiser to enable residents to follow their interests and activities. The home should take the temperature of the food on the meal last served to residents to ensure it continues to reach the appropriate temperature. Domestic staff should be provided with infection control training. The auditing system should be more robust and include evidence of the audit, how it has been audited and where there is non-compliance, a record made. The system should include a record of the action to be taken to address the non-compliance. 2 OP9 3 OP12 4 5 6 OP15 OP26 OP33 Burrell Mead DS0000006939.V296164.R01.S.doc Version 5.2 Page 27 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.V296164.R01.S.doc Version 5.2 Page 28 - 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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