Inspection on 06/09/07 for Burrell Mead

This inspection was carried out on 6th September 2007.

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 06/07/06

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 Unannounced Inspection 6th September 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burrell Mead DS0000006939.V343667.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.V343667.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 info@burrellmead.co.uk 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.V343667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 Elderly persons of either sex Date of last inspection 6th July 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 that 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 £455-550 dependent on whether it is for permanent or short stay care and for single en-suite. 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.V343667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over two days. On the first day, the inspector was supported by an “Expert by Experience”, who discussed with residents their experiences of living in the home. The inspection also included analysing the information provided by the home in the form of the Annual Quality Assurance Audit and other information held by the Commission such as Provider reports and notification of events. This report also includes the outcome from the unannounced inspection in January 2007. On the days of the visit the inspector viewed the home’s records, toured the building, spoke to staff and the manager and observed practices. Seven residents, three staff, a health professional and five relatives also provided written feedback. Nineteen residents were in the home on the first day of the visit with two vacancies and one person in hospital. What the service does well: Burrell Mead is a pleasant comfortable home caring for these elderly people, with love and compassion, which is obvious to all who visit, wrote the “Expert by Experience”. One relative wrote of staff, “Excellent staff who are fully committed to meeting X’s needs. They are very patient and kind and have a lovely relationship with X.” Information is provided to those who wish to live in the home enabling them to make a decision on what the service has to offer. Staff have the experience, are qualified and receive training to enable them to care and support those living in the home. Many clients expressed their satisfaction at such caring staff members with special mention to the Manager and Deputy Manager. The residents are treated with respect and make decisions about the care they receive. Meals are hot, well cooked and enjoyed by the people living there. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 6 Overall the home is well-maintained, comfortable and homely in the way it is decorated and furnished. It was clean and fresh with no unpleasant smells. One relative said of Burrell Mead that it “Provides a good, clean happy home”. The home is well managed with some systems in place for ensuring care is continuously improved and that residents are kept safe. The manager is open and approachable enabling issues or concerns to be dealt with satisfactorily. What has improved since the last inspection? What they could do better: Local Authority funded residents should have terms and conditions of residency to ensure they have the full information about service. Assessment of risks must be carried out and recorded in all areas where the individual is at risks to ensure the home provides the appropriate support to minimise the risks identified. These should be supported with care plans that reflect the care required. Medication practices must be more robust so that individuals’ health is protected. The range of activities should be increased to include external activities, as these would benefit some residents. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 7 The system for managing complaints is satisfactory although records could be improved to ensure openness and transparency. Guidelines on protection of adults should be obtained from other Local Authorities. The decoration in the bungalow is ‘tired’ and could do with some freshening up. The organisation should review the skills mix of staff and consider employing a laundry assistant and activity co-ordinator. Some of the health and safety systems must be improved to ensure residents are kept safe and well. Staff must be formally supervised regularly to ensure residents receive good care. To ensure the care is continually improved, the Providers must produce a report on any review undertaken and should also consider commencing residents’ meetings. 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. The summary of this inspection report can be made available in other formats on request. Burrell Mead DS0000006939.V343667.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.V343667.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6 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 needs assessment means that staff have the information to ensure they are able to meet people’s individual needs. EVIDENCE: The manager has developed a Resident’s Guide and Statement of Purpose that provide good information on the home and what it has to offer. When prospective residents show an interest in the home they are provided with a brochure, Statement of Purpose, examples of menus and information on the fees. A copy of the contract is also provided to ensure people are fully aware of Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 10 the terms and conditions of the placement. The information provided in the Residents’ Guide now includes quotes of what residents and relatives say about the home. It has been done in collaboration with the residents. It also paints a picture of what it is like to live at Burrell Mead. This is good practice. Residents spoken to were not fully aware of the information provided, mainly due to families making the arrangements for the admission. The “expert” spoke to a number of people living in the home and, in particular, discussed the admissions process with two new residents. Neither of the two residents were aware of the information provided, mainly due to families making the arrangements for the admission. The AQAA details that residents are encouraged to visit the home and stay for a few hours. During this time they are able to meet other residents, staff and “get a feel” for the home. They also have lunch and refreshments. It is at this stage that the manager or senior staff assess the individual’s needs to ensure they are able to provide the appropriate care and support. If the resident feels the home is suitable for them and the management team are able to meet their needs, further information is obtained from GP etc. One of the residents spoken to confirmed this process stating that she had decided to enter the home on a temporary basis to see if she can improve her own caring and perhaps return home at some later date. Three staff surveys were received and all said that they had the training, support and experience to meet different needs. One member wrote that they are provided with information on new residents before they arrive in the home to ensure they are aware of their needs. I viewed the pre-admissions information kept in the individual’s files. This includes an application for admission and assessment form. However, it was difficult to determine when the assessment was completed, as they had no dates or signature on. Both contained assessment of capabilities and physical assessment. Where the Local Authority had placed one resident, the home had also obtained the Care Manager’s assessment. (See requirement) Residents are provided with terms and conditions and, as commented previously, a copy of the contract is sent with all other initial information. The contract has been reviewed since the last inspection to ensure it is clearer for all interested parties. Those that are funded by the Local Authority are provided with the Authority’s placement agreement but not the home’s terms and conditions. These should also be provided to ensure the residents are aware of the rights and obligations of the home they are residing in. The administrator understands this and will review the contract to ensure it ties in with the placement agreement. (See recommendation) Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 11 The administrator writes to prospective residents confirming the home can meet their needs. The letters viewed were personalised and welcoming. The home does not provide intermediate care. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 12 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. 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. Although improving, the variable practice regarding the planning and delivery of care means that all services users cannot be sure that their health and personal care needs will be fully met. Medication practices do not always ensure that residents’ healthcare needs are met. EVIDENCE: All residents have a care plan developed outlining the care and support they require. I viewed three care plans and supporting documentation. The home is in the process of changing the documentation to one favoured by the National Care Homes Association. (NCHA) Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 13 It is positive that the home details the routines for each individual and staff often commence the records with the life history for each resident. All three viewed had a care plan either developed or, were in the process of being recorded in the new format. The care planning is still of a mixed standard and does not always address issues/needs identified with the appropriate action. The inspector is particularly concerned where a resident currently living in the bungalow presents a number of risks to their safety. Staff spoken to were quite concerned about her health and welfare as well as the safety risks. There has been some attempt to minimise these risks, although the individual does not appear to understand this. These risks do not appear to have been clearly highlighted in the documentation and, when viewed, the care plan does not reflect the needs or level or risks with caring for this individual. The CPN and psycho-geriatrician are involved in providing specialist support. The inspector is also concerned that the resident, at times, not only locks their door but also “barricades” it with furniture. The Commission has not been informed of these events in Regulation 37 notifications and they have not been documented in the fire risk assessments. Care plans had been develop for the other two viewed, covering a range of identified needs. There were some gaps in these, including the bathing routine in all three, mobility in one other (where there were identified needs) and health issues had not been recorded eg one person with osteoporosis and heart problems. The inspector also had difficulty in one file, determining the progress of the plan and date of reviews. The two files viewed contained risk assessments on pressure care, nutrition and moving and handling. They contained the original assessment, assessment of capabilities and some form of care plan. Some of the assessments did not reflect the concerns with some issues eg one person had low risk as regards nutritional needs but since the assessment there had been weight loss and contact with the GP to assess their healthcare. Risk assessments must be reviewed regularly and updated. Where there are risks the care plan should also detail any action undertaken to minimise the risks. (See requirement and recommendation) The expert by experience found when talking to residents that they thought they could have some say in their care if they wished to and they were all very content with the “excellent care” they received and did not feel the need to be more involved. Relatives who provided written feedback, were impressed by the level of care provided to their family member. One wrote: “Excellent staff who are fully committed to meeting X’s needs. They are very patient and kind and have a lovely relationship with X” Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 14 Another wrote “hearing aids were an issue and irregularly put in-but now done and checked regularly.” The GP feedback stated that Burrell Mead is well run and friendly. “Staff are caring and do not call the doctor inappropriately. I have been particularly impressed with the terminal care given to residents. It is a pleasure to be VMO for this home.” Daily records show access to various health professionals including the GP, DN and chiropodists. The care planning documentation also included a record of health professional visits. One showed that staff had recorded such visits but the other had no visits recorded as yet. The home also records residents’ weights with evidence of the GP being contacted where there are concerns about individual weights. Medication practices were observed during the morning administration round. Medication was administered by the senior staff and was found to be appropriate. Staff who are authorised to administer medication are listed and they give samples of the initials used to sign the medication record. The records were also viewed and it is positive that the records are now preprinted. This saves the deputy manager time when receiving medication in each month as previously she had to hand write these. All residents have a record and these are generally fully completed with the information required, except some gaps on allergies. Where allergies were known this had been detailed but otherwise left blank. It is good practice to note where none are known. Photographs of each resident are in place, although not on the medication records. This would also be beneficial. Medication had been recorded in on the medication record, with the exception of some that had came into the home between the four weekly cycle. One resident self medicates some medication. The records do not show when medications are provided, amounts etc or what they doing to monitor the selfmedication. These must also be recorded as received, date and signature of person receiving them. Also where the medication has been hand transcribed, as often in these cases, the person writing the record out should have the accuracy of the transcription signed. Controlled drugs are maintained by the home, although they have changed their practice from having a controlled drugs register, a hardback copy, to loose leaf. This is not acceptable practice as there is a requirement to ensure the records are noted in a bound book. This has since been addressed with the home reverting to recording in the Controlled Drugs book. The drugs were audited along with the records and were found to be in order. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 15 All medication is stored in a locked medication trolley and in a locked cupboard. The home does not provide homely remedies. Medication that needs to be stored within the fridge are and a thermometer is in place to note the temperatures are appropriately recorded. The prescribed medication that has a timescale for its use had the dates of opening on them to ensure they would be discarded with in the timescale required. (See requirement) It is clear from the feedback and observations of the inspector and Expert by Experience that residents are treated with warmth, respect and dignity in all their dealings with the residents. Doors are closed during personal care tasks and staff are discreet when they support people with personal care tasks. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 16 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. 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. The range of activities within the home has improved meaning residents now have some variety Meals and mealtimes are positive experiences that are relaxed and a social occasion. EVIDENCE: Burrell Mead is a home run by a Christian association and therefore the Christian ethos is integral to any residents living here. This is made clear in the information provided, with services, bible meetings and church visits detailed as part of the activities provided. “The Bugle” newsletter also clearly identifies this relationship. September’s issue shows where the manager had sat down and spoke to residents about their holiday memories and included these in the newsletter. It made very pleasant reading. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 17 One relative wrote of Burrell Mead “they provide a loving and caring environment encouraging independence when possible and more activities are now provided.” It is positive to note that a hearing loop system is now in use in the main lounge, a large print newspaper delivered weekly and a high number of residents have the daily newspaper delivered. Two residents who are sight impaired visit the RNIB club meeting each fortnight. One resident likes to wash her own laundry and another likes doing her own hovering. Both are supported to do this. The “expert” spoke to a number of residents and made the following observations. The notice board held a list of activities for the month of September. One of the more able gentlemen went through this list and provided information on what each session involved. He said he liked to join in all the activities. The activities for this month varied including music, religious services, exercise, discussions, and chiropodist visit. The residents spoken to said, there is also a regular session with two hairdressers every week, although this did not appear on the list. Those that joined in the activities were quite satisfied with the quality of the entertainment. However, one particular lady feels the home does not have enough stimulation for her needs, although perhaps plenty for the “more sleepy person.” She is free to sit outside and watch the traffic and visitor’s arrival and departure which can be entertaining, as the parking is limited. She knows the staff watch out for her and always bring her refreshments. She is happy to return inside for her meals but said she would like more activities to stimulate her. There is no art and craft activity offered this month, but was told that a man does attend the home to make such things as Christmas cards and decorations. Of the seven written feedback provided two said activities were always provided, three usually, one sometimes and one person said, “they watched”. One relative liked the fact that “It is a Christian care home and the loving, prayerful care means a lot to X, including services, though her own vicar visits as well. Everyone stated there was no pressure to join in the events, but it was there if they wish to. The feedback suggests that whilst this has been improved there is still some room for improvement. The list of activities did not show any offer of outings. The resident said that if they wanted to go out then their relatives would be the ones to take them. There did not seem to be any provision for those who did not have relatives to Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 18 take them out. There is a park behind the home. This would be an ideal place for staff/volunteers to take residents for a walk on a fine day. On arrival in the home the inspector found that the dining room had been made ready for breakfast with crockery, cutlery and juices, jams and marmalades on the table ready for residents. Observations of the breakfast routine showed residents to enjoy their meal with tea and coffee supplied. It was a very relaxed time. The “expert” also had lunch with the residents and the following observations were made. The notice board has a list of meals, including a choice for each main meal. The list of meals was of traditional English fare with the usual fish and chips on Friday and Roast on Sunday. The meal tasted was well cooked, hot, and of ample portion size. People were able to serve themselves with vegetables from the dish on the table. The only issue noted here was that the desserts quoted on the menu were not those offered today. Two people mentioned to me that they had a choice everyday except Sunday. On Sundays they could only have the roast meal. However, I was told of one lady who is vegetarian and she gets an alternative to roast dinner. The menu on the board indicated there is a second meat choice on Sundays, although no one recalled this option. (See recommendation) The feedback from written survey wrote of meals that they provide “excellent meals-served nicely” Visitors are warmly welcomed into the home with good relationships between staff and family members and staff and health professionals. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to with formal processes in place ensure residents are protected and the quality of care improved for individuals. EVIDENCE: Records of complaints information on the AQAA supplied to the Commission showed one complaint in the last twelve months. The complaints procedure is on display in the hallway and in the Resident’s Guide. These are appropriate, although the procedure in the hallway did not have the timescale for responding to complaints. (See recommendation) I viewed the concerns and compliments register and noted some minor complaints but no formal complaint. This, I later found to be in the complaints file. The complaint had been investigated by the manager, with the outcome and action recorded. However, the manager could not locate all the correspondence to the complainant, about dealing with the concern and the outcome and if they were satisfied with the outcome and actions being taken. (See requirement) Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 20 The survey undertaken by the Commission for this inspection reflected the findings of the relatives survey undertaken by the home in July 2007. All felt that they are able to raise concerns and that manager is approachable and listens to the issues raised. One resident wrote, when asked, do you know who to go to if you are unhappy? “Yes-but I can’t imagine it happening.” The home also has procedures in place to protect the vulnerable people living there. These include Whistle-blowing procedures. The two staff spoken to were aware of the meaning of this and the security it affords them when reporting any adult protection issues. Both were aware of their role in referring any incidents to the manager and what they would do if they felt the issues were not being addressed. All staff are expected to view a training video on adult protection as part of their ongoing training and development. Adult protection is also included in the Common Induction Standards for all new staff as well as in the NVQ qualification. London Borough of Bromley Inter-agency procedures are in place, although other authorities guidelines are also required for guidance to support the home’s procedures. (See recommendation) The procedures also encourage residents to contact Bromley Advocacy if they require support in making complaints or need guidance with financial matters. Recruitment procedures were audited and found to be of a good standard. All residents are entered onto the electoral register to ensure they are able to exercise their voting rights either through visiting the local polling booth or postal voting. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Burrell Mead provides a warm, well-maintained and comfortable environment for those living there. EVIDENCE: The home itself is situated on the busy main road between West Wickham and Beckenham. Burrell Mead comprises two buildings one of which is the main building with two floors and the other a bungalow. To the front of the buildings is an “in and out drive” with more room recently been made for car parking. There are small lawns to the front with summer bedding plants giving a pleasant view as you Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 22 enter. To the rear of the bungalow the small gardens have shrubs, perennials and trees with a small lawn. The main building has very pleasant lawn area with summer bedding plans and other shrubs and trees. A gazebo had been fixed for the summer with garden furniture and benches around the garden. A small patio area leads from the building to the lawn. This makes a very attractive area for residents to spend time in. However, the only access for those who are disabled is through the conservatory. The main building has two floors with lounge, dining room, conservatory and bedrooms, bathrooms and WCs located on the ground floor together with the kitchen and laundry. The first floor has bedrooms and bathrooms/WCS. The bungalow is for those residents who are more independent and the main building for those requiring more support. The bungalow has bedrooms and bathrooms/WCs and no communal areas, with residents enjoying the use of communal areas in the main building. This area is looking a little tired and worn and in need of some redecoration. (See recommendation) The information supplied in the AQAA details new carpets in some areas and the levelling of the floor in the corridor of the first floor in the main building. A number of rooms have also been decorated as well as two Parker baths installed. The manager has also begun an action plan of replacing some of the lounge chairs. A number of safety improvements have also been completed, including new fire alarm points, emergency lighting, senor lighting for outside between the two buildings and enclosure of the waste bins outside. The main building is well maintained and very homely and comfortable, although the bungalow is looking a little tired and worn in places. Bedrooms are pleasant and personalised with those viewed looking very comfortable and homely. There are adequate bathrooms and WCs. Viewing of the bathrooms and WCs showed them to be fitted with appropriate aids and supplied with soap and material hand towels. With the increase in infections and the uncertainty as to whether residents have an infection, the use of material hand towels increases the risks in the home. Staff were observed undertaking laundry tasks with no protective covering, although protective covering for care and dining room tasks. The risk of infection increases with this practice. (See requirement) The custom of placing staff belongings in the bathrooms or other communal areas should be stopped as this places the staff member at risk of allegations Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 23 where there have been some security breaches. Also the storing of shopping trolleys by staff in residents shower rooms limits their use by residents. (See recommendation) Equipment used is regularly serviced, although the six months has expired for lifting equipment although this has been arranged to take place shortly. A tour of the home showed it to be very clean with no offensive odours. This was confirmed by feedback received. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent and well trained to ensure residents receive the care and support they require. There are good recruitment processes to ensure vulnerable residents are protected from harm. EVIDENCE: Staffing levels on the day of the inspection showed four care staff be working in the morning and three in the afternoon. During the night there are two “waking staff” and one senior on call. Each shift has a senior on duty and this may be the deputy manager of manager, particularly where there is sickness or annual leave. The staff team also includes catering and domestic staff and a full time. Over the years there has been a consistent staffing with many staff working in the home for well over five years. Burrell Mead is very good at valuing their staff and therefore retention is easier. The manager stated in the AQUAA that, a laundry assistant would be beneficial as at present laundry is undertaken by care staff. (See recommendation) Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 25 The feedback from residents and relatives were overwhelmingly supportive of the staff and the high standard of care they provide. “The staff are always welcoming and cheerful making a nice homely atmosphere on entering and are always polite and helpful to the residents.” The home has been very proactive in ensuring staff are trained in a number of areas with over 70 of staff qualified to NVQ 2 or above with all senior staff trained to NVQ 3. The manager has also provided a number of staff with dementia training and safe handling of medication for senior staff. Thirteen staff recently undertaken fist aid training. In many areas staff are trained through the use of BVS videos including, challenging behaviour, adult protection, food hygiene, fire protection and infection control. Discussions with two staff demonstrated good knowledge of adult protection and dealing with accidents. The both felt the recent dementia training was very hard work although very good and had received medication training. However, one staff member has not received moving and handling training since joining over two years ago. This has been a requirement from previous inspections. Two staff have received training in May 2007, although training records show a number still outstanding. Having viewed the accident reports that showed a high number of falls the inspector believes staff need this training as did staff spoken to. (See requirement) It has been a positive move in the home to have two administrators supporting the manager and this has meant an improvement in the organisation and systems as well as releasing the manager to manage the home. There is evidence of new staff being provided with induction training (Common Induction Standards, CIS) with three induction booklets viewed, with some partly completed and others having certificate of competency issued. Each staff member of staff has a training record in place and three of these were viewed. They showed a mixed record of training with two staff in receipt of a variety of training including; adult protection, first aid, dementia, infection control, medication, abuse and food hygiene. The third one viewed for a care staff had CIS, death and bereavement and infection control. A number of staff have been provided with Parkinson’s Disease training by Parkinson’s nurse. Training records are not clear and do not provide information at a glance so it is difficult to determine training taking place. This was discussed with the administrator who said that he would be able to organise this. Discussions with the deputy and three staff showed that two of these were very concerned with one resident who lives in the bungalow and the risks with Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 26 this. They did not feel that there has been a full appreciation of the risks to the individual, focussing more on rights and choices. This is appropriate where the individual has the capacity to make such decisions although not where there is doubt. I viewed the files of the last two members to check the recruitment practices of the home. It is positive that volunteers are now are Criminal Records Bureau (CRB) checked. The staff files viewed related to non-care staff. The checks in place included, application forms, interview schedules; proof of identity; CRB checks including POVA and references. One of the files viewed had two personal references and not one from the previous employer although this period of employment was a ling time ago. The administrator was also advised of the “Focus” reports provided by the Commission to assist homes in good practice. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home provides an open and inclusive atmosphere where residents are safe and provided with a good quality of care. EVIDENCE: The manager is experienced and well qualified to manage Burrell Mead. The feedback from residents, staff and relatives gave a positive view of the way in which the home is managed, with particular favourable comments about the manager and her deputy. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 28 One relative wrote “Mrs P is an excellent lead and example to the staff” whilst another wrote “a well run home, as far as I can see.” She endeavours to make improvements n the quality of care provided taking on board the inspection findings and ensuring requirements are implemented often within the timescales required. The inspector does have some concerns about the manager, at times, not reviewing and referring residents for more appropriate care, particularly where it is clear that staff do not have the full understanding and training to meet particular needs. This is often due to the compassion and kindness demonstrated by the manager. This area will be more closely monitored at the next inspection. Formal residents’ meetings are not held although the managers’ approach is to talk informally to individuals to ensure their needs are being met. From the feedback and internal surveys this appears to be successful, although she should consider a more formal approach. (See recommendation) The Commission receives regular reports from the Provider detailing the monitoring of the home that includes talking to staff and residents. These are of a mixed standard of reporting. A recent survey (July 2007) has been undertaken of relatives’ views of the service. Seventeen were sent out and fifteen returned completed. The results have been analysed and collated into statistics to show the results of the survey. A report with action plan has yet to be completed although the manager is expecting to inform residents of the results in the Bugle newsletter. (See requirement) The three staff surveys recorded that they meet regularly with the manager to provide them with the support and discuss working practices. Both staff spoken to said that they have received formal supervision, although not regularly, perhaps once in the last year. The files viewed confirmed this feedback. (See requirement) I viewed a number of the service contracts and agreements to ensure the safety of the home. This included the lift, gas, fire system, equipment, PAT, nurse call and clinical waste all within date. The fixed wiring completed in 02/07 needed a lot of work doing to it. The work has been completed in the main house and with the Providers awaiting the certificate for bungalow. A fire risk assessment has been completed that includes an audit of the home’s equipment to protect against fire, a general risk assessment of the home and residents. This is quite comprehensive. However there are concerns relating to one resident in the bungalow who locks themselves in and, at times, barricades the door to their room. Since the inspection the resident is no Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 29 longer living in the home due to a change in their needs. However, the manager must be aware of the need to include individual risks in the risk assessment. (See requirement) A weekly fire alarm check also take place, as required and the fire officer who last visited the home in 10/06 was satisfied with the arrangements. The Environmental Health Officer also visited 08/06 and continued the Clean Food Award for the home. The staff record accidents in the home with the manager summarising these during July this year and providing an explanation for the regularity of falls for a number of residents and trying to reduce the falls occurring. The number of falls highlights the need to ensure staff are trained in moving and handling training. The Commission receive notifications for serious events affecting the well being of the residents such as death of residents and serious accidents, although the inspector believes the home should be notifying of other events for example where a resident is not allowing access to staff through locking and “barricading” their door. There are serious risks to these actions. Comments have also been made in the previous standards regarding infection control practices including use of material towels, use of protective clothing during laundry tasks. The Registration Certificate was on display in the home and reflected the current situation. The insurance liability was also on display and up to date. An audit of residents’ personal monies showed there to be good systems in place. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 2 Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 31 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 OP3 Regulation 17 Requirement Records relating to individual residents must be up to date, signed and dated to ensure all information held by the home is accurate. Any risks identified must be recorded and actions taken to minimise the risks clearly recorded. The risks must be reviewed regularly. All prescribed medication, including short-term medication, must be recorded when received into the home ensuring residents health is maintained. There must be systems in place for monitoring the care of those residents who self medicate. Where complaints have been made there must be a full record of the home’s investigation that includes the correspondence with the complainant and whether the complainant is satisfied with the outcome. All staff must be provided with updated moving and handling training and that the practices are monitored. DS0000006939.V343667.R01.S.doc Timescale for action 01/11/07 2 OP8 13 01/11/07 3 OP9 13 01/11/07 4 OP16 20 01/12/07 5. OP38 13 01/12/07 Burrell Mead Version 5.2 Page 32 A schedule for updating staff has begun. 6 OP26 13 Infection control procedures must be implemented that reduce the risk of infection in the home. A report on any review or survey outcome must be produced and a copy sent to the Commission. Staff must receive formal supervision at regular intervals to ensure residents’ quality of care is maintained. Fire risk assessments must be completed on all individuals. The assessment must detail the risk and the action they are taking to minimise the risks. 01/11/07 7 8 OP33 OP36 26 18 01/12/07 01/01/08 9 OP38 13 01/11/07 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 OP2 OP7 Good Practice Recommendations Terms and conditions of residency should also be supplied to residents whose placement arrangements have been made by the Local Authority. Care plans should be further elaborated to ensure staff have clear guidance on how the individual’s identified needs are to be met. Medication records should include photographs of residents and, where the record of prescribed medication is hand transcribed, there should be two signatures confirming accuracy. Inter-agency guidelines on the protection of adults from abuse should be obtained from all authorities who have made placements in the home. The manager should review the activities arranged to include a range of activities in the community. An action plan for the redecoration of the bungalow should DS0000006939.V343667.R01.S.doc Version 5.2 Page 33 3 OP9 4 5 6 OP18 OP12 OP24 Burrell Mead 7 8 9 OP18 OP27 OP14 be produced. Staff must use allocated staff facilities for the storage of their personal belongings. The Providers should consider employing a laundry assistant to undertake laundry tasks within the home. Residents’ meetings should be arranged for residents to have their say in how the home is run. Burrell Mead DS0000006939.V343667.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V343667.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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