CARE HOMES FOR OLDER PEOPLE
Burroughs, The Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector
Robert Bond Unannounced Inspection 25th November 2005 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 Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Burroughs, The Address Mill Road West Drayton Middlesex UB7 7EQ 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) 01895 435 610 01895 435611 manager.burroughs@careuk.com Care UK Community Partnerships Limited Ms Yvonne Jackson Care Home 75 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (65) of places Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include 10 DE and 65 OP Date of last inspection 26th April 2005 Brief Description of the Service: The Burroughs is a care home for 75 older people situated in a pleasant residential area, not very far from West Drayton High Street and associated shops, facilities and public transport. The home was originally built and operated by the London Borough of Hillingdon but is now operated by Care UK Community Partnerships Ltd. The London Borough of Hillingdon remain the sole purchaser of all the places, hence referrals have to be via the Council. The home is divided into six residential units, five of which are for ‘elderly frail’ and one is for 10 people with dementia. The latter is on the ground floor. There are 67 single bedrooms and 4 double rooms. The home was extended in 2001 and all of the bedrooms in the new extension have an en-suite toilet. There is a large enclosed garden to the rear of the building and a large car park to the front. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection is the second of this year’s two unannounced inspections. As such, the inspection concentrated upon the ‘key standards’ of the National Minimum Standards that the Department of Health have published for care homes for older people. The Inspector spent 5 hours at the home. He spoke in detail to the Registered Manager, the Deputy Manager, other staff, and several service users, and examined records, files, policies and practices. Two service users case files and three staff files were examined in detail (case-tracked). There were at the time of the inspection six vacant staff posts, and 8 service user vacancies (three being in the unpopular double rooms). The Inspector assessed the home against 13 of the NMS, and found that 6 of the identified outcomes for each standard were fully met, whereas 7 were only partly met. The Inspector made 14 requirements, 3 of which are carried over from the last inspection having not been achieved within the time scale set. The Inspector also made 4 recommendations. What the service does well: What has improved since the last inspection?
The post of Deputy Manager is newly created and in the opinion of the Inspector essential for a home of this size. Additional staff (from Poland) have been recruited although they are not yet in post. When they are in post it is hoped that temporary agency care staff will no longer have to be employed. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 6 Care records have been partially computerised. Some redecorations have been undertaken and three conservatories have been re-floored. 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. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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 Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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): None of the Standards were inspected this time as they were all covered by the last inspection. EVIDENCE: Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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 and 9. The outcome for NMS 7 was not fully met for the reasons stated below. The outcome for NMS 9 was met. The other Standards in this section were not assessed on this occasion. EVIDENCE: NMS7: Manually written care plans are currently being phased out as their contents are being entered onto a computerised system. This is taking a long time due to the number of service users and the complexity of the task, thus Requirement 1 from the last inspection (which concerned reviewing and updating care plans) has not yet been fully achieved. The Deputy Manager reported that the task was 75 complete, and that the system highlights in yellow when a review date is due. Requirement 2 from last time required that the plan for service users with dementia be modified to show how their changing needs may be met. The Deputy Manager reported that the new system would produce care plans that were easily amended and updated. See new Requirements 1 and 2. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 10 The Inspector examined in detail (case-tracked) two manually generated care files and found that neither care plan had been signed by the service user or their representative. See Requirement 3. All care plans must also give details of the next of kin and the key worker. NMS 9: The Inspector examined the medication storage arrangements, the records of the administration of medication, and the records for medication returned to the pharmacist. No errors or shortfalls were detected. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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): NMS12 and NMS15. The outcome for NMS12 was not fully met for the reasons stated below. The outcome for NMS15 was considered to be fully met, but see the comments below. EVIDENCE: NMS12: The Inspector interviewed one of the home’s activity co-ordinators and examined the activity programme for the home. The Inspector observed a physiotherapy session underway for a group of service users. This activity is commended. He noted that each new service user is given a handout that details the activities available during the week. No advertised activities are offered at weekend however as this is considered ‘family and friends time’, and the activity co-ordinators do not work Saturday or Sunday. See Recommendation 1. It was noted that a volunteer from Age Concern however does visit at weekends, and the possibility of additional volunteers to specifically lead activities for service users with dementia should be considered as a way of further extending the activity programme designed specifically for that client group, as detailed in Requirement 3 of the last inspection report. Recommendation 2.
Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 12 NMS15: The Inspector spoke to a group of service users together one of whom complained about the food not being as good as it used to be. The Deputy Manager explained that a year ago the home had moved to the cook/chill system of production, with lunches and dinners being produced elsewhere and heated up at the home. This system was not as popular as ‘home-cooked’ food. The Inspector observed the lunchtime meal being served and eaten and was impressed by the presentation of the fish, chips and peas, or fried egg chips and peas that was on food. No one wished to complain about the food when asked about it in the dining room. Fresh fruit of a good standard was being served as a dessert, which is commended. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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): NMS16 and 18 The outcome for NMS16 was fully met. The outcome for NMS18 was almost met for the reasons stated below. EVIDENCE: NMS16: The Registered Manager reported that the home had not received any formal complaints during the time since the last inspection. NMS18: The Inspector observed that the home had a copy of the London Borough of Hillingdon’s Adult Protection procedure. However a check of staff training records demonstrated that not all staff in the home had yet been trained in its application (26 out of 66 staff are trained). See Requirement 4. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 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): 19 The outcome for 19 was not fully met for the reasons stated below. The other standards in this section were not inspected on this occasion. EVIDENCE: NMS19; The Inspector toured the home and found that all the environmental requirements from the last inspection had been met. A number of new issues were however noted, as follows. The medication room was seen to be unlocked. The Inspector was told this was because visiting nurses had to gain access to the room but the problem would be addressed by fitting a key-pad lock. See Requirement 5. The store cupboard that is outside of the dementia unit had a broken bolt and hence was not locked despite the instruction on the door to keep it locked. See Requirement 6 and Recommendation 3. The refrigerator in one unit was found to be operating at 10 degrees Centigrade rather than 0 to 5 degrees. The records showed this was a long-standing error that had not been reported or corrected. See Requirements 7 and 8 and Recommendation 3. It was found that the fridge temperatures in another unit were only being recorded sporadically. See Requirement 9.
Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 15 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 and 30 The outcome for NMS27 was not fully met for the reasons stated below. The outcomes for NMS 28, 29 and 30 were fully met. EVIDENCE: NMS27: The Inspector examined the staff rota for the current week. The rota said that 108 hours of care are required each day. The inspector added up the hours for 21st November and found them to be only 105 hours. See Requirement 10. The senior staff rota demonstrated that either the manager nor the deputy manager normally worked at weekends, although the deputy manager reported that she would be working the following Sunday but in her former capacity of senior support worker. See Recommendation 4. There are currently six staff vacancies but new care staff have been recruited in Poland. NMS28: The Registered Manager reported that over 50 of the care staff have an NVQ in care level 2 or 3. NMS29: The Inspector checked the recruitment file of two employees and found that all checks and references were in place. NMS30: The Inspector noted that the home does have an annual training plan in place. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 16 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): 33 and 38. The outcomes for NMS33 and NMS38 were not fully met for the reason stated. The other NMS in this section were not assessed on this occasion. EVIDENCE: NMS33: The home does not have an annual development plan that is informed by service users views. See Requirement 11, restated from the last inspection. However the Inspector did note an action plan that the Deputy Manager had co-authored concerning the introduction of computerised care plans. This is commended. NMS38: A number of Health and Safety issues are reported above under NMS 19. A crucial overarching requirement for the home is that risk assessments of the property, its furnishing and equipment are regularly updated by staff within the home, and that action is taken to highlight or remove identified hazards. The Deputy Manager reported that this duty has been given to her. She needs to be trained in these responsibilities, and all the staff need to be trained also
Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 17 in spotting hazards and reporting them. Although a consultant has recently risk assessed the home, he found very little to be done, but the Inspector noted several instances of trailing wires that could trip up a member of staff or a service user. See Requirements 12, 13 and 14. Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 18 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 19 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 (2) Requirement All individual plans of care must be reviewed and where necessary updated on a monthly basis. THIS IS RESTATED FROM THE LAST INSPECTION AS THE TIMESCALE FOR ACTION WAS NOT MET. The format of individual plans for service users (particularly those with dementia) must be suitable to demonstrate how changing needs are to be met. THIS IS A MODIFIED VERSION OF A REQUIREMENT FROM THE LAST INSPECTION AS THE TIMESCALE WAS NOT MET. Service users and/or their representatives must be involved in drawing up care plans and should sign their agreement to the plans The registered person must ensure that all staff are trained in the duties they must fulfil, including adult protection procedures. The medication room must be fitted with an appropriate locking device
DS0000027126.V254807.R01.S.doc Timescale for action 01/02/06 2 OP7 15 (2) 01/02/06 3 OP7 15 (2) 01/01/06 4 OP18 18(1)(C) (i), 13 (6) 01/02/06 5 OP19 13 (4) (C) 01/12/05 Burroughs, The Version 5.0 Page 20 6 7 8 9 10 OP19 OP19 OP19 OP19 OP27 13 (4) (C) 13 (3) 18 (10) (C) (i) 13 (3) 18 (1) (a) 11 OP33 24 12 13 14 OP38 OP38 OP38 18 (1) (C) (i) 18 (1) (C) (i) 13 (4) (C) The lock on the cupboard outside of the dementia unit must be made good. All refrigerators must be operated at the correct temperatures Staff must be trained to report incorrect fridge temperatures The temperatures of all fridges and freezers in the home must be accurately recorded each day. The registered person must that sufficient numbers of staff are working in the home at any one time. An annual development plan must be devised and implemented that takes into account the criteria listed in NMS33. THIS IS RESTATED FROM THE LAST INSPECTION. THE TIMESCALE FOR ACTION WAS NOT MET. The Deputy Manager must be trained in undertaking risk assessments of the home. All staff must be trained in spotting and reporting hazards. All trailing wires must be made safe. 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/03/06 01/02/06 01/02/06 01/01/06 Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 21 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 OP12 Good Practice Recommendations As not all service users will have family and friends visiting them or taking them out at weekends, consideration should be given to providing some organised activities at weekends. The possibility of using additional volunteers to further extend the programme of activities specifically for service users with dementia, should be actively considered. The procedure for reporting maintenance issues should be improved, perhaps by having a book for the purpose within each unit of the home. It is strongly recommended that the manager and deputy manager do not both work only Mondays to Fridays. A manager should be on duty at weekends. 2 3 4 OP12 OP19 OP27 Burroughs, The DS0000027126.V254807.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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