Inspection on 26/04/05 for Burroughs, The

This inspection was carried out on 26th April 2005.

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

Burroughs, The 02/10/07

Burroughs, The 18/04/07

Burroughs, The 07/12/06

Burroughs, The 28/04/06

Burroughs, The 25/11/05

Burroughs, The 08/11/04

Burroughs, The 14/06/04

Burroughs, The 28/07/03

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 The Burroughs Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector Gavin Thomas Unannounced 26 April 2005 at 11.20am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Burroughs Address Mill Road West Drayton Middlesex UB7 7EQ 01895 435 610 01895 435 611 manager.burroughs@careuk.com Care UK Community Partnerships Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Services users to include 10 DE and 65 OP. Date of last inspection 8th and 9th November 2004 Brief Description of the Service: The Burroughs is a care home for 75 older persons. The home is situated close to West Drayton High Street and public transport routes. It is owned and managed by Care UK. All referrals to the home have to be made via the London Borough of Hillingdon who is a block purchaser. The home is divided into six residential units. Five of the units accommodate sixty five elderly frail service users and the remaining unit is for ten service users with dementia. This unit is situated on the ground floor. There are sixty nine single bedrooms and three double rooms. The home was extended in 2001 and all of the bedrooms in the new extension have ensuite toilet and wash basin facilities. There is a large enclosed garden to the rear, with seating areas, and a large car park at the front of the building. Additional parking spaces are provided to the side of the building. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? 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. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 The Statement of Purpose and Service User Guide were easily accessible to service users and visitors to the home. The home maintains an assessment process for prospective service users to ensure the suitability of the service. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The Statement of Purpose now includes details relating to the size of rooms. The Service User Guide, which is titled “Welcome Pack”, includes details relating to the provisions of service. Although this document does not include a description of the service, these details are provided in a separate brochure and given to prospective service users in addition to the Service User Guide. These documents are displayed in the main entrance of the home. An assessment process was in place. All referrals are made via the London Borough of Hillingdon who is a block purchaser. Initial assessments are carried out by the Registered Manager to assess the suitability of the home in relation to the needs of a prospective service user. Further assessments are carried out on admission. All prospective service users are informed in writing of the outcome of their assessment and suitability of the service to offer them a placement. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8 Although individual plans of care were in place for all service users, the frequency of reviewing these plans of care must still improve. The method of recording the needs of service users with dementia could be improved upon. EVIDENCE: Individual plans of care were in place for all service users. The format of individual plans of care is broken down into various sections. Whilst it was noted that the frequency in reviewing each plan of care had improved, this must still improve to ensure that all sections of each plan of care are reviewed at least monthly. The care plans for service users with dementia must be more detailed and reviewed more frequently to monitor and provide for service users changing needs. At the time of this inspection, one service user had a pressure area. This was being treated by District Nurses. The Community Health Team supports the home, in particular for service users with dementia. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 9 All service users were registered with a GP. Service users had access to primary health care treatments. The types of treatments and services were recorded on service users care plans. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The general activities program outlined the various types of activities available to service users. However, the activities provided in the unit for people with dementia must be more specific. The feedback given on the quality of cooked chill meals on this inspection was more positive on this visit. EVIDENCE: The home has two activities co coordinators who arrange and carry out daily activities with service users. The home does not have its own transport. Some service users use taxis or Dial A Ride transport for trips away from the home. One service user said they go the local pub most evenings to meet up with friends. The Registered Manager said that the home intends to set up more formal meetings to consult with service users on the provisions of social and leisure activities. A general activities program was in place. A separate activities program must be devised to indicate the types of activities carried out with service users with dementia. The home continues to provide “cook – chill” meals. A detailed survey was carried out by an independent consult with service users in January 2005 with regards to the provisions of these meals. The majority of recommendations made as a result of this survey had been implemented. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 11 One staff member said that service users in one unit had not complained about the quality of the food since this survey was carried out. Three service users said they had no complaints about the food. A revised menu for cook chill meals is now in place and kept under review. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints process in this home is satisfactory. The revised document for recording and investigating complaints will provide sufficient information to demonstrate how all complaints are managed. The home does well in providing different aspects of training in the protection of vulnerable adults for the staff team. EVIDENCE: A complaints policy and procedure were in place. The complaints procedure was displayed in the entrance of the home. This was also included in the Statement of Purpose and Welcome Pack. The home had not received any complaints since the last inspection. However, a new format for recording and investigating complaints has been implemented. An adult protection policy was in place. There were no changes to this policy. The home had a policy on implementing the No Secrets guidance. However, the home was not in receipt of a copy of the Department of Health No Secrets Guidance document. This must be obtained and disseminated amongst the staff team. Some staff were attending in house training on the protection of vulnerable adults on the day of this inspection. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21 & 23 The premises were clean and well presented. The matters identified do not impose an immediate threat to service users but must be addressed to improve the environment and first impressions of the home. EVIDENCE: Since the last inspection, areas of the home had been redecorated. This was on going at the time of this visit. Generally, the home was well presented and clean throughout. A number of areas require attention. In particular: • • • • The carpets in the three conservatories, which are also used as dining areas, were stained. These carpets must be replaced. The walls in the conservatories in Lilett and Neilson units were badly marked. Part of the worktop in Lilett unit was chipped. Some of the cupboard doors in High Grove unit were chipped. G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 14 The Burroughs • The wallpaper in the lounge in High Grove was torn. A day-to-day maintenance program was in place. The home has a total of sixteen toilets, five baths and four showers. The provisions of service users bedrooms were in keeping with the criteria as set out in standard 23. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 The deployment of Team Leaders and senior staff enables each unit to function individually in a home this size. Training opportunities are well maintained. EVIDENCE: The home has a total of fifty-eight care staff and a five domestic/housekeeping staff. Staff rotas were maintained. A number of care staff had been recruited since the last inspection. Two new staff said they were in the process of completing their induction. One agency member of staff who has worked at the home for some time said that they enjoy working at the home. Four service users said they could not fault the staff. The service users said that staff are always willing to assist them. The rota is designed to enable Team Leaders to carry out administrative duties and formal supervisions with the staff team. The Registered Manager said that staffing levels meet the needs of the current service user group. The staffing levels in Palm unit which is also the unit for service users with dementia is maintained with two staff on duty at all times. There are six waking night staff on duty at all times and one member of the senior team on sleeping in duties. The Registered Manager is available outside of normal working hours for on – call purposes. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 16 A training officer employed by Care UK provides the majority of training including induction and foundation training. External training companies also provide training. A training program was in place. Four staff spoken to said that they were satisfied with the training opportunities available to them. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 & 38 Progress had been made in devising a quality assurance and monitoring system but this must be fully implemented. Health and safety monitoring checks were in place. However, some of these systems require further detail to maximise the safety of service users. EVIDENCE: The Manager is now registered by the CSCI for this establishment. The Registered Manager is still working towards the Registered Manager Award qualification. The Registered Manager said she operates an open door policy. All staff, service users or visitors are not restricted in expressing their views or opinions with regards to the running of the home. Four staff said they are fully supported by the Registered Manager and the senior team. One staff member said this is one of the best residential homes they have worked in. The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 18 A draft business and financial plan was in place. An annual development plan was not in place. The Registered Manager said that proposed themes for service users surveys have been discussed. An example of this was given at the time of the inspection. Copies of reports for Regulation 26 visits to the home are supplied to the CSCI. A health and safety policy was in place. Inspection of records indicated that gas, electrical and fire appliances are tested by approved contractors. However, according to records in place, the most recent test on fire appliances was carried out in August 2004. Testing of the fire appliances must be carried out at more regular intervals. The record for fire drills had not been updated with the times of fire drills. The record did not state the duration of the fire drills. The format for recording fire drills was updated at the time of this inspection. Fire drills are still being done without the inclusion of service users. Advice has not been sought from a Fire Officer for approval of this arrangement and appropriate evacuation procedures. The record of hot water temperature tests lacked sufficient information to indicate the appliances tested. Health and safety risk assessments in place were devised in 2000. These assessments must be revised and updated. Service users in Neilson unit said that the air conditioning facility was not working. The Registered Manager said that the fault had been referred to an approved contractor for repairs. An approved contractor carried out an audit on the control of legionella in the water system in March 2005 The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 x 3 x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x x x x x The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation Requirement Timescale for action 30/6/05 2. 7 3. 12 4. 5. 18 19 6. 7. 8. 19 19 19 15(2)(b)(c All individual plans of care must ) (d) be reviewed and where necessary updated on a monthly basis. 15(2)(b)(c The format of indivual plans of ) care for service users with dementia must be modified to demonstrate how service users changing needs are met. (Timescale of 31/12/04 not met). 16(2)(n) A separate activities program must be devised to indicate the types of activities carried out with service users with dementia. 13(6) The home must obtain a copy of the Department of Health - No Secrets guidance document. 23(2)(d) The carpets in the three conservatories, which are also used as dining areas must be ideally replaced. 23(2)(d) The walls in the conservatories in Lillett and Neilson units must be redecorated. 23(2)(b) The chipped cupboard doors in High Grove unit must be repaired. 23(2)(d) The torn wallpaper in the lounge in High Grove unit must be G61_s27126_The Burroughs_v213589_260405 Stage 4.doc 31/7/05 30/6/05 30/6/05 31/7/05 31/7/05 31/7/05 31/7/05 Page 21 The Burroughs Version 1.30 repaired . 9. 10. 19 33 23(2)(b) 24 The chipped worktop in Lilett unit must be replaced. (Timescale of 28/2/05 not met). An annual development plan must be devised and implemented, taking into account the criteria as listed in Standard 33. Testing of the fire appliances must be carried out at more regular intervals. Clarification must be sought from a Fire Officer to establish and confirm the arrangements for fire drills and evacuation procedures. (Timescale of 31/1/05 not met). The record of hot water temperature tests must be written in sufficient detail to indicate the appliances tested and action taken to address any issues with the temperature of hot water to bathing and showering facilities. Health and safety risk assessments must be revised and if necessary, updated. 30/6/05 30/6/05 11. 12. 38 38 23(4)(a) (iv) 23(4)(c )(iii)(e) 31/5/05 31/5/05 13. 38 13(4)(c ) 31/5/05 14. 38 13(4)(a)( b)(c ) 31/7/05 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 Good Practice Recommendations The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 The Burroughs G61_s27126_The Burroughs_v213589_260405 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!