Inspection on 28/04/06 for Burroughs, The

This inspection was carried out on 28th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burroughs, The 02/10/07

Burroughs, The 18/04/07

Burroughs, The 07/12/06

Burroughs, The 25/11/05

Burroughs, The 26/04/05

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 Burroughs, The Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector Robert Bond Unannounced Inspection 28th April 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 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.V288352.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include 10 DE and 65 OP Date of last inspection 25th November 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.V288352.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is a ‘key inspection’ in that all the key National Minimum Standards (NMS) for care homes for older people were inspected this time, and the results will be used to benchmark the quality of the home. The Inspector interviewed the Registered Manager and Deputy Manager, met other staff, talked to service users, toured the premises, and examined a variety of records and policies. Two care files were examined in detail (casetracked). The Inspector assessed the home’s performance against 22 of the NMS and found that the NMS identified outcomes were fully met in 15 instances, and were only partly met in 7 cases. The Inspector made 14 requirements (1 of which are restated from the last inspection having not been achieved within the timescale set), and the Inspector made 2 recommendations. The Inspector’s main concerns at this inspection are inadequate assessments of new service users and hence gaps in care plans, reviews of care plans not taking place sufficiently frequently, and the introduction of computerised care plans which is not going as smoothly as hoped. What the service does well: The home is well designed, well decorated and well furnished. The home is clean and hygienic throughout. Good standards of care are provided. The service users had no complaints to make to the Inspector. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The CSCI inspection report displayed in the entrance hall, must be the most current one available. A thorough assessment must be undertaken on prospective service users and the individual plan of care (care plan) must be based on that assessment. Record keeping for service users receiving respite care must be improved. Care plans must include how to meet nutritional and social care needs. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 7 All care plans must be reviewed as required. The Management must be adequately trained in using the computerised care planning system. More activities must be provided, particularly for those in the dementia care unit. The CSCI must be notified straight way of any event that happens in the care home that potentially adversely affects any service user. Fridge operating temperatures must be accurately recorded daily. Old confidential care records must be kept under lock and key. Portable hoists should not be stored in bathrooms. Additional storage areas are required. Improved internal auditing systems are required in order to detect and correct inadequacies in assessments, care plans and review frequency. A full risk assessment of all parts of the care home must be undertaken, and identified hazards must be reduced where possible. 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.V288352.R01.S.doc Version 5.1 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 Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Intermediate care (NMS 6) is not provided at The Burroughs. Prospective service users are provided with inadequate information before they move in. Inadequate assessments are sometimes undertaken prior to a new service user moving into the home. EVIDENCE: NMS1: The Registered Manager reported that the home now offers two respite care places and the home’s Statement of Purpose and Service Users’ Guide have been revised accordingly. The NMS requires that the Service Users’ Guide includes a copy of the most recent inspection report. However the copy of the inspection report on display in the entrance hall of the home was dated 14th June 2004. The previous inspection took place on 25th November 2005. Requirement 1. NMS3: The Inspector case-tracked the admission into the home of two new service users, one of whom was a short-term service user requiring a period of respite care. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 10 The Inspector found that an adequate assessment had been made of the care needs of the respite care service user, these had been recorded but the care plan that had been devised focussed on hygiene and hearing needs, whilst missing the identified needs for social interaction and good nutrition that were fundamental to the service user having been referred for respite care. Requirement 2. No photograph was on file, the property list had not been signed, and there was no evidence to show what property had been returned at the end of the respite period. Requirement 3. The Inspector examined the documentation for a long term service user who had transferred from another care home 26 days before. A pre-admission form had been partly completed by a member of staff from The Burroughs but the form was not signed or dated. Major omissions on the form included physical health, mental health, medication, memory, orientation, sleeping, independence, and interests. Requirement 2. A risk assessment had not been undertaken on this service user. The ‘resident personal details’ sheet on the file was not fully completed as it did not give the date of moving in, or the name of the key worker. Again the form was not signed or dated. The Registered Manager explained that much information was now held on the computer but it was believed that Care UK still required certain information to be kept on paper. There was a lack of clarity about this issue. Recommendation 1. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Individual plans of care do not adequately record social care needs, and as many reviews are over due, the efficacy of the care planning system is suspect. Health needs are sufficiently well met. Service users are sufficiently protected by the home’s medication policies and procedures. Service users are treated with dignity and their privacy respected. EVIDENCE: NMS7: As recorded above, the care plan of the respite care user did not identify how to meet her assessed needs for good nutrition and social interaction, but did consider her hearing and hygiene. The computerised care plan for the long term service user considered her personal care needs in good detail but her social care needs were not considered as her ‘special interests/hobbies’ section was marked as ‘not known’. Her previous occupation or that of her spouse were also marked ‘not known’. Requirement 4. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 12 The Inspector asked the Registered Manager about the present state of reviews of care plans but she did not know and was not able herself to access the computerised care plans to find out. Another member of staff accessed the records to show the Inspector. Half of the care plans showed up as yellow on the computer screen, indicating that their review was overdue. Requirements 5 and 12. NMS8: The care plans examined did consider health related issues such as poor hearing and the use of hearing aids, and hygiene. A weight chart had been set up for the long term service user and her health needs were recorded. NMS9: On the day of this inspection, the pharmacist the home uses had also sent along their own inspector. The CSCI Inspector asked the pharmacist inspector what he was finding and the reply was that the only issue was occasional signatures were missed on the medication administration record. NMS10: The Inspector observed that staff knocked on service users’ bedroom doors, staff treated the service users with respect, and service users were appropriately dressed. No service user any complaints to make to the Inspector. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 The interests of service users are not adequately recorded and sufficient activities are not provided. Service users are able to maintain family and community links. Service users are adequately able to exercise some control over their lives. The food served is sufficiently nutritious and appealing. EVIDENCE: NMS12: The Registered Manager reported that only one of the two activity coordinators was currently in post. The Inspector met the activity co-ordinator and examined the programme of activities. There were errors in the programme in that it showed no activities on certain weekdays but when investigated further it was discovered that weekends remained the time when no activities were organised. The Inspector noted that few of the activities in the programme were for service users in the dementia unit, and that none of the activities slated for the unit were specifically designed for people with dementia, such as reality orientation. See Recommendation 2. The Registered Manager reported that a new activity co-ordinator was about to start who had that relevant skills and training for this work. See Requirement 10, which was Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 14 a recommendation in the previous inspection report that was not acted upon, and see Requirement 6. NMS13: The Registered Manager reported that a fortnightly Church of England service is held at the care home, and two service users are collected weekly to go to the church of their choice. She added that about 50 of service users have relatives that visit the home, but relatives show a lack of interest in attending meetings at the home. NMS14: The Registered Manager reported that a service users’ meeting was held a month before, and would be held quarterly in future. The Inspector examined the minutes and noted that choice of food, bathing arrangements, and GP contact had all been discussed. NMS15: The Inspector examined the home’s menu and noted that it contained sufficient choice. He also observed the food being eaten at lunchtime which was a choice of fish or fried egg with chips. The service users spoken to all said they were satisfied with the food. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are listened to and action taken. Service users are adequately protected from abuse. EVIDENCE: NMS16: No complaints were recorded since before the previous inspection. No service user had any complaints to make to the Inspector. The Registered Manager said that complaints made previously about the cook-chill food had resulted in an investigation and an improvement in the service. NMS18: The Registered Manager reported that all staff had now been trained in Adult Protection (Safeguarding Adults). The deputy manager reported an instance where a referral had been made by the home to Hillingdon’s Adult Protection department. An advocate was involved in this case. The CSCI must also be notified also of any such concern using the Regulation 37 procedure. Requirement 7. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 16 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 and 26 Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. Storage of old files and portable hoists is in need of improvement. EVIDENCE: The Inspector toured the home in the presence of the Registered Manager. The health and safety, security and maintenance concerns that were reported in the last inspection report had been dealt with satisfactorily. The Inspector noted however that the staff’s sleeping in room was not locked. Staff possessions and old confidential care records stored in the lobby of the sleeping in room are therefore not secure. Requirement 8. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 17 The Inspector also found three portable hoists being stored in a downstairs bathroom in Linnet unit. Additional appropriate storage for hoists must be created at the home. Requirement 9. The deputy manager reported that one of the home’s lifts had previously been out of order for some weeks whilst a part was obtained from abroad. This had not been reported to the CSCI at the time as an event adversely affecting service users. Requirement 7. The Inspector found the home to be clean and hygienic throughout, with no unpleasant smells. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 18 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 Service users’ needs are met by there being a sufficient number of staff on duty. Service users are in safe hands. Service users are protected by the home’s recruitment policies and procedure. Staff are sufficiently well trained. EVIDENCE: NMS27: The Inspector examined the home’s staffing rota which demonstrated that sufficient staff were rostered to be on duty. The Registered Manager reported that the home had four care staff vacancies but one new member of staff was about to start. The use of agency staff had been reduced. NMS28: The Registered Manager reported that over 50 of the care staff had NVQ level 2 or 3 in care. NMS29: The Inspector examined a recent staff recruitment file and found that all necessary checks had been undertaken. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 19 NMS30: The Inspector examined staff training records and the home’s training plan. He noted that recent Manual Handling training had taken place. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 The Registered Manager needs to familiarise herself with the computerised care planning system and implement quality assurance systems to ensure that assessments, care planning and review frequency meet the requirements of the NMS. The home is run in the best interests of service users but care plan contents, and the range of activities must be improved. Service users’ financial interests are safeguarded. The health, safety and welfare of service users is not yet adequately promoted and protected. EVIDENCE: Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 21 NMS31: The Registered Manager reported that she is undertaking the Registered Manager Award. She also reported that the manager of another Care UK home is going to provide her and the deputy manager with additional training in the use of the computerised care planning system. Requirement 11. NMS33: The Inspector saw minutes of the last service user meeting. He also saw the home’s Business Plan. What is required in addition is an improved system of internal audit so that the Registered Manager becomes aware of any shortcomings in assessments, care plans and the frequency of reviews so that she can take affirmative action to correct those shortcomings. Requirement 12 NMS35: The Inspector examined a sample of the records kept concerning service users’ money looked after by the care home. NMS38: The Deputy Manager has been trained in Health and Safety and has been made the designated Health and Safety Officer at The Burroughs. Staff have also been trained in their responsibilities by Care UK’s trainer, and each unit of the home now has a maintenance book to report items that require attention. A full risk assessment of the home is now required. Requirement 13. In the Linnet unit, the Inspector found that the refrigerator temperatures were not being recorded accurately everyday. Requirement 14 Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 22 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 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 2 x 2 x 3 x x 2 Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 23 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. 2. 3. 4. Standard OP1 OP7OP3 OP3OP37 OP7 Regulation 5(1)(d) Requirement Timescale for action 01/06/06 01/06/06 01/06/06 01/06/06 5. OP7 The Service Users’ guide must include a copy of the most recent inspection report. 14(1)&15( The care plan must be based on 1) a thorough assessment of needs. 17 Record keeping for the respite care service in particular must be improved. 15(1) The service user plan must show how the service user’s welfare is to be met, including nutrition and social care needs. 15(2) 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. 16(2)(n) 37(1)(e) Activities to stimulate the service users in the dementia care unit must be provided. The CSCI must be notified of any event in the care home which adversely affects the well-being or safety of any service user Confidential records must be kept securely. Hence sleeping in DS0000027126.V288352.R01.S.doc 01/07/06 6 7 OP12 OP18 01/06/06 01/06/06 8 OP19 23(2)(l) 01/06/06 Burroughs, The Version 5.1 Page 24 9 10 OP19 OP12 23(2)(l) 16(2)(n) 11 OP7OP31 9(2)(b)(i) 12 OP33 21(1) 13 14 OP38 OP38 13(4) 13(4)© room must be kept locked. Additional appropriate storage for hoists must be created. Activities must be organised at weekends as half the service users do not have relatives who visit. The registered manager must receive additional training in using the computerised care planning system. An improved internal audit system is required to detect and correct shortcomings in assessment, care planning and frequency of reviews of care plans. A risk assessment of all parts of the home must be undertaken Fridge temperatures must be accurately recorded 01/12/06 01/07/06 01/07/06 01/08/06 01/09/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP12 Good Practice Recommendations The home requires further instruction from Care UK about which documents must continue to be kept as paper copies. The possibility of using additional volunteers to further extend the programme of activities specifically for service users with dementia, should be actively considered. Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 25 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 © 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 Burroughs, The DS0000027126.V288352.R01.S.doc Version 5.1 Page 26 - 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!