Inspection on 02/09/05 for Burrow House

This inspection was carried out on 2nd September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Burrow House 23/08/06

Burrow House 12/08/04

Burrow House 05/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Burrow House Highfield Road Ilfracombe North Devon EX34 9JP Lead Inspector Andrew Towse Unannounced 2 September 2005 10:00hrs 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. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Burrow House Address Highfield Road Ilfracombe North Devon EX34 9JP 01271 863685 01271 866035 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) Devon County Council Mrs Stella Margaret Scoins Care Home 26 Category(ies) of DE(E) Dementia - over 65 (26) registration, with number OP Old age (26) of places PD(E) Physical dis - over 65 (26) Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 April 2005 Brief Description of the Service: Burrow House is a detached, purpose built residential care home. It is situated on three floors with all areas being accesible to residents through the use of stairs or passenger lift The home has several lounge and dining areas, affording a variety of recreational areas for residents. It also offers accommodation to people requiring respite care and a day centre on the premises allows residents to participate in activities alongside day care service users. The home itself is well maintained. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The registered manager was not present and the assistant manager on duty had only recently returned to work. The information contained in this report was obtained through inspection of records, including Care Plans, observation and discussion with the assistant manager, staff and service users. This is the second statutory inspection made of Burrow House and does not include all core standards as many were inspected at the previous inspection of 7th. April 2005 and can be found in the report of that 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. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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 Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) 6 EVIDENCE: Standard 3 was inspected as part of the previous inspection. At that time it was assessed as meeting the requirements of the National Minimum Standards. Burrow House offers permanent, respite and interim care. It does not offer intermediate care. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) 9 Whereas the home has procedures to safeguard residents who self medicate, good storage facilities for medication and appropriate recording systems, that no evidence was available to demonstrate that night care staff, who administered medication, had received training, lessens the safety of an otherwise appropriate system. EVIDENCE: Core Standards 7, 8, and 10 were inspected during the inspection of 7th. April 2005. At that time they were assessed as meeting the requirements of the National Minimum Standards. Burrow House operates to the corporate medication administration policy common to residential care homes run by Devon County Council. Burrow House has a separate, locked room in which medication is kept. Medicines were seen to be kept in a locked trolley. There was suitable storage for controlled drugs and appropriate recording of their administration. There is also a locked fridge where medicines requiring cool storage can be kept. The home has a written self medication policy which would allow for residents who had the capacity, to retain and administer their own medication. At the Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 9 time of the inspection there were no permanent residents who were self medicating. Any resident who wishes to self medicate signs a form to accept personal responsibility to do this, however part of this arrangement is that in the interests of the individual’s safety the situation will be regularly reviewed. Medication Administration Record sheets (MARS) were seen to appropriately record the administration of medication. Whilst it was said that all staff who administered medication had received training, evidence to confirm this could not be found in relation to the staff on duty at night who took responsibility for administering medication. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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 Although the residents of Burrow House can access activities run by the day centre and, when available can go on trips into the community, residents considered that the loss of the activities officer has created a gap in the activities available to them. EVIDENCE: Standards 13, 14 and 15 were inspected during the inspection of 7th. April 2005. At that time they were assessed as meeting the requirements of the National Minimum Standards. At the last inspection the home had an activities officer who was seen working with residents to involve them in stimulating and creative activities. Since that inspection this staff member has left Burrow House. In discussion many residents commented on her departure and that this had reduced the activities available to them. The home’s September Newsletter referred to a forthcoming barbecue at the home as well as informing the residents of the departure of the activities officer. Although this staff member’s position remains unfilled, the inspector was informed that it was intended that it would be filled. In the section of the home which accommodates people who are in receipt of respite care, information regarding daily activities was displayed prominently. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 11 This included access to a computer, bingo, sing-a-long, card games and a flipchart for group games. These residents could as, can permanent residents, choose to join in activities arranged for people attending the day centre part of the building. Residents can also go out on trips out. Discussion with the driver showed that he involved residents in the choice of destination, which was enhanced by his knowledge of the area. A template showed that residents have choices at meal times. Residents spoke positively about the food available. It was seen that residents who chose to, could have their meals in their rooms. Residents’ religious needs are met through access to different members of the clergy and communion articles were seen to be stored in the office. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) These two Standards were inspected as part of the inspection of 7th. April 2005. At that time they were assessed as meeting the requirements of the National Minimum Standards. They have not been inspected as part of this inspection. EVIDENCE: Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) 26 Burrow House offers its’ residents a clean and pleasant living environment which has been further improved by the installation of a new sluice facility. EVIDENCE: At the inspection which took place on 7th. April 2005, Standards 19, 23, 24 and 25 were inspected. They were referred to in the report of that inspection. The home has its own laundry area situated away from areas where food is either prepared or eaten. The laundry room has impermeable flooring and washable walls. The home has a separate room which has recently been converted into a sluicing room, complete with a macerator and handwashing facilities. The home has a good standard of hygiene and cleanliness. There was no evidence of malodours in bedrooms or communal areas. Domestic staff were seen cleaning areas of the home during the inspection. The only visible Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 14 detraction from this was corridor carpets which in some areas looked stained and tired. Wherever possible residents are given a choice of bedroom. Bedrooms seen had been personalised. Residents spoken to confirmed that the rooms met their needs. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) 29 Although the home operates to the recruitment policy common to residential homes run by Devon County Council, the records kept in the home were not completed and therefore unable to confirm the robustness of the recruitment policy in ensuring the safety of residents. EVIDENCE: Standards 27, 28 and 30 were inspected as part of the inspection of 7th. April 2005. At that time they were assessed as meeting the requirements expected by the National Minimum Standards. Burrow House operates to the recruitment policy common to residential care homes run by Devon County Council. This requires that two references and that Criminal Record Bureau (CRB) clearance is obtained prior to a staff member being allowed to work unsupervised. These records are kept at the head office, however there are templates in staff files upon which it should be recorded that such information, as is required by Regulation 17, for the safety of residents, has been obtained. These records remained incomplete and as such the home could not demonstrate that its recruitment policy was ensuring the protection of residents. Since the last inspection new care staff have been recruited. At the time of this inspection there is a full complement of staff working with residents in receipt Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 16 of respite care and there is currently only one part time vacancy amongst the remainder of the care staff complement. The standard of cleanliness within the home demonstrated that there are adequate levels of domestic staff. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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) 35 The home has policies and procedures which safeguard residents’ financial interests, however recent poor record keeping needs to be rectified if this system is to be totally effective. EVIDENCE: Standards 31, 33 and 38 were inspected as part of the inspection of 7th. April 2005. At that time they were assessed as meeting the requirements of the National Minimum Standards. Burrow House has safes in which residents’ monies or possessions can be stored. There is a policy relating to the safekeeping of residents’ personal possessions, however at the time of the inspection none was said to be kept on the premises. The management of the home confirmed that there was a procedure for instances when the home held items of value on the behalf of a resident. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 18 The home operates a system whereby all service users receive interest for monies held in their personal accounts. One resident has chosen not to have a personal account and has signed a disclaimer to this effect A record is kept of monies held in the suspense account and on the premises. Although there is in place a system of checking these accounts this has recently not been maintained and records showed some inconsistencies. A record is kept of personal allowances for those few residents who are in receipt of them. The home operates to corporate policies which serve ro protect residents from financial abuse, including precluding staff from getting involved in the writing of residents’ wills, or from benefiting from them. Whilst Standard 31 was assessed in the previous inspection, there was, at this inspection, further discussion regarding the management of the home. A fulltime assistant manager left the home in February 2005 and due to circumstances beyond the control of the home or authority, has yet to be replaced. Another assistant manager is likely to be away from work for a protracted period, which may lead to issues relating to the smooth and effective running of the home unless this issue is quickly addressed. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 1 x x x Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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 35 Regulation 17(2) Sched 4 (9) Requirement Timescale for action 31.10.05 2. 29 9 (4) 3. 9 18(1) (i) A record of all money deposited by a service user for safekeeping or received on the service users behalf which shall state the date on which money was deposited or received, the date to which any money was returned to a service user. The employer has obtained in 31.10.05 respect of that person the information and documents specified in paragraphs 1 - 7 of Schedule 2 The registered manager should 31.10.05 ensure that staff working at the care home receive training appropriate to the work they are to perform (this relates to staff receiving training relating to the administration of medication when they undertake responsibility for this) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 21 Burrow House Standard 1. Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Burrow House D54 D06_s33415_burrowhouse_v241000_020905 stage 4.doc Version 1.40 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. 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