Inspection on 28/06/06 for Burrows House

This inspection was carried out on 28th June 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

Burrows House 24/06/08

Burrows House 28/06/07

Burrows House 09/02/06

Burrows House 16/02/05

Burrows House 04/11/04

Burrows House 05/08/04

Burrows House 07/11/03

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 Burrows House 12 Derwent Road Penge London SE20 8SW Lead Inspector David Lacey Unannounced Inspection 28th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burrows House Address 12 Derwent Road Penge London SE20 8SW 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) 020 8778 2625 020 8659 6240 Servite Houses Limited Ms Shelley Ratcliffe Care Home 54 Category(ies) of Dementia (22), Learning disability (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (28) Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 places registered for service user category MD(E) for named service users only. 9th February 2006 Date of last inspection Brief Description of the Service: This home is provided by Servite Houses, which has a number of facilities throughout London and the South East. The home has 51 beds for service users in the category of Older Persons and Dementia. The home is purpose built over two floors. Individual bedrooms and communal space are provided on both floors. The kitchen and laundry are on the ground floor. The home is separated into seven units. Each wing has two units, with its own kitchen, dining and sitting area. Staff are allocated to specific units and waking night staff are provided. All policies and procedures are generated centrally with amendments made to reflect the local situation. The head office deals with recruitment of new staff. The kitchen is operated through an external contract agreement. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors spent a full day in the home, and one inspector returned for a further half-day to complete the inspection. The registered manager and members of staff on duty assisted with the visit to the service. The inspectors are grateful to the service users who contributed to the inspection. The inspectors’ visit was unannounced and the standards the Commission considers to be the key standards were inspected. The inspectors spoke with service users, visitors and staff members. They toured the premises, observed care practices, and examined documentation. What the service does well: What has improved since the last inspection? No service users have been admitted whose needs are outside the home’s current terms of registration. There have been improvements to the environment. Handrails have been provided in all communal areas, to assist service users to move about the home safely. A room has been provided for service users to meet with visitors in private other than in their bedrooms. There is a redecoration programme in progress. Evidence was seen that service users’ clothing is now being appropriately labelled in a way that maintains their dignity. Action has been taken to minimise the risk of infection being spread within the home. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 6 The manager has made working links with the local social services adult protection coordinator. Guidance about whistle-blowing has been made available to staff members. Overall, the application of medication procedures had improved since the previous inspection. However, please also see section below. 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. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 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 Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 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): 1, 2, 3, 4 (6 does not apply to this home) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users have the information they need to decide whether to move into the home. Documentation needs amendment to ensure it gives accurate information about the home’s registration. Service users’ needs are assessed before they move into the home, and service users know that the home will meet their needs. EVIDENCE: Copies of the home’s service user guide were seen in bedrooms. The guide had service users’ terms and conditions of residency, including the room to be occupied. The document incorrectly makes reference to the home being registered by the London Borough of Bromley, this should be either updated or deleted. The guide contains information about the homes complaints procedure. A service user whose records were examined had been admitted to the home for respite care. The local authority (Bromley) had supplied a detailed care plan Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 9 and individual assessments had been completed about the service user’s mobility, personal care needs, and dietary preferences. The records were inspected of a service user who had been admitted to the home recently. There was a detailed assessment supplied by the local authority (Bromley) as well as hospital discharge notes. A care plan had been prepared. Two other service users’ records were seen. Each had care management assessments of their needs, with care plans drawn up from the assessments. Care management reviews had taken place, with reports on file. The inspectors saw letters on service users’ files stating that following assessment the home was unable to meet the particular service user’s needs. Subsequently, each service user had been admitted to the home. This was raised with the manager who confirmed the letters were an administrative error that she would rectify. The service users had received letters confirming that the home could meet their needs. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 10 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. All service users have individual care plans. The home aims to ensure their health care needs are met. The application of medication procedures has improved but there are still some shortfalls. EVIDENCE: In the service users’ records examined during the inspectors’ visit, staff had made daily entries about each service user’s health, personal care and general demeanour. However, there was no evidence of the service users or their representatives being involved in the care planning process. During the inspection visit, relatives were seen speaking with the home’s duty officer about arrangements for transferring their newly admitted relative from her existing GP to the home’s doctor. The relatives supplied details of the current GP who is also local to the home, but the duty officer did not explain that it was possible for their relative to retain her current GP if that GP was in agreement. The inspector needed to draw this to the duty officer’s attention so that she could give this information to the relatives. It was evident that the relatives only got this important information by chance, because the inspector Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 11 happened to be present at that time. The home must ensure that service users are involved in planning their care and enabled to make decisions about their care whenever possible. The care plan for one service user case-tracked showed that she should be weighed monthly but there was no record of her weight upon admission or that she had been weighed regularly thereafter. There was a pressure sore risk assessment included in her notes, however the service user’s weight had not been recorded on this document either. Risk assessments for two service users had been dated but not signed, which can impact on accountability for these assessments. It was pleasing to note that, overall, the application of medication procedures had improved since the previous inspection. However, there is no room for complacency, as some shortfalls were still evident. The most serious of these was found when the inspectors toured the premises soon after arriving at the home. They found the door to the medication room unlocked, and the medication fridge (which contained medication) was unlocked with the keys left in the door. The creams cupboard was open. A large box containing medication to be returned to the pharmacist had been left out by the window, which was ajar and had a window lock that was not working. These matters were raised with the manager for her immediate attention. The windowsill of this ground floor medication room is very low and opens on to the home’s car park. It would have been easily possible for a person to step into the room from outside. This was also discussed with the manager, as a security issue to be addressed. The units sampled had a record of staff signatures, and handwritten entries on MAR sheets had been signed by two members of staff and dated. There were no unexplained gaps on MAR sheets, though there were instances of medication doses being changed by hand to ‘as required’. Doses of paracetamol for a service user had also been changed in the same manner. Staff did not know who had changed the record or if the GP had authorised the amendment. There were no photographs for a number of service users in relation to their medication. Morning medication that a service user had refused had been put back in the cabinet, the staff member stating she had been too busy to return to the medication room for its disposal. The medicines policy on file was from Servite Houses Care Services, dated January 2006. The home is to start using the services of Boots (Croydon) shortly. It was understood Boots staff were coming to the home to give training to staff in the use of blister packs. Carers have been undertaking medication training organised by the provider so they can become competent to give medicines. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 12 There were no service users administering their own medication, thus this aspect of practice was not assessed on this occasion. Evidence was seen that service users’ clothing is now being appropriately labelled in a way that maintains their dignity. Thus, a previous requirement in this respect was met. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home must deliver its planned programme of activities for service users. Service users can see their visitors when they wish. A nutritional diet is provided, though more flexibility to accommodate service users’ altered choices would be of benefit. EVIDENCE: Two service users who had not been living in the home long said they found staff were kind and helpful and they had been made to feel welcome. The home’s service user guide states service users would be provided with such activities as music and movement, discussion groups, art group and outings. The inspector spoke with individual service users and a group of five service users, all of who said they would like to take part in more activities. Two service users said they would like to play bingo and one said she would like large print playing cards. Service users made comments such as I just sit here all day, time goes so slowly, or said they had only been out of the home when helped to do so by visiting relatives. At the time of the previous inspection, the area manager stated the task of arranging activities would be allocated to care staff on a trial basis. From discussion with service users and staff and from observation, it seems they have insufficient time to fulfil this Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 14 requirement in addition to the care duties they must perform (please see comments under Standard 27 about staffing levels/mix). A group of service users were watching the tennis on TV in the upstairs lounge but the reception was poor. Moving the indoor aerial was of limited benefit. The service users’ said the TV reception was always poor. It is recommended that the provider take steps to improve the TV reception for the benefit of service users, as this appears to be a main activity for many. It was understood that the provider has arranged for activities training for the manager and the senior care staff. The inspector looks forward to assessing the outcomes of this training, in terms of benefit to service users. Another staff member said sometimes, due to lack of staff, she has to feed three service users at the same time. This practice was not observed during the inspectors’ visit but please see standard 27 for comments about staffing levels. Catering staff are not employed by Servite Housing, but an external contractor has been retained to undertake this task. The chef stated that menu planning is undertaken centrally by his line manager. There was clear evidence of service users being provided with a varied nutritional diet but on this occasion vegetables provided to service users did not tally with the menu and was therefore not an accurate reflection of the food provided. A service user changed her mind when her meal was served from the beef casserole she had ordered to the vegetable quiche the other service users were eating. Staff inquired at the kitchen she could have quiche but there was none available, though the chef did offer to prepare an omelette. Whilst there is a need for the catering company to maintain some portion control, some flexibility is expected to ensure service users’ choice, particularly as in this instance staff stated they knew the service user would change her mind. It was good to see that there is a pictorial menu. The chef inquired if there was any up-to-date information available regarding catering for older people and the inspector suggested Eating for health in care homes”, a practical nutrition handbook from the Royal Institute of Public Health. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users’ complaints will be dealt with in line with the home’s complaints procedures. The provider takes prevention of abuse seriously and is arranging for training from the local authority in this respect for its staff. EVIDENCE: Information about the companys complaints procedure was seen in the service user guides in bedrooms. The home’s manager has developed links with the local authority’s adult protection coordinator. It was understood that adult protection training for staff has been arranged with the local authority (Bromley). It is anticipated that a previous requirement in this respect will be met in full once staff begin this training. Following the previous inspection, guidance about the company’s whistleblowing procedure had been produced and was on display in the staff room. It was evident that the area manager had also discussed this issue with staff. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. In general, there continues to be a disparity between the bedrooms on the physically frail side compared to the unit accommodating service users with dementia. The quality of the environment for the latter is poor by comparison. The home continues to benefit from the ongoing redecoration programme. The call alarm system was not fully operational. EVIDENCE: Since the last inspection handrails had been fitted to all corridors. Thus, a previous requirement in this respect had been met. Apart from one bathroom, all communal areas were clean and free from unpleasant odour. One bedroom had odour and another bedroom had a slight odour. The wardrobe in one bedroom was unstable. An audit and risk assessment must be undertaken in relation to wardrobes, and if this highlights a potential Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 17 risk the wardrobe should be replaced or secured to the wall. This matter was discussed with the manager during the visit. Two bedrooms were assessed, as part of case-tracking the service users occupying them. One room had been very well personalised, with a high level of family input. The other service user had less family contact and the room had considerably fewer personal items and touches. At the previous inspection discussion took place about the need for staff to support service users where necessary to personalise their rooms, and a recommendation was made in this respect. This recommendation is repeated. The home now has a room that service users can use for private conversation with visitors. Issues arose in relation to the emergency call system, and the home must ensure this is kept in good working order. One service user did not have an emergency call point in a room, she stated that she had never had one and if she needed a member of staff she called out from her bedroom door. Another service user could not reach her emergency call alarm, she was sitting at one end of the room whilst the call point and cord remained tied up at the other end. From tests to the call system, it was apparent that care staff working on the units were unable to hear the system when activated. Both tests were responded to by the duty manager, who was carrying a bleep. This matter was discussed with the manager who stated that 10 bleeps had recently been repaired, however eight had disappeared from reception. The manager stated that the memo had been sent to all staff stating that unless these was returned by Friday the 30th of June the police would be contacted. The CSCI had not received formal notification of this incident, which is being considered by the home as possible theft. Improvements were noted to arrangements for preventing infection, in response to a previous requirement. However, staff must remain vigilant to ensure these improvements are maintained. For example, a clinical waste bin was seen in the hairdressing room. This was drawn to the attention of the manager, who took immediate action to remove it. The laundry area needed a thorough cleaning to remove the build-up of dust behind appliances; this not only looked unsightly but was also a potential fire risk. This was raised with the manager during the visit, and she agreed to ensure the cleaning would be done. A large number of tiles needed to be replaced to ensure that the area could be cleaned effectively. The person working in the laundry felt that the current tumble dryers provided were inadequate to meet the needs of the current service user group. The manager stated that she requested an additional dryer approximately eight months previously but to date this had not been agreed. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 18 Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 19 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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The staffing levels and skill mix need review to ensure service users’ needs may be met promptly and effectively. Improvements are needed in the application of recruitment policy and practices. The home supports its staff to undertake relevant training. EVIDENCE: The home was not fully occupied at the time of the inspectors’ visit. However, from discussion with staff and from observation, it was evident that there were not enough members of staff on duty to meet the needs of the current service user group. Staff spoken with stated the current staffing ratio on the physically frail unit was two staff to fourteen service users in the morning, however between approximately 15.00 and 17.00 this was reduced to one staff member, with another member of staff floating between floors as required. A member of staff stated that the previous day the second person working with her was supplied by an agency, the person had not been to the home before and did not know the service users’ specific needs. The member of staff stated that she felt exhausted as the agency staff was very limited by her lack of knowledge of the service user group and, in addition to the service user she was assisting, she had to provide constant guidance to the agency staff. The member of staff stated that she had had no breaks during her working day; Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 20 she said that she did not finish serving breakfast until 10.30am because of her workload. Another staff member said sometimes she has to feed three service users at the same time because she knows they want the food but cannot eat without help. One service user told the inspector “I was told off for asking for milk for my cereals when staff were busy. Service users offered comments such as they are good girls they work very hard were made, and one person said I wish I could do more to help them, they’re so busy. Two of the service users on the physically frail unit were in wheelchairs and discussion took place about how assistance would be provided if they required help with personal care. The member of staff stated that she would either perform the task alone, or the service users would have to sit and wait until the floating member of staff could help. Such delay could result in a service user having to remain unclean and uncomfortable for a period of time, may affect their health and could be hazardous both for the service user and for the member of staff. Staff stated service users were assisted to shower or bath at various times during the day as it was not possible to provide this level of support first thing in the morning or before going to bed. Staff were seen to be writing up service users’ daily records in the communal lounges. There was general discussion about service users and the sort of day they had, and it would be possible for service users to hear information about their peers that should remain confidential. It was clear from discussion with staff that they perceive this as another time consuming task, which they were trying to get through before going off duty. Additional staff would enable staff to move off the floor to complete documents and maintain confidentiality. The inspector observed the duty officer dealing with matters that could be readily handled by an administrator/receptionist. The provider should consider employing an administrator, which would enable ‘duty officers’ to spend more time working with service users and supervising care. An administrator would also be able to give support to the home’s manager. The assistant manager post was vacant and being advertised. The manager said that at least 1277 care staff hours were being provided each week at the home. She said that sometimes it is necessary to increase this amount, which she can do but must give reasons to the provider. There was no assessment available of the dependency levels of the current service users resident in the home, thus this staffing hours figure cannot be compared directly with DH staffing guidance. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 21 The manager advised that there was to be a review next month of staffing at the home and agreed to provide the CSCI with details of the outcome of this review. The home supports its staff to undertake relevant training, though more staff should attain NVQ2 in care. Two staff members said that training was made available to them; “there’s never a problem about asking for training”. Comment has been made above under NMS 18 about adult protection training. The home had not fully met a previous requirement about staff employment records. Three staff files were examined and found to contain some of the documentation required by legislation. The manager stated that some recruitment information is held centrally by the provider’s human resources (HR) department and thus not available for inspection in the home. For example, staff contracts are held centrally. The manager stated that, following selection interview, documentation including the interview notes is sent to HR and a CRB disclosure through the company is then arranged. The staff files did not have job descriptions, and the manager stated that the provider is presently reviewing these. Two of the three files seen did not contain two written references and one did not have proof of identity. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 22 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, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The manager is fit to run the home, having been assessed as such by the Commission. The home is developing its quality assurance processes, with further work still needed. Some staff members receive regular supervision and the manager is taking steps to extend this to all staff. The home promotes the health and safety of its service users and staff. EVIDENCE: A previous requirement to establish and maintain a quality assurance system had been met in part. An internal audit system, centred on a ‘non-conformance and action plan’ was being put in place but was not yet fully operational. The provider was now undertaking monthly visits to the home, in compliance with regulations, and was supplying reports to the CSCI. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 23 Supervision records were seen in two of the three staff files examined. All staff should have supervision, in line with the relevant national minimum standard. The manager stated she has now set up a system to ensure supervision occurs at the appropriate intervals, and the inspector saw a matrix that had been designed for this purpose. It is important that the effectiveness of this new system is monitored to ensure there is benefit to service users. The accident book was seen and included details of an accident when a service user had been taken to hospital the day before the visit, following a fall. A quarterly test of the fire alarm system and emergency lighting had been last carried out on 25/05/2006. Records showed that fire safety training had taken place in the home on four occasions in February 2006, which a total of 32 staff members had attended. A further training session had been carried out for 9 staff members in June 2006. Night staff had been included in the training. Staff members spoken with confirmed they had attended training and understood fire safety procedures. Gas and electrical certificates were up to date. As regards the water supply, a Legionella risk assessment had been carried out by a contractor in March 2006. The passenger lift had been serviced in May 2006. Discussion took place regarding the frequency of the maintenance checks to the hoist, this had only been checked once in 12 months, both inspectors thought this should be undertaken 6 monthly. Following clarification regarding LOLER requirements, an immediate requirement was issued for servicing/inspection of lifting equipment. The home’s manager subsequently provided evidence to the CSCI that this requirement had been met within the given timescale. Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 2 3 Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 25 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. 4 Standard OP18 Regulation 13 (6) Requirement The registered person must make adult protection training available to staff including clear guidelines on the companys whistle blowing policy. Requirement has been partially but not fully met within previous timescale of 30/05/06. Please see comments in the report under standard 18. Timescale for action 31/10/06 7 OP29 7&9 sch2 Records regarding staff 30/09/06 employment are held in the home available for inspection and comply with schedule 2. Requirement not fully met within previous timescale of 30/06/06. Please see comments in the report under standard 29. The registered person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. Requirement not fully met within previous timescale of DS0000006942.V298972.R01.S.doc 8 OP33 24 31/08/06 Burrows House Version 5.2 Page 26 30/05/06. Please see comments in the report under standard 33. 1 OP22 23 The registered person must ensure equipment is maintained in good working order, in this instance, the call alarm system. The registered person must give notice to the Commission without delay of the occurrence of any theft in the care home, in this instance, the call alarm bleeps. The registered person must ensure that the procedures for recording, handling, storing, administering and disposing of medicines are adhered to at all times. The registered person must ensure that staff enable service users to make decisions about their care whenever possible, in this instance, choosing a GP. The registered person must ensure that the care home is conducted so as to make proper provision for service users’ care, in this instance, recording service users’ weights at the intervals shown in the care plan. The registered person must ensure the planned programme of activities is delivered. The registered person must ensure that an audit and risk assessment is undertaken in relation to wardrobes, focusing on their stability. The registered person must DS0000006942.V298972.R01.S.doc 31/07/06 2 OP37 37 31/07/06 3 OP9 13 31/07/06 4 OP8 12 31/08/06 5 OP8 12 31/07/06 6 OP12 16 31/08/06 7 OP19 13 31/07/06 8 OP27 18 31/07/06 Version 5.2 Page 27 Burrows House ensure that at all times the staffing levels and skill mix are sufficient to meet the needs of the service users. (Please advise the CSCI of the outcome of your forthcoming staffing review). 9 OP26 13 The registered person must ensure that the laundry is kept clean, notably at the back of the machines, and tiling replaced. 31/08/06 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 OP15 OP9 Good Practice Recommendations The home needs to ensure a record of all food provided to service users is maintained. A record of staff signatures needs to be maintained for the purpose of auditing medication. Staff need to assist all service users to attain an individually personalised bedroom. All staff need to be provided with a copy of the GSCC code of conduct. The home needs to work toward 50 of the staff group attaining an NVQ2 qualification. The registered person should ensure the home’s service user guide is updated to remove its incorrect reference to the home being registered by the London Borough of Bromley. The registered person should ensure the upper lounge’s TV reception quality is improved. DS0000006942.V298972.R01.S.doc Version 5.2 Page 28 3. 4. OP19 OP29 5. 1. OP28 OP1 2. OP12 Burrows House 3. OP27 The registered person should consider employing an administrator, to support the manager and undertake reception duties. The registered person should monitor the effectiveness of the new supervision matrix to determine the outcomes for service users. The registered person should ensure that risk assessments for individual service users are always signed by the person making the assessment. The registered person should ensure that whenever practicable service users receive the meal of their new choice after change their minds about a previous food order. The registered person should consider installing an additional dryer in the laundry. 4 OP36 5. OP7 6. OP15 7 OP26 Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Burrows House DS0000006942.V298972.R01.S.doc Version 5.2 Page 30 - 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. 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