Inspection on 28/06/07 for Burrows House

This inspection was carried out on 28th June 2007.

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 28/06/06

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 28 June 2007 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.V335495.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.V335495.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 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.V335495.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. 28th June 2006 (key) 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 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. The dementia unit has keypad locks. Staff are normally allocated to specific units. 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. The fees for this home range from £378.51 - £513.49 per week (information provided to CSCI May 2007). Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home. The manager and members of staff on duty assisted with the visit to the service. During the visit, I spoke with residents, visitors and staff members, and I am grateful for their contributions. I toured the premises, observed care practices, and examined documentation. Since the last key inspection, the commission has carried out two random inspection visits on 28/11/06 and 30/01/07. Both these visits were unannounced. What the service does well: What has improved since the last inspection? There is a redecoration and refurbishment programme in progress, which is bringing improvements to the home’s environment. There is clear separation between the older frail and dementia units within the home. The home has appointed a permanent manager. Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 6 The manager has drawn up a written action plan to address issues identified as needing improvement. The home is recruiting more permanent staff, including care staff. The application of recruitment policy and practices has improved. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burrows House DS0000006942.V335495.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.V335495.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 (6 does not apply to this home). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are offered the information they need to decide whether to move into the home but the statement of purpose and service user guide need updating to ensure prospective service users have all the information they need. Prospective residents’ needs are assessed before they move into the home. Not all residents receive contracts/statement of terms and conditions. EVIDENCE: Eight residents who returned completed comment cards to the commission stated they had received enough information about the home before they moved in so they could decide if it was the right place for them. One person stated s/he had not received enough information. During the inspection, a visitor was looking at the home on behalf of a relative needing to move into a care home. She was shown around the home by a senior carer, including a Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 9 visit to the room that was vacant, and was able to have answers to the questions she raised. The manager stated that all residents on the locked dementia unit must have a formal dementia diagnosis from a psychiatrist, which is recorded on their files. The statement of purpose and service user guide must be amended to reflect this change, and copies supplied to the commission (requirement 1). It was evident from discussions and examination of relevant documentation that either the manager or deputy manager carries out pre-admission assessments of prospective residents. The manager supervises the assistant manager in this respect. The assessments seen identified the residents’ needs, and formed the basis for care planning to meet those needs. Of the residents who returned completed comment cards to the commission, four stated they had received a contract, three that they had not. A sample of four residents’ files was examined during the inspection visit, three of which were found to have contracts, although one of these had not yet been signed by all parties (requirement 2). The home’s additional registration condition was reviewed at this key inspection, to ensure it is still of benefit to residents. This is the subject of separate correspondence between the commission and the home. Burrows House DS0000006942.V335495.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. 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. Residents have individual care plans, which set out their needs although it is not always evident that plans have been reviewed regularly, or that residents or their representatives have been involved in the planning and review of care. The home aims to ensure residents’ health care needs are met, and enables ready access to health care services. Further improvements to the application of medication procedures are to be implemented. EVIDENCE: Four residents’ plans were sampled for inspection. It was positively noted that the home’s new manager has been leading staff’s efforts to improve the standard of care planning. It was generally evident that care plans were drawn from the assessed needs of the individual residents but not all plans contained evidence that they had been kept under review (requirement 3). The care plan format in use does not encourage staff to sign and date each entry made (recommendation 1). Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 11 From the plans seen, there is still a need to develop more meaningful information regarding life histories, especially where a resident has dementia, to ensure care staff can provide effective support (requirement 4). This will help to ensure that those residents with dementia or who spend a significant amount of time alone in their bedrooms are provided with an appropriate level of orientation, interaction and stimulation. In the residents’ plans seen, there was not enough evidence of the residents or their representatives being involved in the process of planning and reviewing care. The home must ensure it is evident that whenever possible residents are involved in planning and making decisions about their care (requirement 5). Residents confirmed they have ready access to health care services as they need. This includes medical and nursing support at the home, as well as support to attend hospital appointments. There was considerable evidence of health care input on residents’ plans. The ‘senior staff communication book’ is commended as good practice in helping to ensure that people’s health care needs are met. Five residents who returned comment cards to the commission stated they always received the medical support they needed, four said this was usually the case and one person stated s/he sometimes received this support. I saw how staff dealt with an accident to a resident that occurred during the inspection visit. A resident fell in the communal toilet next to her room. She told me she had slipped and fallen, and that she had pain to the side of her head and her shoulder. She said she had never fallen before and thought she may have tripped because of the type of slippers she was wearing. A carer alerted a senior member of staff who called for an ambulance and also contacted the resident’s next of kin. The carer remained with the resident to offer reassurance but without attempting to move her until ambulance staff arrived to take her to hospital. The resident’s next of kin also arrived at the home and was able to go with the resident to hospital, and take some things in for her. The location of the medicine storage room has been changed, principally to enhance security. The home’s medication policy and procedure was readily available to staff. Medicines were given safely at lunchtime, according to the current procedure. The manager is introducing a change in the way the medicine administration procedure is to be operated, with two staff to administer. I observed the manager explaining this forthcoming change in procedure to staff at a staff meeting. A senior carer told me she has been giving medication by herself, in line with the company’s policy. She said having two staff members to carry out medicine administration “would be better, it means there’s less risk of making a mistake, also one person can look after the trolley while the other takes the medicine to the person – not having to keep locking and unlocking the trolley should save a bit of time.” There were no Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 12 service users administering their own medication, thus this aspect of practice was not assessed on this occasion. Eight residents stated they always received the care and support they needed, and two said this was usually the case. Two residents told me they were normally treated with respect and their dignity maintained while they are being helped with personal care. In general, staff were considerate of residents’ capacities during interactions, but did not always knock before entering residents’ rooms (recommendation 2). Burrows House DS0000006942.V335495.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. 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 is not always making its planned programme of activities available to residents. Residents can see their visitors when they wish. Generally, residents like the food provided and further improvements to their diet are planned. EVIDENCE: Four residents who returned completed comment cards to the commission stated there were always activities arranged by the home that they could take part in. Two people stated this was usually the case and three that there were sometimes activities they could take part in. One person stated this were never any suitable activities. I did not see any planned activities being offered during my visit. Many residents were sitting in the lounges, not watching the televisions that were turned on but often sleeping in their chairs. A staff member said she thinks residents “must be bored, they’ve nothing to do, there’s no activities going on now, we should take them out on trips”. Another staff member said “we used to take them out to Bromley on dial-a-ride but that doesn’t happen now”. I discussed the lack of activities provision with the manager, who said there is Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 14 normally some activities provision but it is a service the home intends to improve. I concluded that a previous requirement about activities provision remained unmet (requirement 6). It is important that activities offered are suitable for all residents, which may mean planning specific activities for individual residents. Residents may choose to see their visitors at any reasonable time, and it was evident that visitors are made welcome in the home. Staff felt that in general the dependency levels of residents were increasing, hence sometimes residents were not attended to at times they preferred. It was positive to observe discussion at the team meeting, led by the manager, that more attention should be given to promoting residents’ individual choice rather than relying on giving care focused on tasks and routines. A catering company supplies the catering service for the home. The manager stated he is currently working with the chef on a revised menu. For example, there is to be more hot suppers rather than reliance on soup and sandwiches, and more fruit made available throughout the day. The manager was encouraging staff to ensure all residents get plenty of fluids. Of the residents who returned completed comment cards to the commission, four stated they always liked the meals at the home, three that they usually liked them, and one person stated s/he sometimes liked the meals. I saw residents on the upper floor taking their lunch. The tables in the dining room were set with tablecloths, mats and napkins. There was little room between the tables. For example, a resident walking to her place at a table, assisted by a carer, was unsteady on her feet and found it difficult to get to her place. A resident in a wheelchair was unable to get very close to the table but said she was comfortable and was able to eat with help from staff with cutting her food. A resident said it would be nice to have some salt and pepper “I think they’ve forgotten”. I asked a carer who then put condiments including ketchup on the tables. I later noticed there were no condiments on dining tables downstairs (recommendation 3). The lunch was fried chicken with mash potato and vegetables. Three residents said the lunch was good and said the food was usually to their liking. They said they choose what they want, and that staff ask us for our choices the day before. Another resident told me, “we choose what we want, you fill in a form”. She also said her lunch had been very nice and that she thought the food was always good. One carer walked around the room, checking if people were happy with their meals and encouraging them to eat. Staff helped residents with feeding, where this was needed. Staff filled residents’ glasses with fruit squash from jugs. They did not leave jugs on the tables, which meant residents had to rely on being asked by staff if they wanted more to drink. Burrows House DS0000006942.V335495.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. 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. Complaints are managed in line with the home’s complaints procedure but improvement is needed to recording of this process to ensure confidence in the process. Protecting residents from abuse is seen as a priority and additional staff training in safeguarding adults is planned. EVIDENCE: Information about the companys complaints procedure was seen in the service user guides in bedrooms. Of the residents who returned completed comment cards to the commission, two said they always knew who to speak to if they were not happy and four said this was usually the case. Two people said they sometimes knew who to speak to. Seven respondents said they knew how to make a complaint and three said they did not know how to do this. The home provided information before the inspection that showed there had been three complaints in the last year, all of which had been upheld. The commission has received one complaint during this period, which was referred to the provider for action. The complaint was from a relative who was not satisfied with aspects of the care his relative had received. The provider subsequently copied the CSCI into correspondence about their investigation and their liaison with the local authority’s adult protection service, and their response to the complainant. The response upheld most aspects of the Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 16 complaint and confirmed to the complainant that action had been taken to address all the issues raised. I saw the box file that is used to store information about complaints. It was difficult to find information relating to specific complaints and it appeared that not all details were available for each complaint received (requirement 7). The manager confirmed he intends to organise the complaints records, probably filing them monthly to enable identification of any trends. The CSCI has been made aware that the provider is carrying out investigations into three recent allegations. The actions taken so far have included liaison between the home’s manager and the local authority’s (Bromley) adult protection manager, in line with the home’s adult protection procedures. The outcomes of the investigations are awaited at the time of writing this report. The home’s manager stated very clearly to me during the inspection visit that safeguarding the residents living at Burrows House was his top priority. He advised that senior staff at the home will be going on Mental Capacity Act training and undertaking further adult protection (POVA) training, and he discussed this with staff during the meeting I observed. Care staff I questioned showed satisfactory basic understanding of their reporting responsibilities if they witness or suspect abuse of residents. The further training that is planned could improve their level of understanding, for example, about whistle-blowing and the protection afforded by relevant legislation. Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 17 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. 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. The home has made some environmental improvements and service users will benefit further from the ongoing redecoration and refurbishment programme. EVIDENCE: Generally, the home was clean and there was minimal evidence of odour. Of the residents who returned completed comment cards to the commission, four stated the home is always fresh and clean, and six stated this was usually the case. Areas of the home were untidy but this was generally due to the ongoing refurbishment programme. For example, there were a lot of containers in the reception area as new furnishings and equipment had been delivered. The manager has a written plan for the refurbishment. There was much work still Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 18 to be finished and outcomes for residents will be assessed at the next inspection. As noted earlier in this report, key coded locks have been installed on some internal doors. Whereas previously residents from the dementia unit were able to move about the whole home, installing the locks has ensured the dementia unit is separated from the home. Advice from the fire officer’s report was being actioned, for example, external fire doors upgraded. Three sluices rooms were being converted to become storage areas for equipment such as wheelchairs. There will be just one room for clinical waste, with the aim of further improving infection control within the home. Burrows House DS0000006942.V335495.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is positive for service users that the home is recruiting more permanent staff, including care staff. The night staffing levels need review to ensure residents’ needs may be met. Service users are btter protected by the home’s recruitment practises following the improvement of recruitment policy and practices. The home supports its staff to undertake relevant training, and should improve the proportion of care staff who have completed NVQ level 2. EVIDENCE: Seven residents who returned completed comment cards to the commission stated that the staff listened and acted on what they said. One person said staff did not do this. A resident commented, “I am treated very well here”. Staff told me they were normally allocated to one of the units in the home, rather than moving between them. A staff member said this helped her to get to know the residents on a particular unit well, and that residents liked to be cared for by the same staff as far as possible. Staff said there were mostly enough carers on duty to get the work done, though an extra carer at ‘peak’ times, such as breakfast time, would be ideal. A staff member said staffing was “a bit tight sometimes”, giving examples of Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 20 how residents can be left unsupervised if several carers have to attend to a resident. Four residents who returned completed comment cards to the commission stated the staff were always available when they needed them, three said this was usually the case and two stated that staff were sometimes available. The manager stated the home was currently advertising to fill various posts, including an administrator, five carers, and two domestics. He said the aim is to lessen the home’s reliance on agency staff, and move towards a position where there is no need to have agency staff working in the home. He also confirmed, both to me and to staff at a meeting, that staff will no longer be asked to work ‘long days’, except in emergencies, to ensure staff do not become overtired and thus risk compromising standards of care. During the day, there are five care staff on each shift on the dementia unit, three on the upstairs older persons unit, and two carers on the ground floor older persons unit. There are one senior and two carers on duty at night. Now the home is full, with increasing dependency levels among residents, and has clearly separated units, it is questionable whether this is enough staff to supervise residents adequately. I raised this with the manager for discussion and have asked that night staffing levels be formally reviewed to ensure they remain sufficient to meet residents’ needs (requirement 8). Allocating night staff to specific units should be considered (recommendation 4). The manager said he had recently done a night shift and plans to continue working at night from time to time in order to monitor care throughout the 24-hour period. The carers were doing hourly rounds at night, but the manager has asked they now do these half-hourly. Three staff files were sampled for inspection. They contained necessary information and it was evident a previous requirement about employment records had been addressed. Training records and certificates were seen for three staff members. Each had completed mandatory health and safety training, and training to enable them to give medication to residents. Two had received training about dementia, and one staff member had complete NVQ level 2 in care. Information provided by the home to the commission before the inspection showed that only 6 of care staff had completed NVQ 2 in care. I raised this with the manager who confirmed he is taking measures to increase this ratio (recommendation 5). Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the necessary skills and experience, and will be applying to the CSCI for registration. The home needs to maintain its quality assurance strategies, based on consulting with residents. The home aims to promote the health and safety of its residents and staff. EVIDENCE: From observation and discussions, it was evident the manager has the skills and experience needed to run the home. He has begun the process of applying to register with the CSCI to be the manager of Burrows House, and thus I anticipate the relevant standard will soon be met in full. The manager is aware he needs to have a CRB disclosure through the commission as part of the Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 22 registration process and that the disclosure must be submitted with his application. I was invited to sit in on a staff meeting that was taking place during the inspection visit. The manager chaired the meeting and thirteen staff members attended. The meeting was used as an opportunity for the manager to keep staff members in touch with current and future developments, and for staff to ask questions and contribute ideas. The manager gave an update about matters such as: progress with refurbishment of the home; recruitment of new staff; allocations of staff to units; abolition of the ‘duty officer’ system; training opportunities; and improvements to the procedure for giving medicines by having two staff members carry this out. The manager stressed to staff the need to work as a mutually supportive team, in ways that recognise this is the residents’ home. The information supplied by the home before the inspection showed that the organisation acts as appointee for 14 residents at Burrows House. The manager confirmed Servite Housing carries out this function, without any involvement of staff working in the home. I was shown a Regulation 26 report from February 2007, that identified issues for improvement. The provider has not been forwarding these reports to the CSCI, preferring to retain them in the home for inspection. However, it was not evident that these unannounced monitoring visits are being carried out and reported upon at the required intervals, which is especially important during the current period of change at Burrows House (requirement 9). The manager confirmed he recognises quality assurance as an area for development. He has drawn up an ‘action improvement plan’ for May 2007, which lists 22 issues and identifies the member(s) of staff responsible for addressing each issue and target dates for completion. The home must maintain a quality assurance system that is based on consultation with residents and/or their representatives (requirement 10). The refurbishments to the home include improvements in ensuring the health and safety of residents, visitors and staff. For example, the fire officer’s advice was being acted upon in respect of external fire doors. The information supplied by the home before the inspection showed that only 4 of staff held a first aid certificate. First aid provision was discussed with the home’s manager who said he was taking measures to address this, as he wants to ensure there is a qualified first aider on each shift. I later observed him informing staff about first aid training at a staff meeting. The commission takes the view that first aid provision is best tailored to the first aid needs of people using a particular service, decided through a process of risk assessment by the provider (requirement 11). The manager may wish to consult relevant Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 23 guidance about qualified first aiders, available to providers from the commission’s website. Burrows House DS0000006942.V335495.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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Burrows House DS0000006942.V335495.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. 1 Standard OP1 Regulation 4&5 Requirement The registered person must ensure the home’s statement of purpose and service user guide are amended, specifically, to reflect the creation of the locked dementia unit, and that copies are supplied to the commission. The registered person must ensure that all residents are issued with a contract outlining the terms and conditions of their stay within the home, which they sign, and that a copy is kept on their individual files. The registered person must ensure it is evident that all residents’ care plans are kept under regular review. The registered person must ensure that information about life history is gathered for all residents and used to address their individual needs. The registered person must ensure that, whenever practicable, residents and/or their representatives are involved in the development of the care plan and in the DS0000006942.V335495.R01.S.doc Timescale for action 31/08/07 2 OP2 5(1)(b) & 5(3) 31/08/07 3 OP7 15(2)(b) 31/08/07 4 OP7 12(1) & (3) 31/08/07 5 OP7 15 31/08/07 Burrows House Version 5.2 Page 26 6 OP12 16 7 OP16 22 8 OP27 18 9 OP33 26 10 OP33 24 11 OP38 13 reviewing process. The registered person must ensure the planned programme of activities is delivered. Previous requirement. The registered person must ensure that where complaints have been made, the records of the investigation together with the outcome, action taken and response to the complaint are fully recorded. The registered person must formally review the night staffing levels to ensure they remain sufficient to meet residents’ needs. The registered person must ensure that the provider’s unannounced monitoring visits are carried out and reported upon at least monthly. 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. The system must provide for consultation with residents and/or their representatives. The registered person must either complete a risk assessment to decide the home’s first aid needs or have someone on duty at all times who has undertaken a suitably approved first aid at work qualification. 31/08/07 31/08/07 31/07/07 31/08/07 30/09/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 27 No. 1 2 3 4 Refer to Standard OP7 OP10 OP15 OP27 Good Practice Recommendations The registered person should consider reviewing the present care plan format, to make it easier for staff to always sign and date their entries. The registered person should ensure staff always knock before entering residents’ rooms. The registered person should ensure condiments are always readily available to residents at mealtimes. The registered person should consider allocating night staff to specific units, taking account of residents’ dependency levels in deciding how many care staff are needed on each unit. The registered person should ensure the ratio of care staff with NVQ level 2 or above is increased, in line with this standard. 5 OP28 Burrows House DS0000006942.V335495.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V335495.R01.S.doc Version 5.2 Page 29 - 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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