CARE HOMES FOR OLDER PEOPLE
Burrows Lea 502 Lytham Road South Shore Blackpool Lancashire FY4 1HJ Lead Inspector
Mr Kevan Royston Unannounced Inspection 12th November 2005 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 Lea DS0000009792.V251976.R01.S.doc Version 5.0 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 Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Burrows Lea Address 502 Lytham Road South Shore Blackpool Lancashire FY4 1HJ 01253 341294 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) Mr Robert James Shirt Mr Robert James Shirt Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: Burrows Lea is registered for eight older people. The home is a large detached residence situated in the south of Blackpool close to Highfield road shopping centre and local bus routes. All the rooms are en-suite and aids and adaptations have been fitted where required. The home is on two floors and there is a stair lift to access the first floor. There is a large through lounge with a conservatory attached and a dining room. The outside provides seating at the front and rear of the property with a ramp fitted for wheel chair access. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on the 12/11/05 over a period of approximately 4 hours and was unannounced. The Inspector spoke to the registered manager, staff and six residents. As part of the inspection process the inspector used case tracking as a means of assessing some of the National Minimum Standards. The process allows the inspector to focus on a small number of people living at the home. All records relating to these people are examined and the rooms they occupy are looked at. Other residents are invited to pass their opinions to the inspector if they wish. A tour of the premises was undertaken. Examination of the homes documentation, policies and procedures formed the basis of the inspection. What the service does well:
The home has a small settled staff team which helps build relationships and provides stability. This was evidenced by comments from people in the home and observation of interaction between the staff and residents. One resident spoken to said, “You wont find a better place they know what everyone likes and doesn’t like.” Residents spoken to said the food was very good. And the inspector observed fresh home made meals being cooked at lunchtime with fresh produce used to make sure a healthy diet was provided. Comments from residents included “Lovely meals and always a choice”. Another said, “We get good wholesome food and there is plenty”. A member of staff was observed baking home made cakes and appropriately dressed for cooking ensuring proper hygiene and food safety procedures were being followed. One staff member said, “I enjoy baking I like to see the residents enjoy my cooking”. The home has a system in place which records the intake of food and drink at every meal for the residents ensuring the health of the residents is monitored and any changes in eating habits would be noticed. Records and care plans are up to date, accurate and give a true picture of each persons daily health, social and welfare needs. A resident spoken to said “I enjoy going out with my relative the girls know what I like to do during the day”. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 6 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. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 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 Lea DS0000009792.V251976.R01.S.doc Version 5.0 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): 3 The admission and assessment procedures were clear to ensure the care needs of residents are met. EVIDENCE: The records of three residents examined, had full assessment information. Staff members confirmed they had access to this information and could describe in detail the care needs of residents. One staff member spoken to said “With they’re being only a few residents and with good recording it makes it easier to follow each persons care needs”. Social worker assessments examined had been obtained prior to admission. The homeowner carries out the initial assessments of residents. A staff member said “Bob assesses any new residents with carers if needed”. One resident said “Bob visited me before I moved in to see if I would like it”. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Promotion of health is taken seriously. Resident’s welfare is closely monitored and health needs are identified and met. However medication procedures could be improved to provide further protection for residents. EVIDENCE: Records of three residents spoken to were examined and accurately reflected the individuals health and social care needs. Care plans were up to date and regular reviews taking place outlining any changing health needs required. One resident said “I don’t know what a care plan is but there always check on me and ask if I need anything regularly”. The senior carer on duty said “all the residents had recently been reviewed”. And this was confirmed by records examined, ensuring the needs of the residents are being monitored. Discussion with the senior carer and examination of records show risk assessments are constantly reviewed and updated reflecting any changes that have occurred individually and the environment. Medication practices observed were safe and good records had been kept ensuring residents health is maintained. However further checks and staff training in relation to staff recording of administering medication could be put in place to ensure the safety and protection of the residents.
Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15. Contact with families and friends is encouraged and supported by staff to maintain relationships. Activities suit each individual. Meals are varied and wholesome with choice provided ensuring residents dietary needs are met. EVIDENCE: Lunchtime meals served were seen to be wholesome, home baked with fresh vegetables providing a nutritious meal. Menus examined are balanced and interesting. Meal times are set although flexible enough to accommodate preferences. Residents spoken to commented on the high quality of food at the home. Comments included “The food, you can’t fault it”. “Always something else if you don’t like what is given”. Activities are centred on each individuals preferences ensuring flexibility and residents can enjoy their own personal interests. One resident spoken to said “ I enjoy a game of dominoes in the afternoon with the other residents”. Another said, “The staff are always willing to take part in a game or two”. Residents spoken to confirmed visitors are allowed at any time of the day or night. One resident said, “I get out when I can I enjoy it”. Another resident said my daughter visits often and is able to come at any time”. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 11 Resident rooms seen had evidence of personal belongings, and provided residents with a homely and comfortable environment. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The arrangements for recording and reporting of complaints are good ensuring people feel listened to. The homeowner and staff have good knowledge and understanding of adult protection issues, which protect residents from abuse EVIDENCE: The home has a detailed complaints procedure, which is made available to all residents on admission and is included in the homes brochure ensuring the residents feel protected. One resident spoken said, “If I want to complain I know who to”. Staff spoken to are aware of the complaint and abuse procedures. One member of staff said “We covered complaints policies during our induction training”. Another staff member said, “My NVQ training has a section on abuse issues”. Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 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 the following standard(s): This section of standards was not assessed. EVIDENCE: Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 14 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): This section of standards was not assessed. EVIDENCE: Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 15 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): This section of standards was not assessed. EVIDENCE: Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 16 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 17 No 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. Standard Regulation Requirement Timescale for action 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 Standard Good Practice Recommendations Burrows Lea DS0000009792.V251976.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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