CARE HOMES FOR OLDER PEOPLE
Burrows Lea 502 Lytham Road South Shore Blackpool Lancashire FY4 1HJ Lead Inspector
Mr Kevan Royston Unannounced Inspection 13th July 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 Lea DS0000009792.V338629.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 Lea DS0000009792.V338629.R01.S.doc Version 5.2 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.V338629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 04/08/06 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 bedrooms are single rooms with an ensuite 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. The range of fees at the home is from £291:41 to £340:00 per week. There are additional charges made for hairdressing and chiropody. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 13/07/07, over a period of approximately 5.0 hours. The Inspector spoke to the homeowner, three staff, three residents individually and briefly to a group of residents in the lounge. 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 persons are examined and the rooms they occupy are looked at. Other residents are invited to pass their opinions to the inspector if they wish. The response from surveys sent to residents and relatives for there views on how the home is run was good, seven completed questionnaires received from residents and three from relatives. Comments were positive about the standard of care and support provided by the staff and homeowner Records of two members of staff were also examined. A tour of the premises was undertaken. Examination of the homes documentation, policies and procedures formed the basis of the inspection process. What the service does well:
The home has recently achieved the “Investors In People Award” which means the home is run and operates to a high standard with a good standard of care provided to the residents to ensure they are well cared for and supported. The homeowner spoken to said, “We are proud of our report and the work we have all put in”. Examination of training records and discussion with staff and the homeowner confirm the home provides excellent training opportunities for all staff to attend and access courses in relation to their job role. This ensures the development of all staff and provides the skills and competencies required to support and provide good care for the residents. Staff spoken to said, “Excellent training opportunities”. And, “training its easily accessible”. The home has a small settled staff team with little change in staffing since the previous inspection, which helps relationships to develop between staff and resident’s and provide a better understanding of residents wishes and needs.
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 6 Observation and talking to staff confirmed support, communication and knowledge of residents needs is good. Comments from staff included, “We all get along fine”. And, “With it being a small place we get to know each other well and support one another”. One resident spoken to said, “There doesn’t seem to much change in staff which is a good thing because they get to know you well”. All surveys from residents and relatives returned for their comments on how the home is run and standard of care provided were positive confirming the support and care of residents is a priority. Comments included, “Always there when needed”. And, “Staff are helpful”. Observation of staff helping and talking to residents was good, with one staff member helping a resident in her room with breakfast in a dignified and sensitive way ensuring her dignity and privacy is respected. 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. The summary of this inspection report can be made available in other formats on request. Burrows Lea DS0000009792.V338629.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 Lea DS0000009792.V338629.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures were very clear and precise to ensure the needs of the residents are met. EVIDENCE: Records of three residents were examined and had full assessment information recorded in detail. All three residents are funded by social services and been assessed by social workers with information on file for the homeowner to carry out there own assessment to develop a care plan to ensure all health, welfare and social needs are identified and recorded. One of the residents whose records were examined was spoken to and said, “Bob was really nice when he came to see me and went through everything with me and my family”. A staff member spoken to said, “The residents are assessed thoroughly by the home owner before admission and invite relatives for their input”.
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 9 Standard 6 was not assessed, as the home does not provide intermediate care. Burrows Lea DS0000009792.V338629.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously. Resident’s welfare is closely monitored and health needs are identified and met. EVIDENCE: Records of resident’s case tracked were accurate and had good information about their health, welfare and social care needs that supported the staff to maintain and promote each individuals daily needs. Care plans were up to date and regular reviews taking place with involvement of the residents and relatives and good information of care provided ensuring the welfare and general wellbeing of residents is continuously monitored. Comments from survey returned by residents said, “Staff very versatile and helpful”. And, “Always there when needed”. Also, “We go through my health needs every month”. Records examined confirmed risk assessments have been completed and are reviewed when required and updated reflecting any changes that may
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 11 have occurred individually and in the environment ensuring the resident’s needs are being monitored. Medication practices observed at lunchtime were safe and examination of residents case tracked records were good ensuring residents health is properly monitored and medicines administered are correct. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 12 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 and15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: Lunchtime meals were seen being prepared, and were wholesome, home baked with fresh produce used providing a nutritious meal. The staff spoken to said “We use fresh fruit and vegetables as much as we can”.Observation at Breakfast time confirmed a member of staff supporting a resident who was in her room poorly with their food in a sensitive and dignified way. Menus examined are balanced and interesting with variation to allow residents a choice. Meal times are set although flexible enough to accommodate preferences. Comments from residents included “Good food”. And, “They try and prepare meals every one likes”. One member of staff spoken to said, “All staff preparing food have passed there Health and Hygiene Course”. A resident who was having his meals in his room said, “Its not a problem they are willing to bring my food to my room its my choice”.
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 13 Activities are centred on each individuals preferences ensuring flexibility and enable residents to enjoy their own personal interests, which are recorded on their care plan. One resident spoken to said, “ I do like quizzes and dominoes and the staff join in”. A staff member said, “This afternoon myself and one of the residents are going out”. Residents spoken to confirmed visitors are allowed at any time of the day or night. One resident said, “Any time in fact my friend is due”. One member of staff spoken to confirmed visitors are allowed any time and said. “Yes they come and go as they please and we provide a drink”. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 14 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for recording and reporting of complaints are good ensuring people feel listened to. The management team 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 contained in the Statement of Purpose and Service User Guide to ensure they feel protected. Residents and relatives in surveys returned confirmed all are aware of the complaints procedure and who to complain to. Comments included, “I certainly do know who to speak to”. And, “Yes in know the complaints procedure”. Staff also are aware of the complaints process, one staff member said, “Complaints policies are covered when we do induction training”. There have been no complaints since the previous inspection. There is a procedure in place for dealing with allegations of abuse and safeguarding adults The homeowner and staff spoken to have a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. One staff member spoken to said, “We have
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 15 all done abuse courses, the training here is really good”. Another staff member said, “We all have recently attended a safeguarding adults protection course”. Burrows Lea DS0000009792.V338629.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is safe and clean maintained to a good standard providing comfortable surroundings for the residents. EVIDENCE: A tour of the building found it to be clean and tidy. The home is maintained to a good standard and maintenance records confirmed there is a rolling programme of general repairs and renewal of the premises ensuring the comfort and safety of the residents is maintained. Recently improved wheelchair access to the front of the home has been built to provide easier access to the building for wheelchair users. Some residents rooms have been redecorated and a new large television in the lounge area ensuring residents are provided with pleasant comfortable surroundings. Residents spoken to said, “The home is always kept clean”. And, “The new television is nice”.
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 17 There are policies and guidance for laundry processes and for the control of infection ensuring the home is kept clean, pleasant and hygienic. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures for the recruitment of staff are good ensuring the safety and protection of the residents. Training for staff is excellent and enables staff to have the skills and competencies for their roles. EVIDENCE: Observation of staff working at the time of the site visit, examination of rotas and discussion with staff confirmed there were sufficient numbers on duty to ensure the resident’s needs are being met. One member of staff spoken to said, “We never a problem with staff shortages”. Residents spoken to said, “Yes there is enough girls around”. And, “There is always someone available”. Examination of two staff files confirmed the recruitment procedures of the home are good ensuring the protection of the residents is maintained. Staff records include, application forms, Criminal Records Bureau (CRB), Protection of Vulnerable Adults (POVA) disclosures and references, all in place prior to employment. To improve recruitment procedures start dates on records would help check references and other required information has been obtained prior to employment starting. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 19 Examination of training records and staff spoken to confirmed the excellent training opportunities available, also the number of courses and training days staff have attended whilst working at the home enabling them to provide a better service and have the skills and competencies to support and acre for the residents. Staff members spoken to said, “This is so much better than the last place I was at for training”. And “Excellent access to training”. Another said, “Never a problem with access to training”. Discussion with the homeowner and examination of records confirm the target of 50 of care staff to complete National Vocational Qualification (NVQ) level 2 in care has been achieved with some staff on level 3 and over 90 of care staff completed the recognised qualification. One member of staff said, “Yes the NVQ training is helpful”. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and systems and policies in place for the protection and safety of staff and residents are good. EVIDENCE: The homeowner has the necessary skills, qualifications and experience required to support the staff and residents and enable the home to meet its stated purpose and objectives. Residents and staff spoke positively about the homeowner and how the home is managed comments included, “Very helpful”. And, “Always supportive and willing to listen”.
Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 21 Examination of records for residents confirmed they are comprehensive, well written and up to date ensuring the correct information is available and health and welfare needs are continuously monitored. Records show the homeowner has good systems to gather staff, residents and relative’s views to enable ongoing improvements to the home. Staff and resident meetings are held regularly and recorded. Also informal discussions with residents occur on a regular basis both informally and formally ensuring there views are acknowledged and helps to improve the running of the home. The homeowner spoken to said, “”Meal times when we get together is a god way of hearing the resident views”. Relative surveys are sent out every three months has a quality assurance system to gather the views of friends and relatives to ensure they feel the home is run smoothly and any suggestions to improve the home are noted and put into practice. A resident spoken to said, “Bob is open to suggestions”. Examination of records confirmed regular tests to emergency lighting, fire procedures and extinguishers had been carried out ensuring the safety of residents and staff is maintained. Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 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 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Burrows Lea DS0000009792.V338629.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. 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.V338629.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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