CARE HOMES FOR OLDER PEOPLE
Burrows Lea 502 Lytham Road South Shore Blackpool Lancashire FY4 1HJ Lead Inspector
Mr Kevan Royston Unannounced Inspection 4th August 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 Lea DS0000009792.V296608.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.V296608.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.V296608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 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 are from £291:41 to £340:00 per week. There are additional charges made for hairdressing and chiropody. Burrows Lea DS0000009792.V296608.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 over two days on the 4th and the 10th August 2006. The Inspector spoke to the homeowner, two staff, a relative visiting the home four residents on there own and a group of residents in the lounge. The inspection visit was undertaken over a period of two days. 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 relative’s residents and GP surgeries was good four completed questionnaires received from relatives, six from residents and one from a GP. All comments were positive about the standard of care provided by the home. Records of three staff members 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:
All ten Surveys returned from relatives and residents 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. Relative comments included, “I think she is well cared for, the staff are very kind to her”. And. “I give the staff and owner full marks for the care”. Another said, “Very good all round”. Residents responses included “Lovely no problems”. And also “Good staff”. Food observed being prepared was wholesome with fresh fruit and vegetables ensuring a healthy diet were provided. Residents spoken to said, “The food is lovely”. Another resident said “ Always plenty and a choice if you don’t like something”. A staff member spoken to said, “We try and cook home made cakes and pies”. The home has a system in place which records the intake of Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 6 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. 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, “Its nice the staff stay here you get to know them”. A new member of staff said “They make you welcome it’s a nice atmosphere to work in”. What has improved since the last inspection? What they could do better:
The continuation of redecorating some of the bedroom areas is required to ensure the residents live in pleasant homely surroundings. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 7 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.V296608.R01.S.doc Version 5.2 Page 8 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.V296608.R01.S.doc Version 5.2 Page 9 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 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 clear to make sure the care needs of residents are identified and met. EVIDENCE: Social worker assessments of two residents had been obtained prior to admission and provided the home with information in relation to health and welfare needs. The homeowner carries out the initial assessments of residents. A staff member said, “Bob assesses anyone who might be admitted”. Burrows Lea DS0000009792.V296608.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 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. Medication policies and procedures have improved and provide protection and safety for residents. EVIDENCE: Records of two residents were examined and accurately reflected the individual’s health and social care needs. Care plans were up to date and regular reviews taking place with signatures of residents evident ensuring their involvement of the process and outlining any changing health needs required. One Staff member said, “ We let the residents know what we are doing”. One resident spoken to said “Oh they check on me properly every month”. Records examined confirmed risk assessments are constantly reviewed and updated reflecting any changes that have occurred individually and in the environment ensuring the resident’s needs are being met.
Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 11 Medication practices observed at lunchtime were safe and good records had been kept ensuring residents health is maintained. A senior member of staff said, “Only staff that have had medicine training administer medicines”. Burrows Lea DS0000009792.V296608.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contact with families and friends is encouraged and supported by staff to maintain relationships. Activities are centred on resident’s interests. Meals are varied and wholesome with choice provided ensuring residents dietary needs are met. EVIDENCE: Residents spoken to say the routines of the home are flexible and they have a choice of how to spend their daily life. One said, “Its nice to go out for a coffee now and then with the girls”. Another said, “I choose to stay in my room a lot the staff respect that”. Lunchtime meals being prepared were seen to be wholesome, home baked with fresh vegetables providing a nutritious meal. Menus examined are balanced varied and interesting. Meal times are set although flexible enough to accommodate preferences. Residents spoken to said “Plenty of choice”.
Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 13 And, “Lovely home made food”. One resident said “A lot better food than the last place I was at”. Activities are centred on each individuals preferences ensuring flexibility and residents can enjoy their own personal interests. Observations of residents rooms showed personal belongings are allowed into the home so to provide a homely atmosphere for each individual. Residents spoken to confirmed visitors are allowed at any time of the day or night. One resident said, “Lots of visitors come and see me at all times”. A relative spoken to visiting at the time of the inspection said “The staff make me welcome at any time and always offer me a drink and biscuit”. Burrows Lea DS0000009792.V296608.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 inspected at least once during a 12 month period. 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 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 and relatives on admission and is included in the homes brochure ensuring the residents feel protected. Staff spoken to are aware of the complaint and abuse procedures. One new member of staff said “We covered complaints and abuse in our induction”. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 15 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 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. Some parts of the home require redecoration to ensure the home is pleasant to live in. EVIDENCE: A tour of the building found the home to be clean and tidy. The home is maintained to a good standard and examination of maintenance records showed there is a rolling programme of general repairs and renewal of the premises ensuring the comfort and safety of the residents is maintained. There has been some redecoration and new furniture has been placed in the sun lounge area providing residents with a comfortable place to relax in. Some
Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 16 of the bedrooms require redecoration to continue to provide pleasant surroundings. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 17 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 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 robust ensuring the safety and protection of the residents. Training for staff is very good ensuring they have the skills and competencies for their roles. EVIDENCE: Observation of duty rotas and discussion with staff confirmed there were sufficient numbers of staff on duty to ensure the resident’s needs are met. One member of staff spoken to said, “With it being a small home we have time to spend with the residents”. Examination of two staff files confirmed the recording procedures of the home are good. And staff records include, application forms, individual photographs, CRB (Criminal records Bureau), POVA (Protection of Vulnerable Adults) checks and references were in place to ensure the residents are protected. Staff spoken to commented on the good training opportunities on offer. A staff member said “It’s excellent there is usually a list on the board”. Another staff member said, “Bob puts on courses we want to go on”. Each staff member has there own training and development file which examined confirmed the
Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 18 training provided by the home is extensive and thorough ensuring staff have the skills to carry out there duties. Records show training is ongoing and the home now has 90 staff that has completed NVQ (National Vocational Qualification) level 2 in care which exceeeds the 50 required by the National Minimum Standards. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 19 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): 31,33,35 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 good systems are in place for the protection of staff and residents. EVIDENCE: Examination of records and information sent by the home owner confirmed regular tests to emergency lighting, new improved fire procedures and extinguishers had been carried out ensuring the safety of residents and staff is maintained. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 20 Staff and residents found the homeowner supportive and approachable to enable the smooth running of the home. One Staff spoken to said “Bob is willing to listen and helpful”. One resident said “You can have a laugh with Bob”. The home owner has completed the necessary qualifications needed to meet the National Minimum Standards in management and care. Also the senior carer has completed NVQ (National Vocational Qualification) to level 4 in management and care ensuring they have the skills and competencies to provide the support to staff and care to the residents. Records show the management team 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 ensuring there views are known and implemented if needed and improves the running of the home. Relative surveys are sent out 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. Burrows Lea DS0000009792.V296608.R01.S.doc Version 5.2 Page 21 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 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 4 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.V296608.R01.S.doc Version 5.2 Page 22 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.V296608.R01.S.doc Version 5.2 Page 23 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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