Inspection on 10/02/06 for Burstow Lodge

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burstow Lodge 03/05/07

Burstow Lodge 07/06/06

Burstow Lodge 12/07/05

Burstow Lodge 26/01/05

Burstow Lodge 26/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Burstow Lodge Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 10th February 2006 10:00 Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 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 Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 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 Adults 18-65. 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. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burstow Lodge Address Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ 020 8659 6874 020 8776 9833 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) Mills family Limited Mrs Elizabeth Maoneyi Nicholas Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 13 Adults of either sex with a learning disability and or a mental illness Date of last inspection 12 July 2005. Brief Description of the Service: The home is a detached house located in a residential area of Penge. It has parking to front of the building and an enclosed garden to the rear. Bedroom accommodation is located on all floors. There are two dining areas and kitchens, one of which is used specifically for rehabilitation sessions. There is a large bright lounge furnished in a domestic manner. The home is registered for thirteen places however the maximum number that the home takes is twelve, as one double bedroom is used as a single. Bedrooms were personalised, clean and tidy as were all areas in the home. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced. At the time of the inspection the manager was on duty with one support worker. There were no other staff on duty. At the time of the inspection there were 12 residents, six of whom are on enhanced levels of the Care Programme Approach. The registration certificate will need to be reissued, as the details for the current registered manager are incorrect. The inspection focused on the last requirements and the progress made on these areas. In addition those standards not addressed at the previous inspection were assessed. The inspector met with several residents, including one ex-resident, who was in the home visiting. Both of the staff members on duty participated in the inspection. In addition, a selection of records including a care plan and medication charts were inspected. Feedback from the residents was positive specifically regarding their stay and staff support. The staff member who was new into post was enthusiastic and expressed interest in her job. Generally the findings of the day were satisfactory, with positive comments received from the residents, two relatives and the staff on duty. What the service does well: What has improved since the last inspection? The home has been provided with administration assistance one day a week. This has allowed the manager to concentrate on residents’ needs and support of the staff group. The refurbishment of the kitchen is due to start 22 February 2006. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 6 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. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home retains insufficient records relating to assessments and trial visits, hence it is difficult to establish whether the service is suitable to meet the prospective residents’ needs. EVIDENCE: The assessment information relating to the last admission to the home was viewed. It consisted of information received from Oxleas Mental Health Trust and information from the placing authority. These documents related a number of mental health issues, which could pose a risk to the resident. The manager stated that the home had no formal assessment tool, although on previous inspections this had been available. It was difficult to establish what assessment had been conducted by the staff in the home. Information on introduction and trial visits was also omitted. The information and documentation relating to trial and introductory visits must be in place to confirm that the residents are suitable for placement. The assessment tool must accurately reflect all of the residents’ needs including physical, physiological, social and spiritual. The home does have a letter offering placement. This will need some amendments to include a sentence confirming that the home is able to meet all of their needs. Please see requirement 1. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Care plans and risk assessments are not sufficiently comprehensive in content to reflect the residents’ needs and are particularly lacking in respect of their mental health issues. Without detailed care plans staff would be unable to provide the care in a consistent manner. EVIDENCE: The care plan of the resident admitted three months previously was inspected. There was a photograph in place, although the inspector was advised that she had changed since then and it was not current. This needs to be addressed with a current photograph available. The care plan of this resident was limited both in the identified problems specifically those related to mental health, and the interventions that staff should apply when addressing the problem. This is particularly concerning as the resident is on CPA (Care Programme Approach), enhanced level. On the care plan documentation signatures of the staff and resident were omitted, as were the dates the care plan was generated. The care plan had headings stating “nursing interventions”. This needs to be amended as this is a care home and nurses are not employed in that capacity. Some entries and daily events were limited in reflecting progress or otherwise in mental health issues. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 10 Some entries were signed with the first name of the staff only. Full signatures need to be in place. The last review of the care plan had been 17/12/05. There was no review of the CPA care plan available. The risk assessment was dated 6/1/06. It is a standard risk assessment tool with areas marked as high or low risk. Within this resident’s risk assessment two areas were marked as high risk, although these did not have sufficient information documented to reduce or eliminate the risks as identified. Supporting care plans should be in place as the two areas identified were around activities of daily living. Please see requirements 2 and 3. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15. Activities, both in-house and as part of the wider community, are encouraged as part of rehabilitation, which promote daily living skills and integration. EVIDENCE: At the time of the inspection two relatives of a resident were in visiting. Both were made welcome. For one lady it was her first visit, the other had been in the home previously. She confirmed that staff were always welcoming and helpful when she raised any queries. Neither were able to comment on other aspects of the service as their relative had spent considerable periods in hospital since her initial admission. The staff have developed activities for the evenings as many are at day centres during the day period. The activities include a film night, games and relaxation sessions. Three residents are attending college courses, including cookery for one, English for another and computers for the third resident. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The medication records are not sufficiently completed to reduce the margin for error. EVIDENCE: Currently there are four residents who are sel- medicating as part of more independent living skills. The medication administration sheets were inspected and on several charts the amount received into the home was not entered, although this was entered overleaf under the section headed “carers notes”. There is a section on the chart itself for the amount to be stated. On some charts there were hand transcriptions, although again the amount received was not stated and two staff signatures were omitted. Two staff signatures should be in place to confirm the accuracy of the information. One photograph was missing although this was available in her personnel file. Changes which had been made on the medication charts to the amount of medication to be administered, were not signed. Please see requirement 4. Please see recommendation 1. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff are not sufficiently updated or trained in abuse awareness to ensure that they are fully conversant in identifying abuse or the action to take in the event that this is suspected. EVIDENCE: Since the last inspection, where training on abuse awareness for all staff was identified, this has still not been addressed. The new staff member with whom the inspector met had not received abuse awareness training from this employment although had had some instruction through a two week training course prior to her employment. The manager confirmed that no further training on abuse awareness had been conducted. This needs to be addressed. Please see requirement 5. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards were assessed in this section. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 Recruitment procedures need to be fully implemented including two references and a full employment history. Training needs to be reflective of residents’ needs and be updated at appropriate intervals EVIDENCE: The home is fully staffed currently. Since the last inspection, one staff member has left. The newly recruited staff member met with the inspector and her personnel file was inspected. The staff member had started work in the home two and half months ago. She had previously worked in a restaurant, and thereafter had completed a four week training course for carers. She confirmed that she worked full time on day duty. She stated that she completed an application form and attended an interview. She had had an induction period, which included orientation to the building, introduction to the residents, care plans etc. The training that she had received at Burstow Lodge was report writing and medication both external courses. She had not received training in respect of abuse awareness and she had a limited knowledge of topics relating to psychiatric issues, health and safety, particularly COSHH and manual handling. The inspector was advised that manual handling training was due to be conducted 7 March 2006 for all staff. The new staff member’s personnel file was inspected. It contained a completed application form, however this was poorly completed with only one Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 16 entry under previous employment which did not have the specific date of employment, stating the month only. One reference only was stated, and this did not state the title of the person, it simply gave their name and telephone number. Other items available in the personnel file included the completed CRB, medical questionnaire, passport, proof of identity, terms and conditions, a confidentiality statement and the offer letter. Six staff have completed their NVQ level 2 and one is doing NVQ level 3. All staff except the newest staff member have done first aid, two staff have completed the four day course, one is due to attend a refresher course. Other training included dual diagnosis and drug awareness conducted August 2005. Other training in relation to mental health was negligible. The home provided internal medication training. It is essential that staff are trained on all aspects of health and safety, mental health and rehabilitation and that they receive regular updates. Please see requirements 6 and 7. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The home is managed in an open and democratic manner where residents are involved in the decision making process as far as possible. EVIDENCE: The manager is a trained nurse in the field of psychiatry. She has been in post for over six months and has completed the CSCI registered manager’s process. She works four days a week “ hands on”, as part of the staff complement, and one-day supernumerary. One day the home is provided with administration support. She had received limited training since taking up the post and was only able to state two topics. In addition all managers must undertake a suitable course to address the management and care component of the work e.g. NVQ 4 or the Registered Manager’s Award. This must be investigated. Each resident has a key worker who co-ordinates their care. The individual key worker sessions are detailed in the care plans. The manager is available at most times to speak with residents. The Mills Group undertake residents and relative surveys, which are coordinated through the head office staff. Residents have their own group where open discussion is encouraged. Any developments arising in the home would be discussed. Residents themselves felt that they did have enough opportunities to raise issues and as far as possible where Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 18 involved in the home, stating redecoration, outings and holidays as some of the decisions they had made. The fire records include weekly fire alarm testing, checking of fire escape routes and monthly fire doors. The records for the weekly escape route checks had not been completed since 23/1/06.The fire risk assessment needs to be updated, particularly when building work is ongoing, which is due to start imminently. All risks posed by the proposed work must be identified and measure in place to ensure the safety of residents, staff and visitors. Please see requirements 8 and 9. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X 2 2 X X 2 X Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 20 Yes 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. 1 Standard YA2 Regulation 14 Requirement The Registered Person must ensure that the home assesses all prospective residents using an appropriate and comprehensive tool. The Registered Person must ensure that care plans and daily records are comprehensive in content and reflective of needs. Previous time frame for action 30/9/05. This is now outstanding The Registered Person must ensure that robust risk assessments are in place to reflect all elements of risk posed and the actions to reduce this. The Registered Person must ensure that all records relating to medication are fully completed with two staff signatures in place to confirm amendments. The Registered Person must ensure that all staff have training in abuse awareness which is updated. Previous time frame for action 30/09/05. This is now outstanding. Timescale for action 30/03/06 2 YA6 15 30/03/06 3 YA9 13 30/03/06 4 YA20 13 30/03/06 5 YA23 18 30/03/06 Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 21 6 YA34 19 7 YA35 18 8 YA37 9 9 YA42 23 The Registered Person must ensure that all recruitment procedures are fully completed prior to employment. The Registered Person must ensure all staff have appropriate training, which is current, related to the work they do and includes all statutory topics. Previous time frame for action 30/09/05. This is now outstanding. The Registered Person must ensure the manager applies for a suitable course in management and care i.e. NVQ 4. The Registered Person must ensure that all records relating to fire are updated and particularly the fire risk assessment. 30/03/06 30/03/06 30/06/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The Manager must ensure that two staff sign all hand transcriptions of medication. Burstow Lodge DS0000006919.V279085.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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