Inspection on 12/07/05 for Burstow Lodge

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burstow Lodge 03/05/07

Burstow Lodge 07/06/06

Burstow Lodge 10/02/06

Burstow Lodge 26/01/05

Burstow Lodge 26/10/04

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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 17/19 Howard Road Penge London SE20 8HQ Lead Inspector Rosemary Blenkinsopp Announced 12 July 2005 09:30 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 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 Stationary 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 G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burstow Lodge Address 17/19 Howard Road, Penge, London, SE20 8HQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8659 6874 020 8776 9833 Mills Family Limited Vacant Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 13 Adults of either sex with a mental handicap and/or a mental illness. Date of last inspection 26/01/05 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. Bedrooom accomodation 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 take is twelve, as one double bedoom is used as a single. Bedrooms were personalised, clean and tidy as were all areas in the home. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an announced inspection, of which the home had been notified in advance. The notice regarding the inspection was on display. The inspection was facilitated by the home manager and the Director of Nursing for the Company. One relative’s comment card was received although no comments were contained within it. The home has completed the pre-inspection questionnaire, however this was not received by the CSCI prior to inspection due to postal delays and was received afterwards. The inspector met with three staff and three residents during the inspection. A tour of the home was undertaken including communal areas and bedrooms and all were found to be in good order. What the service does well: What has improved since the last inspection? What they could do better: Records and care plan documentation must be maintained in a robust manner. This is particularly important with mental heath residents to ensure that comprehensive information is available and communicated to all of the multi disciplinary team. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 6 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 G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5. Residents are provided with enough information on which to base their decision, however with limited provision in this area for this resident group, this reduces the amount of choice. EVIDENCE: In the reception area the Statement of Purpose and Service Users Guide were both available. These were also in each of the bedrooms. In addition copies of the last inspection report were on display and the notice regarding the inspection. Prospective residents are invited to visit the home and, if needed, several visits can be undertaken before any decision is reached. In the care plan documentation, there was evidence of assessments received through the Care Programme Approach system, and those conducted by staff in the home. Terms and Conditions are issued to all residents, which include a trial period, the room to be occupied and a general outline of the service. Those seen were signed by residents. The home has devised a letter confirming its ability to meet residents’ needs; this will be issued to all future placements. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10. Residents are supported to maximise their daily living skills to facilitate more independent living on leaving the home. EVIDENCE: Some residents in this facility are monitored under the Care Programme Approach. This is a system of after care whereby regular reviews are conducted with the multi-disciplinary team and care plans drawn up. Residents have a Responsible Psychiatrist who oversees their progress and mental health. Three care plans were randomly selected. The residents’ photographs were included. Each resident has an allocated key worker who co–ordinates their care, working individually with the resident achieving goals. Care plans are, as far as possible, agreed with the resident. The care plans identified problems related to activities of daily living. The focus is on rehabilitation and maximising the skills needed for more independent living. Leisure and recreational activities were included as part of the care plans. Care plans included information relating to finances and benefits and the assistance staff would provide to address these issues. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 10 Risk assessments included missing persons, which were individual to each resident. Daily events were recorded although on occasions these were not reflective of the identified problems. Please see requirement 1. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17. Staff support and encourage residents to engage with the community in accessing all appropriate facilities to maximise their daily living skills and enhance their quality of life. EVIDENCE: Residents usually spend a period of about two years in this home. During this time they will have been supported to develop daily living skills, including involvement in the local community, accessing health care provision and dealing with finances and personal development. Individual rehabilitation programmes are drawn up between residents and the key workers with agreement, where possible, reached. In-corporated into the programme are goals and achievements all aimed at meeting the resident’s needs. In addition residents attend the local MIND centre in Beckenham, which is on a less formal basis. Residents are encouraged to maintain friends and family links; several do go home for periods including overnight stays. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 12 All leisure activities can be accessed locally. Residents have freedom passes for public transport. An allowance is given for meals out. Residents are encouraged, and supported to shop, prepare and cook their own meals. Storage space is provided for foodstuffs including cold storage. Staff provide assistance with budgeting and healthy eating where this is necessary. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18,19,20 Health care is accessed through the local community, which is appropriate for this setting. Staff provide ongoing support in all activities of daily living. EVIDENCE: The residents are supported to access all health provision via the community. This provides avenues to enhance daily living skills and involvement with the local community. Residents under the Care Programme Approach (CPA) system are reviewed through the multi-disciplinary team who oversee their mental health care and any related medication. The GP addresses all other health care. The medication systems were inspected. The monthly medication cycle had just begun, therefore, it was not possible to audit charts against medications. The medication charts contained appropriate information including resident’s allergies. Some medication charts had been hand transcribed, in these cases two staff should sign to confirm the accuracy of the information recorded. Residents in this home are encouraged to self medicate with staff support and guidance. Discussion at the CPA reviews, and formal assessment would take place prior to any resident self-medicating. Staff would keep this under review by monitoring of medications, change in behaviour or an increase in symptoms. If any of these were observed then this would prompt a review of the situation. Please see recommendation 1. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 14 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 standard(s) 22,23. The system for raising complaints is sufficiently robust to protect residents. Staff take concerns seriously and action is taken as appropriate to the situation. EVIDENCE: The home operates on an open and inclusive manner where residents’ views are taken seriously and acted upon. The three residents with whom the inspector met confirmed they felt able to raise issues on any topic relating to the home including those about other residents. The complaint information is available in the hallway of the home. It includes timeframes and the contact details of the CSCI. The CSCI has received no complaints regarding this service. Residents stated that they would raise concerns/complaints through the manager or their Community Psychiatric Nurse/Social Worker. The three staff with whom the inspector met were aware of what constitutes abuse and the people to refer it to. The first line was usually the manager of the home or the on call system for the Company. One staff member had had abuse training,“ some while ago “ whilst the other two staff had had an induction session. All staff must have on going and updated training on abuse. Please see requirement 2. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24,25,26,27,28,29,30. The home is well maintained and appropriate for this group of mobile, physically able-bodied residents. EVIDENCE: A tour of the home was undertaken. It was clean, tidy and well maintained through ut. The ground floor kitchen area, which has been referred to in previous reports, is still awaiting refurbishment. On this occasion there was more evidence of wear and tear to the drawers and door fronts. The Nursing Director, Ms Knighton, advised the inspector that work was due to start September 2005, with a complete re-fit planned. The manager must ensure during this period that there is no disruption to the availability of food and meals. A plan outlining the work and timeframe for completion needs to be forwarded to the CSCI. Bedrooms were personalised. Two residents took me to their bedrooms, one was very pleased with the recent redecoration. The residents are encouraged to smoke outside, although this is hard to enforce and monitor 24 hours a day. Residents were smoking outside and there was no evidence of smoking in the communal areas although one bedroom did smell of smoke. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 16 Stairs give access to all floors as there is no lift access in the building. Currently there are no residents who require equipment of any kind. In the activities room there was a good selection of leisure items including a computer, exercise bike, books, games, magazines and daily newspapers. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35. Residents are protected by the home’s recruitment procedures. Staff are provided in sufficient numbers to meet residents’ needs. EVIDENCE: The Mills Family have recently undertaken a recruitment campaign including working with a Polish agency. The Polish agency has provided the home with two staff that have been in post for one month. Both staff are qualified doctors in Poland and are working in Burstow Lodge as support workers. The personnel files of these two staff were inspected and contained appropriate information, however one was awaiting CRB clearance although the POVA check was in place. The two staff were interviewed during the inspection. They confirmed that during the month in the home that they had worked under supervision. They stated that they had received a comprehensive induction managed at an appropriate pace to absorb the information. They were allocated to key residents and were working towards their care plan goals. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 18 The personnel file of the newly appointed manager was also inspected. This too had appropriate information including CRB clearance, with the exception of one reference, which contained limited information and was of little relevance to the post. A further reference should have been sought prior to employment. The training file contained certificates for staff study days. Certificates confirmed training on statutory topics in addition to those covering mental health issues. Some of the training had been conducted a while ago, and this should be reviewed to identify if topics need renewing. The training for first aid had expired for one staff member who had completed the four-day course. All statutory training needs to be in date particularly those topics relating to health and safety. Please see requirement 3. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,41,42. Health and safety measures are well addressed although training in respect of statutory topics needs to be maintained to ensure staff are suitably skilled to undertake the tasks. EVIDENCE: The current manager had, prior to the previous manager leaving, worked as a support worker. During her period as a support worker she had worked with the previous manager covering all aspects of running the home, including management issues. The manager facilitated the inspection satisfactorily, although she was still finding difficulty with some topics. She needs to make herself familiar with the standards and regulations relating to this service, namely Care Homes for Adults, 18-65, Care Standards Act 2000. A copy of these were on site although the manager had not accessed them prior to the inspection. The manager will have to complete the registration process through the CSCI, and once she has satisfactorily completed this, she will be the Registered Manager for Burstow Lodge. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 20 Ms Knighton undertakes Regulation 26 visits; reports for these were in place and comprehensive. Health and safety measures are incorporated into the building including window restrictors, radiator guards, several first aids boxes and hot water testing. A selection of health and safety records were viewed and found to be satisfactory with the exception of the five-year electrical wiring test, which is overdue. Fire records including service certificates were in place including the fire risk assessment conducted March 2005. The home is reminded that all day staff should receive fire training twice a year and night staff four times a year. Please see requirement 4. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burstow Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 3 x x 3 2 x G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 22 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 6 Regulation 15 Requirement Timescale for action 30/9/05 2. 3. 23 35 18 18 4. 42 23 The Registered Person must ensure that care plans and daily records are comprehensive in content and reflective of needs. The Registered Person must 30/9/05 ensure that all staff have training in abuse which is up-dated. The Registered Person must 30/9/05 ensure all staff have appropriate training, which is current, related to the work they do and includes all statutory topics. The Registerd Person must 30/9/05 ensure all heath and safety certificates and training are up to date. 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 20 Good Practice Recommendations The Manager must ensure that all hand transcriptions of medication are signed by two staff. Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Burstow Lodge G51-G01 s6919 Burstow Lodge AI v228077 120705 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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