Inspection on 14/04/05 for Burgess Park Nursing Home

This inspection was carried out on 14th April 2005.

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 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

Burgess Park Nursing Home 21/04/10

Burgess Park Nursing Home 08/03/10

Burgess Park Nursing Home 05/01/10

Burgess Park Nursing Home 04/12/08

Burgess Park Nursing Home 07/12/07

Burgess Park Nursing Home 15/05/06

Burgess Park Nursing Home 21/10/05

Burgess Park Nursing Home 01/12/04

Burgess Park Nursing Home 11/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Burgess Park Picton Street Camberwell London SE5 7QH Lead Inspector Alison Pritchard Announced 14 April 2005 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 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. Burgess Park Version 1.10 Page 3 SERVICE INFORMATION Name of service Burgess Park Address Picton Street, Camberwell London SE5 7QH 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 7703 2112 020 7701 4220 burgess.park@ashbourne.co.uk Exceler Healthcare Service Ltd see standard 31 CRH Care Home 60 Category(ies) of Care Home with Nursing (60) registration, with number of places Burgess Park Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: OP Old Age, two people may be aged between 60 and 65 years. Date of last inspection 11 March 2005 Brief Description of the Service: Burgess Park Nursing Home is located in a residential area of Camberwell. The home is registered to provide care for 60 older people who have nursing needs. At the time of the Inspection there were 38 people resident in the home. The facilities in the home are spread over three floors. Dining facilities are are on the ground floor and there are lounges on the ground and first floors of the home. Bedrooms are located on all three floors of the home. There is a garden to the front of the home and on street parking is available. Burgess Park Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An additional unannounced visit was made to the home on 11th March 2005, observation during this Inspection confirmed that action has been taken to address the requirements made at the visit and also the requirements of the previous unannounced Inspection of December 2004. This Inspection was announced and carried out over two days in mid April 2005 and lasted a total of 15 hours. The first day of the Inspection ended at approximately 9pm so that arrangements for the transfer of information between day and night staff could be assessed. On the second day of the Inspection a Pharmacy Inspector assessed arrangements for the management of medication in the home. The Inspection methods included discussion with approximately ten residents and two relatives; interviews of a nurse, the cook, the Manager and two care staff (one of whom works during the day and the other is a member of the night staff); discussions with nurses, ancillary staff and a visiting professional; sampling a lunch time and an evening meal; observation of care practices, a handover meeting and activities sessions; examination of records and a tour of the building. The Manager had ensured that residents, relatives and involved professionals were informed about the Inspection enabling them to contribute if they wished to do so. Comment cards were received from eight residents, thirteen relatives / visitors and two health care professionals. The current Manager has been in post since 1st March 2005. The previous post holder left her post in January 2005. Satisfactory interim arrangements were made for the management of the home. What the service does well: There is a full activities programme provided for the majority of residents. During the Inspection a resident was supported to run an activities session which approximately 16 other residents attended and seemed to enjoy. It is commendable that she was supported to contribute in this way. Meetings are held for residents and relatives to meet with the Manager and the cook. Feedback about the meals provided in the home was largely positive. The service has arranged staff training appropriate to the needs of the residents, including training for a significant number of staff to NVQ level 2. Burgess Park Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burgess Park Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Burgess Park Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3. As the home does not provide intermediate care standard 6 is inapplicable. The information provided for potential residents prior to admission does not include all of the information required. This does not give potential residents all of the information they require to make a decision about where to live. There is a suitable form for pre-admission assessments to be carried out and assessments by placing social workers are obtained prior to admission. This ensures that the home has sufficient information to make a decision about whether they can meet the potential residents’ needs. EVIDENCE: There is a Statement of Purpose for the home which is included in a colour brochure which together form the Service User Guide. Parts of the Statement of Purpose had not been completed fully and other parts had been completed wrongly. The document should be reviewed. Statements of terms and conditions were viewed on service users’ files. There is a pro-forma for an assessment of a potential resident’s needs which is completed as part of the home’s admission procedure. The assessment format Burgess Park Version 1.10 Page 9 is thorough and addresses the full range of needs likely to be presented and indications of how these will be met. The most recently admitted resident came to live at the home in October 2004. This person’s file was examined and it was found that the pre admission assessment had been completed and, subsequent to admission, appropriate assessment tools had been used for example to assess the person’s nutritional and continence needs, risk of falls and risk of developing pressure sores. Assessments of need carried out by placing social workers are obtained prior to admission. All of the current residents had been admitted to the home prior to October 2004. Standard 3 will be examined in more detail for a wider range of residents at the next Inspection. Burgess Park Version 1.10 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 standard(s) 7, 8, 9 and 10. The home needs to be sure that when residents have a need for specialist input from physiotherapists and speech and language therapists that referrals are made. This would benefit residents by ensuring that care is appropriate to address the full range of their needs. The home has made good progress with regard to medication handling and recording of administration since the last pharmacy inspection in December 2004 , and now ensures that residents medication needs are met. There are two areas which require improvement: -ensuring that when a resident is discharged from hospital, all changes to their medication regime are implemented. -ensuring that residents receive all prescribed food supplements unless there is documented evidence that the GP has decided these are no longer needed. EVIDENCE: On the care plans sampled on an additional visit to the home on 11th March 2005 satisfactory recording practices were noted. The Manager intends to audit all of the care plans and ensure that any areas of omission are addressed. Files viewed on this occasion included information on residents’ social history, but in some cases this was rather limited. Wherever possible family members who are asked to provide such details should be assisted to do so with the aim of Burgess Park Version 1.10 Page 11 ensuring that this information can be used as part of the care planning process. One of the nurses in the home is the ‘link nurse’ for tissue viability matters and she has undertaken specialist training in this area of patient care. Discussion with the staff member indicated that, in addition to the training, she had made links with specialist nurses from the Primary Care Trust. At the time of the Inspection two service users had pressure sores, one of whom had acquired the sore while an in-patient at hospital. The service user’s notes showed that a specific care plan had been put in place to address the needs arising from this and the resident had been recently reviewed by the GP. Continence assessments for service users were in the process of being undertaken by the specialist advisor from the local PCT Care Homes Support Team, with whom the home has positive links. The care plan of one resident indicated that she had communication difficulties as a result of her medical condition. While there was some limited information available in the file about her communication methods these could have been developed further and there was no information noted on the file about any referral to, or input from, speech and language therapy services. Another resident’s file indicated a need for physiotherapy input but the file did not indicate any referral to specialist services and a staff member said that no specific input in relation to physiotherapy needs was provided. Weight monitoring charts included only the month in which the weight had been measured, the date should be included to allow effective monitoring to take place. As noted below although nutritional risk assessments were viewed on residents’ files there is currently no system for the home to adequately monitor residents’ nutritional intake and this needs to be introduced. Feedback from health care professionals involved with the home was positive and one noted particular improvements made since the new Manager was appointed. Medication Administration Record (MAR) charts for all residents were inspected. Recording has improved, and is now of a good standard. All staff have now received a copy of the home’s new medication policy. The MAR chart folders still contain a collection of guidance notes written by the previous manager. These should be removed, as they have been superseded by the new policy. All storage facilities are good. Staff were keen and able to handle all queries raised during the inspection. A few receipt checks of medication have not been recorded, in particular items which have been received mid-cycle. A reason for this is that the pharmacy has been supplying loose dispensing labels to the home to be attached to the MAR chart, a practise which the Royal Pharmaceutical Society of Great Britain (RPSGB) has instructed should stop. A Burgess Park Version 1.10 Page 12 copy of this guidance will be supplied to the home to provide to the pharmacy. Controlled Drugs were checked and recording/stock checks were accurate. Four residents have been prescribed food supplements, however none had been received this month, so these were not being given. If the pharmacy is out of stock, the home must ensure supplies are ordered elsewhere, and if the food supplements are no longer needed, the GP must authorise this. The home does send residents’ weights to the GPs surgery every month for review, which is good practise. There were 3 cases where the medication regime on recent hospital discharge letters did not match up with what was being given at the home. The home must ensure that all changes are implemented, unless the home’s GP has documented that he/she wishes the old regime to be used. One resident who does not speak English is refusing all 10 prescribed items. This situation needs to be kept under constant review with the GP, and perhaps discussed with the resident using a translator to explain why the medication is needed. One change to an insulin dose was made mid-cycle, however the date of the change was not recorded. The date of any changes, and the nursing staff initials should be added to the MAR chart, or better practise would be to write in the new dose on a new line on the MAR chart so that the date the new dose was started can be clearly identified. Overall, the home has made very good progress. The majority of residents with whom the Inspector had contact were well groomed, with their hair and nails attended to. A hair- dresser visits the home regularly. Two residents were seen to be rather unkempt. Staff explained that these residents dressed themselves independently and this may have led to their less than satisfactory appearance. Consideration should be given to how the residents can be assisted to dress appropriately without compromising their independence and maintenance of their skills. Some care plans examined did not indicate the preferences of service users or their family members about whether they would prefer to be cared for by a male or female staff member. Observation was that staff interaction with residents is respectful and warm. However staff were observed, during handover meetings, to knock and enter residents’ bedrooms without waiting for permission to enter. This compromises residents’ privacy. Standard 11 was not assessed on this occasion. The Inspection of 1st December 2004 found that the standard was met. The Regional Manager stated that policies in relation to the care of residents at the end of their lives are to be reviewed by the organisation. Burgess Park Version 1.10 Page 13 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 standard(s) 12, 13, 14 and 15. There is a good programme of activities in the home, some residents, particularly those who do not leave their rooms, need to have an individualised activity programme devised so that all residents’ social needs are met. Care needs to take into account residents’ cultural needs so that these are addressed by the home. Relatives and friends are able to visit freely so residents are able to maintain relationships of importance to them. Feedback from residents about the food provided was largely positive. Meal time arrangements should be reviewed to ensure that residents are provided with appropriate help to eat and that their nutritional intake is adequately monitored. Training for the cook should be provided in catering for older people, particularly those with dementia so that their particular needs are taken into account and their nutritional needs are met. The reasons for a large proportion of the residents choosing to eat in their rooms should be reviewed with the aim of ensuring that arrangements for meals meet all residents’ needs. Burgess Park Version 1.10 Page 14 EVIDENCE: There is a full time activities organiser employed in the home who provides a weekly programme of activities. The activities organiser has links with the local PCT Care Homes Support Team and attends a group for people in similar posts in the area. This is an important source of support and information and has been of benefit to the residents. Two activities sessions were viewed during the Inspection. One session was being run by the activities organiser and was an art activity using photographs and other items of significance to each resident to make personalised table mats. The other was an opera session run by a resident, assisted by the Activities Organiser. Both activities seemed to be enjoyed by the participating residents. It is commendable that residents who wish to do so are supported to contribute to the activities programme in this way. There are some residents who are unable to leave their rooms, and some who, it was stated, prefer not to do so. Some of these residents have had wheelchair assessments arranged recently so that they will be able to access other parts of the home. The Inspector was concerned that activities for these people are developed further so that their individual needs in this area can be met. There is scope for further development of the way in which the home addresses residents’ cultural needs and the linguistic needs of those residents whose first language is not English. Although the home has made arrangements for attendance at culturally appropriate day centres there is scope for further integration of residents’ cultural and linguistic needs within the practices of the home. Information on how residents’ religious needs are addressed should be forwarded for inclusion in the final report. Relatives and friends were visiting residents of the home throughout the time of the Inspection visits. Feedback from relatives and friends was that they are able to visit freely and most relatives commented that they are welcomed by staff at the home. The organisation handles the financial affairs of only one of the residents, most others are managed by family members or the Court of Protection. No other advocacy services are involved in the home. The Statement of Purpose for the home refers to the existence of local advocacy services but the contact details are not included. These should be added to the document. A programme of quarterly residents and relatives meetings has begun and will be a useful forum for discussion of issues of concern with the Manager. Burgess Park Version 1.10 Page 15 Menus were provided as part of the pre-Inspection information. They showed that a range of dishes is provided which are generally traditional British meals. The cook confirmed that additional dishes are prepared to meet specific needs, some of which may arise from residents’ cultural background or dietary needs. These should be added to the prepared menus so that there is clarity about the range of food provided and so that informed choices can be made. The menus provided did not include details of the breakfasts served but the Inspector noted a request at a recent residents and relatives’ meeting for cooked breakfasts to be provided. Feedback received from residents as part of the Inspection was largely positive. Five of those residents who used comment cards stated that they liked the food, and three stated that they sometimes liked the food provided. One additional comment was that the food was ‘getting better’. Residents are asked the previous day to make choices from the prepared menus, if they are unable to make such a choice staff will do so based on their knowledge of their preferences. The Inspector viewed some of the ‘pre-order’ forms and noted that one resident regularly chose to eat just yoghurts at meal times. On the second day of the Inspection another resident had chosen only desserts. Some family members bring additional food to the home and this may have accounted for this. The concern was brought to the attention of the Manager during the Inspection. Although nutritional risk assessments were viewed on residents’ files there is currently no system for the home to adequately monitor residents’ nutritional intake and this needs to be introduced. The cook has not received training in the nutritional needs of older people, particularly in catering for people with dementia, this would be of benefit to the residents. The Inspector joined residents for two meals during the Inspection. It was noted that only around 50 of residents join the main group in the dining room for the main meal at lunch-time and a much smaller proportion were present in the dining room for the evening meal. The reasons for this should be reviewed to ensure that the meal-time arrangements meet all residents’ needs. In the evening at about 8pm a drink and a sandwich is served to residents. The observation of arrangements at the lunch-time meal for assisting those residents who need help and encouragement to eat indicated a need for review and consideration of how their needs can be met appropriately. It was noted that there was a lack of structure in relation to the way in which staff assisted residents resulting in some individual residents being assisted by several different staff members at the meal. This does not lend consistency to the care provided and could have been confusing to residents. Burgess Park Version 1.10 Page 16 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 standard(s) 16, 17 and 18 The management of complaints has improved in recent months and there were clear records of action taken in response. This has meant that residents’ views can inform the quality of care provided. Protecting residents from abuse forms part of the training programme for staff and is discussed in staff meetings. Staff were clear that they would take appropriate action if they had concerns about the welfare of service users. This contributes to the systems in place to protect residents from abuse. EVIDENCE: Complaints records were examined as part of the Inspection. While it was possible to identify the action taken in response those complaints made since January 2005 the previous records of complaints made to the home were in poor order and were difficult to track. Four complaints had been made to the home since January 2005, three of which were upheld and one was unresolved. There were clear notes of action taken in response to the complaints which was appropriate to the issues raised and aimed at improving standards. This Inspection took place some weeks prior to the General Election. During the Inspection the Manager of the home was making arrangements for those residents who wished to vote to be able to do so. There is a ‘prevention of abuse’ policy in place in the home which has reference to the Department of Health Guidance ‘No Secrets’. The Manager stated that the issue of the prevention of abuse is discussed at staff meetings. Training in Burgess Park Version 1.10 Page 17 such issues has been provided for staff and further training is planned for May and October 2005 and January 2006. In addition each member of staff is issued with information on whistle-blowing as part of the employee’s handbook. Staff who were interviewed as part of the Inspection were clear about the action to take if they had concerns about the welfare of any service users. The home has co-operated with adult protection investigations undertaken by placing authorities. There were no unresolved issues of this nature at the time of the Inspection. Burgess Park Version 1.10 Page 18 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 standard(s) 19, 20, 21, 22 23, 24, 25, 26 The standard of the environment within this home has improved so that residents have a more attractive and homely place to live. Further redecoration is planned, as is a programme of refurbishment. EVIDENCE: The building was found to be very clean at the time of the Inspection. Some redecoration has been undertaken and more is planned as part of a schedule of redecoration and refurbishment. The redecoration will include the exterior of the home which is planned for the summer period. There are a number of communal facilities in the home. On the ground floor is a large living room, two dining rooms, an activities room and there is a small living room on the first floor of the home. Call bells are being fitted to the communal rooms. The size of the rooms meets the required standards. New chairs have been ordered for the communal areas as some are in poor condition and in need of replacement. Several residents like to sit in the Burgess Park Version 1.10 Page 19 hallway of the home so that they can see out to the garden and the street. The garden area to the front of the home is large and shaded by trees. 23 of the bedrooms have en-suite facilities. In addition there are six WCs and seven WCs located in bathrooms. There are eight bathrooms throughout the building and two showers. The Manager stated that the bathrooms and shower rooms are included as part of the redecoration and refurbishment plan. An assisted bath is to be replaced by a shower which has been judged to be more appropriate to the needs of the residents. 23 of the current resident group are wheel-chair users. There are five hoists to assist with moving and handling, along with a range of equipment such as sliding sheets. There are handrails in corridors and grab rails in place in WCs and bathrooms. Several bedrooms were viewed throughout the three floors. Many of the rooms were personalised while others were less so. The Manager stated that relatives are encouraged to bring items to the home which will be of significance to the service users. The two double rooms are currently used as single occupancy rooms. Some of the bedrooms are furnished with items which are old and mismatched. The Manager is aware of this and it is planned that items will be replaced. On the Inspector’s previous visit to the home in March 2005 it was noted that several doors throughout the building were held open thus compromising fire safety arrangements. This was raised with the Manager of the home and it was found to have been addressed on this visit. Some residents prefer to have their doors open and consideration should be given to the fitting of safety devices to allow this without leaving staff and residents at risk. At the additional visit made on 11th March 2005 the standard of cleanliness and odour control throughout the building was found to be good with the exception of the ground floor corridor off which bedrooms are situated, and one of the bedrooms in this area. At this announced Inspection there was no odour detectable other than in the one ground floor bedroom. The management of the home are aware of this problem and a review of continence management arrangements has been undertaken and plans are in place to replace the flooring. Burgess Park Version 1.10 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There are enough staff on duty to make sure that residents’ needs for care and support can be met. Staff recruitment records examined were, in the main, in good order. Care needs to be taken to make sure that independent references are always taken up so that residents are cared for by people who have been judged to have the appropriate experience and skills. There has been a comprehensive training programme over the last year and future training is planned for the year ahead. The home has a significant number of staff who have undertaken training to NVQ level 2. This means that staff are provided with training to assist them in meeting the residents’ needs. EVIDENCE: There are fourteen qualified nurses employed to work at the home and twenty seven care staff. There are seven ancillary staff employed by the home, covering catering, cleaning, laundry and maintenance duties. At the time of the Inspection in addition to the Manager of the home there were three qualified nurses on duty and seven care staff. A nurse works on each floor of the home and the care staff are placed throughout the home – two on the ground floor, and on the second floor and three care staff on the first floor of the home. Overnight, for the current occupancy levels in the home, there are two qualified nurses and four carers working in the home. These staffing levels were judged to be appropriate for the current numbers and needs of the residents. Burgess Park Version 1.10 Page 21 A check of three staff recruitment files showed that these staff had two references taken up at recruitment stage. For one member of staff the second reference had been supplied by Burgess Park Nursing Home. The reason for this was unclear as a total of three independent referees’ details had been given on the application form. Other checks and references had been taken up appropriately. At the time of the Inspection there were two care staff members who had achieved NVQ level 2 and a further twelve care staff who have completed the course and are awaiting the results. Four care staff are to begin the training in May 2005. This meets the standard requiring that at least 50 of the staff team are appropriately trained to NVQ level 2 by 2005. There is a comprehensive training programme in place for the coming year. Half day sessions are planned to take place twice a month in a range of issues including resident welfare; customer care; 6 broad values of care; vulnerable adults issues; prevention of tissue damage; communication; continence management and the care of people with dementia. Training has been provided in the last twelve months in care planning, end of life care; medication management; moving and handling; health and safety awareness; food hygiene; fire safety and the responsibilities of a key worker. Burgess Park Version 1.10 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 38 The newly appointed Manager has made a number of positive changes in the home which has had a positive impact on the care provided to the residents. Residents’ financial records were in good order, this contributes to the systems in place to protect residents’ welfare. Although most aspects of health and safety were in good order consideration should be given to providing safety devices on doors which residents prefer to leave open. This will ensure that residents and staff are protected from the risk of fire. EVIDENCE: A newly appointed Manager is in place at the home. She is appropriately qualified in nursing and experienced for the role. The Manager is studying for the Registered Manager’s Award and is due to complete her studies in October 2005. The Manager expressed commitment to raising standards of care in the Burgess Park Version 1.10 Page 23 home. The indications of this Inspection were that staff are supportive of her efforts. Staff described the new management style as ‘open door’ and stated that the manager is supportive and receptive to their ideas. Some relatives who provided feedback as part of the Inspection also commented positively on recent changes in the home. The Manager stated that she has been supported by the senior management of the organisation in her initial weeks in post. The Manager will be subject to detailed assessment as part of her application to be registered under the Care Standards Act 2000. Records of residents’ finances which are managed by the home were examined with the assistance of the Administrator who has day to day responsibility for such matters. A random sample of records and receipts tallied and showed that expenditure is made appropriately and in accordance with residents’ wishes and best interests. No valuables (other than money) were held on behalf of residents at the time of the Inspection, but there are safe arrangements for storage, record keeping and return, should this need arise. Audits of finances are carried out every six months by representatives from the organisation, random checks are carried out as part of additional audit systems and information is passed to Head Office each month allowing reconciliation of accounts. Only two senior members of staff have access to finances in the home and receipts of money are signed by the receiving staff member and a senior. Health and safety records showed that there are systems in place for the testing of safety systems to ensure the safety of residents and staff. Weekly checks of the fire alarm system and hot water temperatures are carried out and fire drills were undertaken in March and April 2005. The fire risk assessment, conducted in February 2004, is due for review. As noted above some residents prefer to have their bedroom doors open and consideration should be given to the fitting of safety devices to allow this without leaving staff and residents at risk. Tests of electrical equipment were conducted in February 2005. The Inspector has been informed by Food Hygiene Authorities that, at their most recent Inspection of the home in January 2004, satisfactory conditions were found. There are auditing systems in place to ensure that important aspects of safety are subject to monthly management review. Recent audits have been undertaken in relation to medication, and infection control. Burgess Park Version 1.10 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x 3 x x 2 Burgess Park Version 1.10 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5(1) Requirement The Registered Provider must ensure that the statement of purpose and the service user guide include all of the information required by regulation. The Registered Provider must ensure that residents identified needs for specialist input to the care planning process is addressed through referrals to appropriate specialists such as physiotherapists and speech and language therapists. The Registered Provider must ensure that care plans include full information on residents communication methods. The Registered Provider must ensure that weight monitoring includes the date of when the resident was weighed to aid effective monitoring. The Registered Provider must ensure that a system for the home to adequately monitor residents’ nutritional intake is introduced. The Registered Provider must ensure that the social needs of those residents who rarely leave Version 1.10 Timescale for action 1st September 2005 2. 8 13(1)(b) 1st july 2005 3. 7 12(1) (a)(b) 12(1) (a)(b) 1st July 2005 1st July 2005 4. 8 5. 8 12(1) (a)(b) 1st July 2005 6. 12 16(2) (m)(n) 1st July 2005 Burgess Park Page 26 7. 12 12(4)(b) 8. 15 12(1)(a) 9. 15 18(1) (c)(i) 10. 29 11. 8 19(1) (b)(i), schedule 2 16(2)(k) 12. 9 13(2) 13. 9 13(2) their rooms, are assessed and action taken to address them, The Registered Provider must ensure that care planning systems take into account and address residents’ cultural and linguistic needs. The Registered Provider must ensure that meal time arrangements are reviewed with the aim of ensuring that appropriate and consistent assistance is provided for residents. The Registered Provider must ensure that training is arranged for the cook in catering for older people, particularly those with dementia. The Registered Provider must ensure that staff recruitment practices include obtaining two independent references. The Registered Person must ensure that continence management on the ground floor is reviewed. (This requirement was brought forward from the additional visit of 11.3.05, and still within timescale at the time of this Inspection. It was noted during this Inspection that continence assessments were underway.) The Registered Provider must ensure that when a resident is discharged from hospital, all changes to their medication regime are implemented. The Registered Provider must ensure that residents receive all prescribed food supplements unless there is documented evidence that the GP has decided these are no longer needed. 1st July 2005 1st September 2005 1st September 2005 1st July 2005 1st May 2005 1st June 2005 1st June 2005 Burgess Park Version 1.10 Page 27 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 7 Good Practice Recommendations Wherever possible family members who are asked to provide such details should be assisted to do so with the aim of ensuring that this information can be used as part of the care planning process. Consideration should be given to how the residents can be assisted to dress appropriately without compromising their independence and maintenance of their skills. Care plans should indicate the preferences of service users or their family members about whether they would prefer to be cared for by a male or female staff member. Staff should receive management input on how to conduct handover meetings with regard for residents privacy. The review of meal time arrangements should include reference to those residents who currently do not eat in the dining room to assess whether changes can be made to encourage them to do so if it is judged that this will be beneficial to them. Some residents prefer to have their bedroom doors open, consideration should be given to the fitting of safety devices to allow this without leaving staff and residents at risk. 2. 3. 7 7 4. 5. 10 15 6. 25, 38 Burgess Park Version 1.10 Page 28 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 0EH 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 Burgess Park Version 1.10 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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