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Inspection on 15/05/06 for Burgess Park Nursing Home

Also see our care home review for Burgess Park Nursing Home for more information

This inspection was carried out on 15th May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector received positive feedback about the way that the home runs from several residents. One stated - `this home works well, there is nothing to complain about` and another said that the staff were `fantastic`. Residents and their relatives are encouraged to contribute to the way that the home runs through meetings which are planned for the year and through regular informal contact with staff and the manager of the home.

What has improved since the last inspection?

The way in which medication records are kept has improved. Night time care practice now reflects residents` wishes about when they prefer to get up and this is recorded in their care plans. The rota is now arranged to ensure that staff have adequate time off between shifts and staffing levels in the mornings have been increased. Several rooms have had devices fitted to ensure that they can remain open, in line with residents` preferences, but will close in the event of the fire alarm being activated. This ensures residents` safety.

What the care home could do better:

The home is in the process of changing care planning systems, as a result requirements which related to care planning will not be examined until this process is complete. It is anticipated that the new system will be more effective in this area. There were some areas of recording of care practices which can be improved, particularly ensuring that monitoring charts and assessments are completed fully, consistently and accurately. Care plans mustbe reviewed regularly and whenever possible signed by residents, their relatives or advocates, to confirm their involvement and agreement. Some areas of the building, particularly the bathrooms and WCs, are in need of redecoration, as is the exterior of the building.

CARE HOMES FOR OLDER PEOPLE Burgess Park Nursing Home Burgess Park Picton Street Camberwell London SE5 7QH Lead Inspector Ms Alison Pritchard Unannounced Inspection 10:45 15 & 16th May 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burgess Park Nursing Home DS0000007011.V291227.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 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 Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burgess Park Nursing Home Address Burgess Park Picton Street Camberwell London SE5 7QH 020 7703 2112 020 7701 4220 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) Exceler Healthcare Services Limited Mrs Spiwe Ruth Rondozai Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of which two persons may be aged 60 years to 64 years Date of last inspection 21st October 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 sixty older people who have nursing needs. In mid May 2006 there were fifty-one residents in the home. The facilities in the home are spread over three floors. There are lounges on the ground and first floors of the home and dining facilities are on the ground floor. Bedrooms are located on all three floors of the home. There are two double bedrooms and the remainder are single. Twenty three of the bedrooms have en-suite facilities. There is a passenger lift allowing all residents to have access to all parts of the home. There is a garden to the front of the home and parking is available on the street as well as in a car park to the rear of the home. Information about the service is made available to potential service users in a number of ways including when telephone enquiries are made, during introductory visits to the home, through the home’s brochure, statement of purpose and service user guide. In addition the home holds open days, a fete and a fun day which are open to the community. Information about the home is passed on to Social Services Departments and multi-disciplinary teams. The home ensures that copies of CSCI inspection reports are made available to potential service users through ensuring that a copy is located in the hallway for review, enquirers are directed to the CSCI website and the reports are discussed at relatives meetings and staff meetings. In mid May 2006 the range of fees charged was between £462 and £653 per week. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The findings of this inspection report are based on discussions with and feedback from a range of people including residents of the home, relatives of residents, staff members and managers from the home, community based health care professionals and staff from Social Services Departments who fund placements. In addition the inspector visited the home on two days. During the visits, as well as holding discussions with some of the people noted, care practice was observed, a range of records was examined and the inspector looked around the building. Information is also gathered through notifications made by the home to CSCI. All of this information has been taken into account in compiling this report. What the service does well: What has improved since the last inspection? What they could do better: The home is in the process of changing care planning systems, as a result requirements which related to care planning will not be examined until this process is complete. It is anticipated that the new system will be more effective in this area. There were some areas of recording of care practices which can be improved, particularly ensuring that monitoring charts and assessments are completed fully, consistently and accurately. Care plans must Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 6 be reviewed regularly and whenever possible signed by residents, their relatives or advocates, to confirm their involvement and agreement. Some areas of the building, particularly the bathrooms and WCs, are in need of redecoration, as is the exterior of the building. 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. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 3, 4, 5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People who are considering living at the home are given information so that they can decide if it is a suitable place for them to live, and they or their relatives may visit prior to admission. Some of the information contains errors which need to be amended. The home conducts detailed assessments to ensure they can meet the person’s needs. EVIDENCE: The service user guide and statement of purpose are displayed along with the most recent CSCI inspection report in the hallway of the home. Copies of the statement of purpose and service user guide are provided for residents, relatives and people who are considering coming to live at the home. The statement of purpose contains most of the information required but does not include details of the age range and sex of residents for whom care will be provided, nor details of the range of needs that the home intends to meet. In addition there is an error on the page which describes the accommodation as it Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 9 states that there are more double rooms than is actually the case. This error and the omissions should be amended. The service user guide also contains some errors in the number of people the home is registered to care for and the telephone number of the CSCI. In addition there are some statements made in the document which are presented as a summary of the last CSCI inspection report. In fact the statements reproduced do not come from the last inspection report and as a result of copyright restrictions the reports may only be used in their entirety unless permission has been granted to use extracts. The records relating to recently admitted residents showed that the home had obtained a copies of the care management assessment and care plan from the Social Services department. Prospective residents are visited by the manager or another senior member of staff prior to the admission and the home’s assessment is completed. The assessment carried out is full and detailed. A statement confirming that the home could meet the potential resident’s care needs was seen on file. Relatives, and where possible, potential residents, are able to visit the home prior to admission. There was feedback that the way in which this visit was conducted by the home was helpful and enabled the relative who visited to ask questions to help them to make a decision about the suitability of the placement. Care notes completed around the time of a new resident’s admission showed understanding of the need to help the person to settle in the home and of the emotional impact that admission may have on the resident. A relative confirmed that they had received a contract to confirm the details of the placement. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A new care planning system which is being introduced should improve the recording of residents’ cultural and social needs. Overall there is good attention to residents’ medical and health care needs but monitoring charts need to be completed consistently. Residents are treated respectfully and with regard for their privacy. EVIDENCE: The information used to assess this outcome group includes examination of four care plans, observation of care practice, discussion with residents and staff, information from relatives, and information provided by the home in the annual return questionnaire and through notifications to CSCI. The home is in the process of introducing a new care planning system. The care plans currently being used varied in quality, some were full and detailed, others needed further development to ensure that they reflected the residents’ range of needs, particularly those which do not relate to solely physical and medical matters. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 11 The new system is comprehensive and, if used well, should address the need to ensure that care plans reflect the residents’ full range of needs including those that arise from their cultural and linguistic backgrounds and their social needs. Some residents’ care plans had been transferred to the new system but this was only in the introductory stages and the transfer was not complete. The staff with whom the new system was discussed were positive about the change and felt that the new plans were sufficiently detailed to enable them to document residents’ care needs and how they will be met. As a result of the state of transition that the care planning system is in it was not possible to accurately make a judgement about a requirement previously made about the need to ensure that care plans were full and reflective of residents’ social and cultural needs. The requirement remains in place and will be fully assessed at the next inspection of the home when the change of care planning system is complete. Residents spoken to felt that they received the care that they need, one described the staff as ‘very kind and good’ and said ‘they understand me, we get on in a chummy way.’ Another resident described the staff as ‘fantastic’ and as ‘nice people’. Residents’ family members have been invited to attend care planning reviews so that they can contribute to the care planning process. The resident or their family members should be encouraged to sign the care plans to confirm their involvement with the process and agreement with the plan. Care plans included details of residents’ health care needs. Residents confirmed that they see the GP regularly and this was supported by records. There was information to confirm that appropriate referrals are made to other health care professionals such as the podiatrist, dentist, dietician and optician. The care plan of a resident with significant medical problems was examined in detail. It was found that the plan had not been reviewed at the required monthly intervals and that charts to monitor the resident’s condition had not been completed consistently. For example a fluid chart completed on 15th May did not have entries for the day after 2pm, and on two previous days there were no entries beyond 5pm. Staff provided assurances that the resident had received fluid but this had not been recorded. It is essential that records are maintained with accuracy. One file contained two different risk assessment tools to indicate the resident’s nutritional status. The results of the two assessments conflicted and there was no care plan to show any action indicated. Attention must be given to ensuring that such assessments are completed with consistency so that they inform care practice. At the time of the inspection there were four residents with pressure sores all of which were improving and only one of which was acquired in the home. One Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 12 of the nurses employed at the home is a link nurse to co-ordinate pressure care. Specialist advice is sought from the tissue viability nurses who visit fortnightly. The incidence of pressure sores is one of the issues reviewed as part of the home’s regular audits of the quality of care provided. A sample of medication stocks, records and systems was checked. Each of the three floors has a medication trolley which stores the medication securely. A pharmacist from the Care Homes Support Team and the home’s supplying pharmacist carry out audits of the medication systems. Medication reviews by the GP take place regularly. The system is for five residents a month to have reviews of their medication and for this to take place when a resident has been in hospital. The medication administration records are in good order, with no gaps and with codes being used appropriately. Residents confirmed that they are able to maintain their privacy and that staff treat them appropriately, with respect and regard for their dignity. This confirmed the inspector’s observation of the attitude of staff towards residents. Residents were well dressed and groomed. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from an activity programme which takes account of residents’ interests and cultures. There are effective systems to make sure that residents’ preferences and views are taken into account when planning meals. EVIDENCE: Discussion with residents and examination of records showed that residents are able to choose when to get up and when to go to bed. This is an improvement on the findings of a visit in December 2005 when it was found that insufficient choice had been given to residents about their morning routine. There is a well developed activity programme in the home which includes a range of activities such as bingo, craft work, reading, poetry and opera sessions, games, hair dressing and manicures, shopping and trips out in good weather. Some of the residents go to local day centres (some of which reflect the residents’ cultures) and the activities co-ordinator is making arrangements for a local church day centre to visit the home to run activities. The activities co-ordinator said that she visits residents who rarely leave their rooms so that she can discuss with them their social interests and how the home can take Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 14 action to meet them. The activity co-ordinator has undertaken relevant training and is supported to fulfil her role. One of the residents described the activities co-ordinator as ‘an excellent master of ceremonies’. Members of local churches come to the home and conduct services. Visitors were observed to come to the home freely to see their friends and relatives. Residents are able to see their visitors in private and to choose who they see. Residents are able to handle their own financial affairs if they wish and have the capacity to do so. In most instances relatives of residents look after their financial matters. The feedback about the meals provided was generally positive, one person said that they did not like some of the meals and had passed this message back to catering staff. The chef took the comments seriously and went to discuss the matter with the resident and made changes to reflect her views. Monthly meetings are held in the home for the residents and the manager to meet with the catering staff. This allows a regular forum for discussion of the menu. Efforts are made to include individual preferences and needs arising from residents’ culture and health in the menu. There are appropriate guidelines in place to ensure that residents who need assistance to eat are provided with the necessary support. Some residents choose to eat their meals in their rooms but they do not have access to the menu which is displayed on the ground floor. It is recommended that they are provided with a menu so that they can make choices and are aware of the day’s meals. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon. The system to ensure that residents are safe from mistreatment is understood by staff and this contributes to the residents’ protection. EVIDENCE: The complaints procedure is included in the statement of purpose and the service user guide. Both documents include details of the CSCI with whom concerns can be raised. The Registered Person agreed to ensure that the telephone number of CSCI is amended so that the information is accurate. Residents and relatives confirmed that they would feel confident in raising concerns with the Registered Manager of the home. Records are kept of all of the complaints made and action taken in response. The CSCI has found that the Registered Manager is responsive to concerns raised and that she is keen to take action to address any areas needing attention to improve the service provided to residents. In December 2005 an anonymous complaint was received by the CSCI about staffing levels, the length of shifts and night time care practice. One element of the complaint was upheld and two were partly upheld. The Registered Person took the matter seriously and changes have been made to the rota and to care planning and practice as a result. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 16 All staff have undertaken training in adult protection issues as part of a training programme on residents’ welfare. Staff interviewed were clear about the action they would take if they were concerned that any residents were at risk. There are no outstanding matters of this kind at the time of the inspection. The records of finances held on behalf of residents were checked with the assistance of the administrator. The funds are stored safely, records are in good order and there are systems in place to carry out regular checks. The policies relating to residents’ finances were not available at the time of the inspection as a result of a change in the managing organisation. It is recommended that the policies are sent to the CSCI. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents have benefited from the redecoration that has been completed, but some areas still need to be improved, including some bathrooms and the exterior of the building. EVIDENCE: A programme of refurbishment is underway, many of the communal areas and residents’ bedrooms have been redecorated and this has improved the appearance of many parts of the building. There remain some areas where improvements are still required such as some of the bathrooms where some rooms have damaged walls and bath panels. In one bathroom it was noted that the WC seat needed to be replaced. The exterior of the building is to be redecorated in the near future. The Registered Person acknowledged that the external and internal works have been delayed for a number of reasons and anticipated that they would be completed soon. A selection of bedrooms on each floor was seen, they were all clean, homely, personalised and decorated to a satisfactory standard. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are enough qualified and trained staff to meet residents’ needs. Staff are recruited safely and given induction training so that they become familiar with the needs of the residents and how to help them. EVIDENCE: The staffing levels have been reviewed and improved in the last few months. At the time of the inspection the staffing levels (for 55 residents) were as follows: Morning Afternoon Night 3 nurses and 9 care staff 3 nurses and 7 care staff 2 nurses and 5 care staff This is appropriate for the numbers and needs of the residents and this was confirmed by feedback from both residents and staff who find the staffing levels satisfactory. The allocation of the staff is determined according to the numbers of residents on each floor of the home and their particular needs. A rota is maintained showing an accurate record of which staff are on duty at the home. There are sufficient numbers of domestic staff who cover cleaning, laundry and catering duties. The post of maintenance person is being recruited to. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 19 Of the 27 care staff employed to work at the home 6 have attained qualification to NVQ2. A further 12 staff are part way through the training course. Additional training has been conducted in a range of issues including health and safety matters and resident welfare issues. Staff have also undertaken training provided by the local PCT Care Homes Support Team, with whom the home has close links. Recruitment records were examined for three newly recruited staff. It was found that the records were in good order and included all of the required checks and references. All three of the files included confirmation that the staff have undertaken a suitable induction programme. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents benefit from an effective manager who is resident focussed and promotes teamwork amongst the staff. Health and safety is generally well managed. EVIDENCE: The Registered Manager has been in post since early 2005. She is appropriately qualified in nursing and holds the Registered Manager’s Award (NVQ 4). She has a range of appropriate experience in care homes. A Deputy Manager has recently been appointed from within the staff team. The feedback about the manager and her approach was very positive from both residents and staff. A resident described the manager as: Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 21 ‘an excellent manager…very understanding and helpful, but not soft.’ A staff member made this comment about the manager: ‘I think she does well….she acts on things’ and another said ‘she knows management’. The style of management is very focussed on the residents and this is demonstrated by the manager’s familiarity with the needs of the residents which is gained through her spending time with residents and ensuring that she has regular contact with staff who work directly with them. The staff are supported to do their jobs through formal means such as regular supervision and staff meetings and through informal access to the manager and other senior staff. The management style promotes a positive approach to team work which one member of staff identified as a particularly good thing about the home. The policies and procedures of the home are being changed to reflect those of the new managing organisation. There are a number of quality auditing systems which will be introduced, replacing those already in place. The Registered Manager ensures that she conducts regular audits to identify areas needing improvement. Residents or their relatives are encouraged to maintain control of their financial matters, but in some cases this is not possible. In these situations either the placing authority or the managing organisation will maintain the responsibility. Additional audits are completed by the Regional Manager who visits the home regularly. Appropriate insurance certificates were seen during the inspection. Health and safety matters are managed well and there were no concerns of this kind during the inspection. Devices have been fitted to doors to ensure that they close in response to the fire alarms being activated and this helps to protect residents. Although some of the records seen were incomplete this was because the method of keeping the records was changing as the new systems of the managing organisation were being introduced. The lift requires repair and new parts to be fitted. The Registered Person should inform the CSCI when this work has been completed. It was noted that an examination of the lift in February 2006 identified that the required work should be undertaken within one month. Nevertheless, although the order for the work had been made it was not complete at the time of the inspection. At the time of the inspection the front door could not be used as it was unsafe and needed to be replaced. Alternative arrangements for the access to and exit from the building had been made and a fire drill held to ensure that staff were aware of the new place to gather in the event of such an emergency. A new door had been ordered and was to be fitted shortly after the inspection. No other major works were identified as necessary. Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 14(2)(b) 15(1) Requirement The Registered Person must ensure that care plans document the range of residents’ assessed needs and include information from assessments by other health care professionals. This requirement is not met, the target date for compliance was 01/04/06. As the home is changing the care planning system and the change is not yet complete the target date has been extended. Timescale for action 01/10/06 2. OP12 15(1) The Registered Person must ensure that care plans include residents social, cultural and linguistic needs and that recording includes reference to activities as well as physical and medical aspects of care. This requirement is not met, the target date for compliance was 01/04/06. As the home is changing the care planning system and the change is not yet 01/10/06 Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 24 complete the target date has been extended. 3. OP1 4&5 The Registered Person must ensure that the statement of purpose and the service user guide are amended to correct the errors identified. The Registered Person must ensure that care plans are reviewed each month. The Registered Person must ensure that monitoring charts, such as fluid intake charts, are completed with consistency. The Registered Person must ensure that assessments of residents’ nutritional status are completed accurately so that they can inform care practice. The Registered Person must inform the CSCI of the schedule for the redecoration of the bathrooms and WCs and the exterior of the building. 01/09/06 4. 5. OP7 OP8 15(2)(b) 17(1)(a) sch3 para(k) 17(1)(a) sch3 para(k) 23(2)(d) 01/07/06 01/07/06 6. OP8 01/07/06 7. OP19 01/09/06 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. 2. 3. 4. Refer to Standard OP7 OP15 OP18 OP38 Good Practice Recommendations The Registered Person should ensure that, whenever possible, care plans are signed by the resident, their relatives or advocates. The Registered Person should ensure that those residents who choose to eat in their rooms are provided with a menu. The Registered Person should ensure that copies of the policies relating to the management of residents’ finances are sent to CSCI for consideration. The Registered Person should inform the CSCI when the required repairs to the lift have been completed. DS0000007011.V291227.R01.S.doc Version 5.1 Page 25 Burgess Park Nursing Home Burgess Park Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection SE London Area Office 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 Nursing Home DS0000007011.V291227.R01.S.doc Version 5.1 Page 27 - 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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