Inspection on 07/12/07 for Burgess Park Nursing Home

This inspection was carried out on 7th December 2007.

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

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 15/05/06

Burgess Park Nursing Home 21/10/05

Burgess Park Nursing Home 14/04/05

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 Nursing Home Burgess Park Picton Street Camberwell London SE5 7QH Lead Inspector Ms Alison Pritchard Unannounced Inspection 11:00a 7 December 2007 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.V353770.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 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 burgess.park@ashbourne..co.uk www.schealthcare.co.uk Exceler Healthcare Services Limited 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) 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.V353770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of which two persons may be aged 60 years to 64 years As agreed on 21st June 2006, one service user age 56 years, can be accommodated within the home for no more that six weeks from the date of admission. The Commission for the Social Care Inspection must be informed when this service user leaves the home. 15th August 2007 Date of last inspection 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 December 2007 there were fifty 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. The home ensures that copies of CSCI inspection reports are made available to potential service users by 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 December 2007 the range of fees charged was between £582 and £680 a week. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over three days in December 2007. The inspection methods included observation of care practice, discussion with residents and staff, inspection of residents’ files and a range of other records, including an audit of personnel files. We made a partial tour of the premises. A selection of care plans was checked, and aspects of these residents’ care were examined by case tracking. Involved professionals, relatives and staff were sent survey forms so that they could contribute to the inspection process. We are grateful for the contributions of everyone who responded to requests for feedback and all of the people who spoke to us during the inspection. A short period of time was spent observing residents in one lounge to understand more about life in the home. The last key inspection of the home took place in May 2006; a random unannounced inspection took place in August 2007. At the time the passenger lift had been unreliable and the visit was made to assess the impact of this on residents and staff. Since that time remedial action has been taken to repair the lift and reports during this inspection visit were that it is now operating reliably. The CSCI also has access to information gathered through notifications from the home. A document called an Annual Quality Assurance Assessment (AQAA) was completed by the Registered Manager of the home in advance of the inspection and returned to the inspector. All of this information has been taken into account in compiling this report. The Registered Manager and staff from the home facilitated the inspection visits; we are grateful for their assistance. What the service does well: The home provides clear information for potential residents about the services it provides. Introductory visits to the home are encouraged and new residents are helped to settle in to the home. Arrangements for managing medication on residents’ behalf are safe and checked by senior staff. Staff are respectful and warm when dealing with residents. Several residents and relatives spoke highly of the care provided at the home. One person said that the home looks after her relative ‘very well’, and another said ‘everybody Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 6 at Burgess Park seems to be very caring…..we are very satisfied with the care that [my relative] gets.’ Residents and relatives said that they are confident that they could talk to staff or the manager about any problems or complaints and that they would do what they can to help. More than 50 of the care staff team have achieved the appropriate qualification for their work (NVQ level 2 or higher). Staff were observed to be hard working and committed to providing a good service. The management approach in the home is targeted at the achievement of good standards of care. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents have enough information about the home to make sure that they can decide about whether the placement is suitable. Potential residents and people important to them can visit the home to assess whether it will be a suitable place for them to live. Assessments are carried out by the home to make sure that their needs can be met there. EVIDENCE: Information about the home and the services it provides is available in the statement of purpose and the service user guide. People who are considering living at the home are provided with a copy of the service user guide which is available on audio cassette or printed form. Current residents of the home are also given copies of the document. Each of the residents is given a contract which details the rights and responsibilities of the resident and the home, the information provided includes details of fees and additional payments which may be required for specific services such as hairdressing, personal shopping, and newspapers. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 10 New residents confirmed that they or their relatives had been encouraged to visit the home to help them make a judgement about its suitability. Assessments carried out by placing social workers are obtained by the home prior to the resident’s admission. Senior staff conduct an additional assessment to ensure that the home can meet the person’s needs. One resident who had moved to the home a short time before the inspection praised the assistance he has received from the home saying ‘I have settled in very well, that’s because of the help from the staff.’ Standard 6 does not apply to this home, as intermediate care is not provided there. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are generally comprehensive although more detail needs to be recorded about needs which arise from residents’ religious and cultural backgrounds. Staff take into account advice given by health care professionals but there should be more attention paid to recording of how to implement the advice in the care plan. Residents benefit from the good management of medication in the home. Residents are treated with respect and their right to privacy is maintained. EVIDENCE: Each of the residents has a care plan, which details the care to be provided by the home. The plans are reviewed each month and updated as necessary. Six residents’ care plans were examined, they included residents from all floors of the home, some who were newly admitted and others who had lived at the home for a longer period. It was found that the plans included reference to physical, social and cultural needs although, given the needs of the resident group, there is a greater emphasis on the physical and health care needs. Account had been taken of Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 12 the outcomes of assessments undertaken including those relating dependency levels; pressure care; nutrition and moving and handling. to One of the care plans included information about the resident’s religion and there was useful information about the resident’s social history. Nevertheless the only reference in the care plan to implications arising from the resident’s religious and cultural background was about the person’s dietary needs. Consideration should be given to other implications for care indicated by the person’s background. See requirement 1. Files contain a pro forma of contact details for health care professionals. In one file the sheet was not completed although the resident had moved to the home more than three months earlier. Other forms in the file including the admission checklist and the service user profile were also incomplete. See requirement 2. Good liaison with health care professionals was shown in the files examined. Health care needs are well attended to, however one instance showed that documentary evidence of the implementation of specialist advice needs to be improved. In one file a specialist nurse had made a recommendation about the dietary needs of a resident. The advice was that the resident be given soft and mashed food. Written entries made by some of the staff team appeared to indicate that the advice was not being followed as the entries stated that the resident had been given sandwiches. Discussion about the matter with the Registered Manager showed that the advice was being heeded and that the sandwiches were moistened so that they were suitable for the resident, this was not made explicit in the documentation. It is required that the care plan and daily care notes are sufficiently detailed to confirm that specialist advice is incorporated into care practices. See requirement 3. At the random inspection carried out in August 2007 it was found that some residents from the upper floors of the home had been unable to attend health care appointments as a result of the lift being out of action. The remedial action taken to repair the lift has ensured that residents are able to leave the building to attend planned appointments. Feedback received from health care professionals was that staff are committed to meeting residents’ care needs and act on advice given. One person stated, in relation to the care given at the end of residents’ lives, that ‘the standard of care they are giving is very good’. Each of the floors has safe storage arrangements for medication and a nurse administers it. Nurses have access to appropriate professional guidelines and internal policies. A sample of medication recording was checked and found to be in good order. The Registered Manager and Deputy Manager of the home carry out monthly audits of medication management. The results of the audits show good medication practice in the home. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 13 Residents confirmed that the staff treat them with respect and that they may choose to spend time alone if they wish. Residents spoke highly of staff, for example one was described as ‘excellent’ and that she has ‘human warmth’; another person said ‘I couldn’t wish for better staff’ and a third said ‘the management and staff are very kind to me.’ Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 14 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. 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 this service. Activities are organised for residents taking into account their needs and interests. A range of Christmas activities were planned including a pantomime, a visiting choir and a party. Residents would benefit from more opportunities to have trips out of the home. Visitors to the home are encouraged and welcomed. The residents are encouraged to make choices about their daily activities. Meals are arranged to reflect residents’ wishes and their cultural and nutritional needs. EVIDENCE: An activities organiser is employed at the home. A programme of activities is arranged each month and in December the events included a pantomime, a visiting school choir, a carol service and a Christmas party. There is an activities room which can be used for craft activities as well as a large lounge in which group activities are held. The Registered Manager stated that it is planned that a handiwork group will begin over the next year. During the inspection some time was spent observing residents taking part in a gentle exercise session. It was noted that staff spent time with individual residents during the activity and that these residents particularly enjoyed this. Other residents enjoyed watching a Benny Hill video. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 15 Representatives from the Church of England and Roman Catholic churches visit the home. The needs of a Muslim resident were discussed and showed that there had been liaison with the person’s family to make sure that appropriate arrangements were in place. These discussions should be reflected further in the resident’s care plan. Some feedback received from residents and relatives was that they would like the opportunity to go on more outings, both informal trips, for example to the local shops, and others which involve more planning. An outing to the Imperial War Museum had been held. However, it is acknowledged by the home that this is an area in which they can improve and hope to do so over the next year. Visitors are able to come to visit residents of the home at all reasonable times. Relatives told the inspector that they are welcomed to the home by staff. Some visitors who were unable to use the stairs had been unable to visit their friends and relatives at the time that the lift was not working properly. The action taken to repair the lift has ensured that residents are able to maintain contact with their friends and relatives. Residents are helped to exercise choice, for example by handling their own financial affairs when they are able to do so, and if this is not possible, requesting that relatives do so. Information about the contact details of a local advocacy service is provided for residents in the service user guide. Residents can choose whether to eat in their rooms or in the dining room. Any necessary assistance is provided. A four week menu is prepared and amendments made to it in the light of the particular needs of the residents. The cook is knowledgeable about the preferences, nutritional needs and cultural requirements of the residents and provides meals which reflect them. The menu showed that the meals are varied and nutritious, including fresh items. Special menus were prepared for the Christmas and New Year period and cakes are provided for residents’ birthdays. Some residents need to have meals which are blended or mashed. These meals are presented in a manner which is attractive and maintains the flavours of the different elements of the meal. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies for complaints and dealing with adult abuse contribute to the protection of residents. EVIDENCE: The service user guide includes a copy of the complaints procedure. It includes contact details of the manager and other senior staff within the organisation and the different stages and timescales for the process. Residents said that they felt confident that the Registered Manager would deal properly with any concerns they had. The complaints record showed that the Registered Manager had addressed concerns raised and informed complainants of action taken to address them. Several complaints made concerned the problems with the operation of the lift. The statement of purpose makes it clear that the home will assist residents to participate in local and general elections. Staff were clear about action they would take in event of concerns about the safety of residents. They expressed confidence in the commitment of the Registered Manager to the protection of residents. The manager acknowledged the need for some staff to receive further training in safeguarding issues. She is aware of the local authority safeguarding adults procedure and has cooperated with it. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The communal rooms are in good condition but some bedrooms need to be improved by redecoration, re-carpeting and refurbishment. Some residents would benefit from their rooms being made more homely. A programme of redecoration and refurbishment is underway. The appearance of the exterior of the building has been in need of improvement for a long time. The addition of patio doors to a communal lounge will allow residents to have easier access to the garden. The building is clean and hygienic. EVIDENCE: The communal areas of the home on the ground floor are in a good state of decoration, they are attractive and homely. A relative commented that the communal areas of the home are ‘always clean and fresh’. The large lounge on the ground floor has been improved by the addition of patio doors which will allow easier access to the garden. The residents will benefit in the warmer months from this improvement. Attractive and sturdy garden furniture has been purchased for use in the garden. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 18 A redecoration programme is underway and at present the decorative standard of bedrooms vary in quality. Some bedrooms were attractive, well decorated and made homely with personal items. However another room seen on the second floor was in need of redecoration and would have been made more homely with a new carpet and the addition of personal items. A relative’s comment about another room was ‘bedroom and furniture in need of attention’, another respondent agreed stating that the home ‘needs new soft furnishings’. See requirement 5. The exterior of the building has been in need of redecoration for a significant period. It is stated in the information provided prior to the inspection that the work will be undertaken when the interior works have been completed. See requirement 4. Improvements have been made to some of the bathrooms and more work is planned to improve the facilities and make them more suitable for the residents’ needs. For example a room with a standard bath is to be replaced with a ‘wet room’ with a shower allowing it to be used by residents who have mobility problems. Some of the bedrooms have an en-suite WC. Other WCs are available and on the ground floor facilities are reasonably close to the communal rooms. Other adaptations in place for residents include grab rails , a call bell system and hoists As mentioned elsewhere in the report problems with the operation of the lift in the summer of 2007 had a significant impact on the residents. These problems are now resolved after major works have been carried out. The home is clean and free from offensive odours. There are suitable laundry facilities for the home. On each floor of the home hand cleaning products are available to staff, residents and visitors. This is a part of the home’s infection control strategy. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need review to ensure that they are available in sufficient numbers to meet residents’ needs. The rota must not include excessively long shifts for staff. Nursing staff have undertaken a range of courses relevant to the work they undertake, more than half of the care staff team have achieved NVQ level 2 or above. Residents benefit from a well managed staff recruitment system which contributes to their safety. EVIDENCE: When complete the nursing and care staff team consists of, in addition to the Registered Manager, ten qualified nurses and thirty care assistants. The staff team is fairly stable, particularly amongst the nursing staff, and this allows for consistency of care. Agency staff are not used and, in the event of vacancies caused by annual leave, sickness or vacant posts, they are covered by members of the bank staff team or by permanent staff working additional shifts. The rota is arranged to comply with a staffing notice issued in 2001 by a previous regulatory authority. While the notice has been a useful guide it is no longer the best current measure of appropriate staffing levels as the resident group has changed. The information provided prior to the inspection visit was that all of the residents require help with personal care. Approximately two thirds of the group require two people to provide assistance with their care Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 20 during the day and about a third of the group need this level of help at night time. During the inspection the issue was discussed with residents and a range of staff; time was spent observing the early morning routine; the rota and staff deployment records were examined in detail. Several residents commented that sometimes the call bells are not answered as quickly they would like; one person said that generally the response is in a reasonable time ‘but sometimes they are short staffed’. Two relatives commented that their relative would benefit from the opportunity to go out of the home occasionally but staffing levels prevented this. Staffing levels for the number of residents at the time of the inspection were: Nursing 3 3 2 Care 7 7 5 Morning Afternoon/ early evening Night The observation on the morning visit was that, on the first floor, one nurse and four care staff provided care. It was noted that some of the staff choose to arrive early for their shifts as, it was reported, this assists in managing the workload. There were twenty two residents on this floor, seventeen of whom need a significant amount of assistance with personal care. The residents have a range of medical needs requiring nursing input (for example care of catheters and stomas, pressure care and fluid monitoring). The majority of residents require medication to be administered by the nurse on duty. Up to eight of the residents required moving and handling assistance with the use of a hoist. A professional referred to the high care needs of residents on this floor of the home and expressed concern about the staffing levels and the impact on staff morale. It was felt that staff were working very hard to provide a responsive service. Similarly a relative commented ‘I feel the morale of the staff is low, although they are all helpful’. It is required that a review of staffing levels is conducted to ensure that staff in sufficient numbers are deployed to meet the needs of the residents. See requirement 6. Examination of the rota revealed issues of concern. It showed that there are occasions when members of the waking night staff team (both nursing and care) are called upon to do additional shifts during the daytime. This has resulted on several occasions in staff working a six hour day shift followed immediately by a twelve hour waking night shift. It is not reasonable for staff to be rostered to work a shift lasting for eighteen hours and this could present risks to residents. See requirement 7. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 21 Discussion with senior staff in the home showed that some aspects of the rota had been changed without being recorded adequately. It is required that an accurate record is kept of the staff working arrangements. See requirement 8. Of the thirty care staff nineteen already hold NVQ level 2 or above and a further seven are working towards it. This meets the standard requiring that 50 of the staff team have achieved the qualification. A sample of recruitment records was checked. They were in good order, the appropriate checks and references are taken up and this contributes to the protection of residents. Staff stated that their induction to their post was comprehensive. They said that training received since they have been in post is relevant to their roles, and helps them to understand and meet the needs of the residents. Courses they have undertaken include end of life care, medication, catheter care, wound care and nutrition. Staff also receive training in a range of health and safety matters including fire safety, food hygiene and moving and handling. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from effective management systems. The quality of the service provided is audited regularly although the visits made to the home on behalf of the provider need to be reported on more regularly. Health and safety is generally well managed in the home although care needs to be taken to ensure that dangerous substances are locked away. 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 substantial experience in the care of older people and continues to update her knowledge and skills in the field. The Registered Manager is familiar to the residents and with their needs. It was noted that she begins her daily work by going around all of the floors of the home and speaking to each resident. A resident said of her ‘she is very Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 23 very good………..she doesn’t let anything slip’. The resident explained this as meaning that high standards of care are important to the Manager and she makes sure that staff work towards achieving them. The staff confirmed that the management approach is one which encourages them to raise concerns with the Registered Manager, they expressed their confidence in her. The Registered Manager has dealt with staff issues appropriately and with the interests of the residents as her primary concern. There are a number of quality assurance systems in place, in particular an audit system is used to check a number of issues each month. These issues include health and safety, medication and care planning. A series of relatives meetings have been arranged and at these relatives’ views are sought about the operation of the home. The reports of visits required to be conducted on behalf of the provider were viewed. Although the visits must be made monthly there were only six reports on file for 2007. It is understood that the Operations Manager who conducts the visits comes to the home more frequently than this would suggest and was in the home on one of the days that the inspector visited. Nevertheless a report of each visit made under regulation must be made and available for inspection. There are efficient systems in place for dealing with financial matters. The Registered Manager and the Administration Manager conduct checks of the balances held in the home and the transactions undertaken. No valuables are currently held in the home on behalf of residents, although there are safe facilities to do so should the need arise. Health and safety matters are generally well managed, the staff member responsible for maintenance carries out regular checks of safety systems, including the fire alarm system, the call bell system, and hot water temperatures. The Registered Manager ensures that the checks are done. On one floor some items which could have been dangerous to residents if ingested were not stored securely. These were pointed out to the senior member of staff who agreed to ensure that they are kept safely. No other matters of concern with regard to health and safety were noted. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 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. 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 X X 2 Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 12(4)(b) Timescale for action The Registered Person must 01/03/08 ensure that care plans include reference to care needs which are indicated by the residents’ religious and cultural backgrounds. This will ensure that care provided takes into account the full range of residents’ needs. The Registered Person must 01/03/08 ensure that the residents’ files include contact details for health care professionals involved with the residents. Other forms containing important information about the resident such as the service user profile must also be completed. This will ensure that staff are able to access easily essential information for residents’ care. The Registered Person must 01/03/08 ensure that the care plan and daily care notes are sufficiently detailed to confirm that specialist advice is incorporated into care practices. This will ensure that account is taken of specialist DS0000007011.V353770.R01.S.doc Version 5.2 Page 26 Requirement 2. OP7 13(1)(b) 3. OP8 15(1) Burgess Park Nursing Home advice and incorporated into the daily care routines. 4. OP19 23(2)(d) The Registered Person must 01/04/08 send to the CSCI a schedule for the on going decoration and refurbishment. Timescales must be given for the improvement of the decorative state of the exterior of the building and for the outstanding internal works. This will allow residents to benefit from a more pleasant environment. The Registered Person must 01/04/08 ensure that improvements are made to bedrooms which need redecoration, refurbishment and making more homely. This will allow residents to benefit from a more pleasant environment. The Registered Person must 01/04/08 undertake a review of staffing levels throughout the home at all times of day. The review must take into account the dependency levels of the residents to ensure that staff, in sufficient numbers, are available to meet the residents’ needs. The Registered Person must 01/02/08 ensure that staff are not rostered to work shifts of an unreasonable length. This will ensure that residents are not put at risk. The Registered Person must 01/02/08 ensure that an accurate record is maintained of the duty roster of persons working at the home. This will ensure efficient monitoring of the staffing levels. The Registered Person must 01/02/08 ensure that arrangements are DS0000007011.V353770.R01.S.doc Version 5.2 Page 27 5. OP24 23(2)(d) 6. OP27 18(1)(a) 7. OP27 18(1)(a) 8. OP27 17(2) Schedule 4 para 7 9. OP38 13(4)(c) Burgess Park Nursing Home made to keep in a safe place items which could present a risk to residents. 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 OP13 Good Practice Recommendations The Registered Person should consider how residents can be assisted to have more trips out of the home so that they can take part in activities such as shopping and visiting local facilities. Burgess Park Nursing Home DS0000007011.V353770.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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