Inspection on 17/04/07 for Burley House Nursing Home

This inspection was carried out on 17th April 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Burley House Nursing Home 258 Burley Road Leeds Yorkshire LS4 2LA Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 17th April 2007 09:30 Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 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 Burley House Nursing Home DS0000068158.V323639.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burley House Nursing Home Address 258 Burley Road Leeds Yorkshire LS4 2LA 0113 230 5485 0113 224 9197 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) European Care Lifestyles (B) Ltd Susan Jane Mackie Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first key inspection Brief Description of the Service: Burley House is registered to provide nursing care for 22 people who have enduring mental health problems. It is situated in the Burley area of Leeds. Buses into Leeds City Centre, and surrounding areas are within easy access. Local shops and amenities are only a short distance from the home, and a large leisure complex is within ten minutes walking distance. Accommodation is on three levels in the home, this consists of eighteen single bedrooms and two double bedrooms. Communal space includes a dining room, a large lounge and a small quiet lounge. Due to the layout of the home, parts of the home are not accessible to people who have mobility problems. The weekly charge is £483 per week. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. This is the first key inspection. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were sent to people who use the service and their relatives, and some healthcare professionals; some of the responses have been included in the inspection report. Nineteen surveys were received from people who use the service; sixteen were completed with help from staff. One inspector carried out a site visit which started at 9.30am and finished at 5.00pm. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, talked to people who use the service, staff and the manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: The care planning process is generally good and staff try to make sure people’s care needs are met. Staff have good knowledge about people who use the service and they encourage them to do different recreational activities. People who use the service and their relatives are happy with the quality of the service. The following comments and responses were made: • • • • • • • • • You can go out when you want The cook is good, the food is lovely I’m more settled since I came here There are always sufficient staff on duty Staff welcome you to the home I am happy to leave my relative in very capable care Staff are kind and friendly. Staff are like my own relatives The manager is lovely DS0000068158.V323639.R01.S.doc Version 5.2 Page 6 Burley House Nursing Home The manager and registered provider are working hard to improve the service. The area manager has visited the home regularly and identified important areas where the home should develop. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Up to date information is not readily available and people who use the service are not receiving enough information about the service. EVIDENCE: Everyone had lived at the home for at least two and a half years, therefore there was very little recent evidence available for many aspects of this outcome group. Admission assessments and the admission process for people who have moved into the home have been looked at during previous inspections and the relevant National Minimum Standards were met. Some potential admissions were in the early stages. The manager was organising visits to the home for some people and talking to other professionals that would be involved in the admission process. European Lifestyles became the registered provider of Burley House in October 2006. The Statement of Purpose and Service User Guide were still in draft form at the time of the inspection although the manager said the documents would be ready at the end of April. Because these shortfalls were being addressed, Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 9 requirements to produce a Statement of Purpose and a Service user Guide have not been made. Each person who uses the service had an agreement in their file that sets out the home’s terms and conditions but these were from the previous registered provider, therefore they were not relevant. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The care planning process is generally good and staff try to make sure people’s care needs are met. Sometimes risk management impinges on basics rights even though this has not always been agreed through the care planning process. EVIDENCE: Three people’s care records were looked at. Care plans and risks assessments described how care needs should be met and identified potential risks. For example, one assessment stated that the person was vulnerable in some situations and there was good guidance for minimising risks. Another plan gave details of set routines the person prefers to follow. Plans and assessments had been regularly evaluated. One person talked about their care plan and was familiar with the contents. They said staff talk about the care plan and risk assessments and they sign it. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 11 Staff had good knowledge of people who use the service and their individual care needs. They were able to provide specific details about how they looked after them. These were consistent with what had been recorded in care plans and assessments. Nine surveys from people who use the service stated that they always make decisions about what they do; eight surveys stated they sometimes make decisions about what they do. There are some restrictions for some individuals and these are generally written in risk assessments and their care plan. Restrictions include areas to smoke, access to money and cigarettes. Several people have budget plans to help them manage their money. The amount they have each day is written in their care plan and this has been agreed with the person. Most people receive money on a daily basis. The home has ‘banking times’ twice a day when money can be accessed. On the morning of the inspection several people were queuing for money. Although it is a well established routine it does not promote individuality. Daily records stated that within a period of a week, on two occasions, one person had refused to hand in their smoking materials and as a result they were not allowed in their bedroom to go to bed. On one occasion they had slept outside their door for two hours. This was written in the daily notes but had not been recorded on the specific monitoring sheet. It is important to minimise risk but it also important to make sure people are treated with dignity and respect. A member of the public had called at the home and voiced concerns about dangers to members of the public. Staff had recorded this on an incident form and spoken to the person involved. A risk assessment had not been completed and staff or management had not explored the concerns to establish the level of risk. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are satisfied with their lifestyle, which has gradually become more fulfilling, although there is room for development in this area. Relatives are very happy with the quality of the service. EVIDENCE: People who use the service spoke positively about the staff and the manager and these comments have been included in the staffing section. There were also comments about the home in general. These were as follows, “it’s alright here, you can go out when you want, the cook is good, everything is ok, I’m more settled since I came here, the food is lovely.” Surveys from people who use the service stated they could do what they wanted to do during the day, in the evening and on a weekend. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 13 Two relative surveys were returned; these were positive about the standard of care that is provided and the following statements are a sample of responses and comments: • There are always sufficient staff on duty • Staff welcome you to the home • I am happy to leave my relative in very capable care • Staff are kind and friendly People who use the service said staff asked them to play board games and they could join in most days. They also talked about going out to the shop and the pub with staff. One person talked about going to watch football. An activity programme plan was displayed in the dining hall and this offered a range of activities including bingo, football, pub night, french boules and dominoes. Care plans and risk assessment provided information about social and recreational activities. Staff that had worked at the home for a long time said they had seen gradual improvements for the people who use the service because they were more involved in helping around the home and more willing to take responsibility for their personal care. They said this is an area where more progress could be made and when the domestic kitchen is ready for use, this will create more opportunities for developing independence. Four people attend day care or drop in centres. Several others regularly go out independently. Daily records for the last four weeks were looked at for three people. There was evidence of community participation, family contact, health appointments and varied bedtimes and times for getting up. There was not much evidence of recreational activities in two of the daily records but their care plans stated that there is a reluctance to participate. One care plan suggested 1-1 activities but there was no evidence that these had been offered. Staff agreed that this is an area that could be developed. The inspector sat with people who use the service for lunch. The meal was well organised and people enjoyed the food. A hot drink was served with the meal. People said they thought the food was good. A four weekly menu was provided with the pre- inspection questionnaire; a choice of meals is always offered. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s healthcare needs are met but the lack of written evidence could result in healthcare needs being overlooked. EVIDENCE: One healthcare survey was returned. The survey was very positive and stated that the service always seeks advice and individual’s healthcare needs are met. Comments included; • • The service manages very difficult individuals well and prevents crises The manager has always been excellent Daily records stated that people had received input from external healthcare professionals. There were also details when people had refused healthcare. Staff said they thought the home was good at consulting healthcare professionals when they want advice and support. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 15 A record was available for all appointments with any consultant psychiatrists but there were no separate health care records for other appointments and information was only in the daily notes. This makes it difficult to monitor healthcare needs. The manager said this had been identified as an area for development and they were devising a system for this. Because the home had identified the shortfall and had started to address this, it has not been necessary to make a requirement but a recommendation to develop the system has been made. The administration of lunchtime medication was observed and this was administered appropriately. Medication and medication records were looked at and the amount of medication and the records corresponded. One person said they were concerned about their future and wanted to make some plans, and agreed for their concerns to be passed on to the manager. The manager agreed to talk to the person and follow this up. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service will report their concerns to staff and management, therefore they are protected but because procedures have not been updated people do not have the right contact details if they want to make a formal complaint. EVIDENCE: All the surveys from people who use the service stated that they know who to speak to if they are not happy and eighteen stated they know how to make a complaint. People who use the service said they talk to staff or the manager if they are unhappy. One person said the area manager had visited the home and had asked people if they were happy. The complaint’s procedure was displayed in the home but it referred to the previous registered provider. Staff have attended adult protection training and were familiar with adult protection procedures. ‘Breakaway and de-escalation techniques’ training was booked for the week after the inspection. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 17 Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. One person’s monies were counted and the amount corresponded with the amount on the balance sheet. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are comfortable in their environment and the decoration and maintenance in most areas is satisfactory. EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was generally clean and tidy and there were no noticeable odours. People who use the service walked freely around the home and used all communal areas. Several people were clearly pleased with their bedrooms and understood it was their personal space. A number of bedrooms were personalised and had a lot of items that reflected individual preferences. The domestic kitchen had just been refurbished and was being set up for people who use the service to develop their daily living skills. The manager Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 19 said they were going to complete individual skills assessments and offer support to people who want to use the facility. Several areas have been decorated and some new furnishings have been purchased, although other areas were in need of decoration. The following maintenance and decoration problems were noted during the tour of the building: • • • • • • • • • • • Paint flaking in several rooms Curtains coming away from the header tape Damaged plaster where the telephone had been moved Loose floor tile Water from the washing machine coming up through the sink plug hole in the laundry Cracked ceiling Cigarette burns on the edge of the bath Hot water flow on the top floor was very slow. The temperature of water in the top floor bathroom was very hot. Velux windows in bedrooms did not have covering to block out light Stair carpet was worn Each room had been fitted with hand washing facilities. The laundry has appropriate industrial washing and drying facilities. Fifteen surveys from people who use the service stated that the home was always clean and fresh; three stated the home was sometimes clean and fresh. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are satisfied with the support they receive from the staff team. Staff are supported and enabled to carry out their duties properly so the needs of people who use the service are met. EVIDENCE: People who use the service talked about staff and the manager and everyone was positive. Comments included, the manager’s alright, they are good to me, staff are very kind, staff are like my own relatives, the manager is lovely. Fifteen surveys from people who use the service stated that staff always treat you well; three stated staff sometimes treat you well. Fourteen surveys from people who use the service stated staff listen and act on what you say; four stated staff sometimes listen and act on what you say. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 21 One staff member talked about the recruitment process and confirmed she had completed an application form, attended an interview, and two references and other relevant information were obtained before she commenced employment. Recruitment records for three staff were looked at. All the relevant information was available. Staff said they had all been given a handbook from the new organisation when they took over the running of the home. Training records and a training plan were also looked at. The manager had identified that some staff had not updated their training and had produced a training plan. The key areas to update were fire safety, moving and handling and first aid. The training programme was commencing the week after the inspection. Because this shortfall was being addressed it has not been necessary to make a requirement to meet the Care Homes Regulations. Staff said they had attended staff meetings, received support and supervision and had opportunities for personal development, although supervision meetings were not regular. Most staff had received an individual performance review. The manager said supervision would be offered more frequently because two senior staff had attended supervision training and they would also have some responsibility for staff supervision. Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The manager and registered provider are working hard to develop and improve the service. EVIDENCE: The manager has been in post for over nine years. She is a Registered Mental Nurse and holds a management qualification. Staff were complimentary about the manager and they thought the home was well managed. Staff said the manager was organised and they could go to her for advice. Once a month the provider visits the home and looks at the general conduct, these visits are called Regulation 26 visits. Copies of reports from these visits have been sent to the CSCI. The reports are detailed and identify where the Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 23 home must improve. Reports identified that some training was not up to date, all personnel records were not available and complaints were not recorded; action plans to address the problems were also in the report. The certificate of registration was displayed at the entrance of the home but this had the name of the previous registered provider and is therefore not a valid certificate of registration. A new certificate was issued when the home was registered in October 2006. People who use the service have attended meetings to talk about the home and put forward suggestions for improvement. They have also been asked to complete satisfaction surveys and had recently completed a food survey, although it was acknowledged these were not done on a regular basis. The manager said she thought people had become more comfortable with putting forward their views and this was an area they wanted to develop further. Daily records were completed on a regular basis and there was good information about personal care, medication and healthcare. However, some wording was inappropriate and vague. For example the phrase ‘toilet training’ was used regularly. The term ‘very abusive’ and ‘verbally abusive’ was also used but there was no definition of this. In some instances an incident form was completed if people had been ‘verbally abusive’ and on other occasions the daily record was the only reference point. It is important staff write clear information to make sure people’s health and welfare can be properly monitored. Incident records were looked at. Staff had recorded specific details and any follow up action. The records were filed together but there was no system for auditing the number of incidents. For example it was very difficult to find out how many incidents people had been involved in within the last few months. This again is a useful source for monitoring people’s health and welfare. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. The manager had received a new policies and procedures file and was going through them to make sure they were all appropriate to the home. Burley House Nursing Home DS0000068158.V323639.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X 2 3 X Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 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 YA7 Regulation 12 (3) Requirement All people using the service must be able to access their money and their accommodation unless it has been clearly stated in their plan of care. All risks must be appropriately assessed and recorded. This applies specifically to the risk identified by a member of the public. An up to date complaints procedure must available for people who use or visit the service. The home must be decorated and furnished to a reasonable standard so people who use the service can live in pleasant surroundings. A current certificate of registration must be displayed in the home. Timescale for action 31/05/07 2 YA9 13 (4) 31/05/07 3 YA22 22 31/05/07 4 YA24 23 30/09/07 5 YA37 Care Standards Act 31/05/07 Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 26 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 5 Refer to Standard YA5 YA14 YA19 YA36 YA39 Good Practice Recommendations People using the service must be given a statement of terms and conditions that has been issued by the current registered provider. There should be more opportunities for people using the service to engage in recreational activities and personal development. Health care needs should be more closely monitored. Staff should receive supervision at least six times a year. Quality assurance systems should continue to be developed to provide people who use the service with more opportunities to put forward their views. Records should provide sufficient information to properly monitor people’s health and welfare. This relates to the content of daily records and monitoring the number of incidents involving people who use the service. 6 YA41 Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Burley House Nursing Home DS0000068158.V323639.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!