Inspection on 12/02/08 for Burlington Court Care Home

This inspection was carried out on 12th February 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Burlington Court Care Home 06/08/08

Burlington Court Care Home 16/05/07

Burlington Court Care Home 08/05/06

Burlington Court Care Home 03/10/05

Burlington Court Care Home 10/05/05

Burlington Court Care Home 25/10/04

Burlington Court Care Home 05/05/04

Burlington Court Care Home 05/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Burlington Court Care Home Roseholme Road Abington Northampton NN1 4RS Lead Inspector Judith Roan & Irene Miller Unannounced Inspection 12th February 2008 09:00 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 Burlington Court Care Home DS0000029409.V358610.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. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burlington Court Care Home Address Roseholme Road Abington Northampton NN1 4RS 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) 01604 250225 01604 887664 Burlington Care Homes PLC Vacant Care Home 102 Category(ies) of Dementia - over 65 years of age (66), Old age, registration, with number not falling within any other category (36), of places Physical disability over 65 years of age (6) Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into Burlington Court where there are 36 persons of category OP already accommodated within this home No one falling within category DE(E) may be admitted into Burlington Court where there are 66 persons of category DE(E) already accommodated within this home No one falling within category PD(E) may be admitted into Burlington Court where there are 6 persons of category PD(E) already accommodated within this home No person to be admitted to Burlington Court in categories OP, DE(E) or PD(E) when 102 persons in total of these categories/combined categories are already accommodated in this home 12th October 2007 Date of last inspection Brief Description of the Service: Burlington Court Care Home provides personal care for up to 102 service users when it is running at maximum capacity. The home currently caters for older people over the age of 65 years, including up to 20 service users with dementia. Burlington Court is located in Northampton, close to Abington Park, and is near the local shops and facilities of Wellingborough Road. Within the home there are lifts serving the first floor and the building is designed around landscaped gardens. There are three wings, namely Tudor, Saxon, and Windsor wings, each with ground and first floor accommodation, including lounge and dining areas. The first floor of Tudor wing caters for service users with dementia related needs. All bedrooms have en-suite facilities and there are only three shared bedrooms. For enhanced security there is a camera system monitoring the external areas of the home as well as electronic security gates leading to the visitors parking bays. Fees range from £331.60 to £425. Information about the service can be found in the homes Statement of Purpose and service users guide. A copy of the Commission for Social Care Inspection is kept at the entrance to the home. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people using the service and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting people using the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. During the inspection the inspectors also spoke with health care professionals The lead inspector also received questionnaires completed by 10 people using the service and six staff. The questionnaires seek to ascertain the satisfaction of people using the service and others visiting the home as to the standard of care and service provided. Questionnaires provided a mixed view of the quality of care and service, which is detailed more in the body of this report. The homes acting manager and area manager completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and took place over two days over a period of 15.5 hours with two inspectors on the first day. This report also includes information from two random inspections undertaken. One on the 12th October 2007 to check compliance of requirements made at the last key inspection and to investigate a complaint about security, bullying by senior management, use of Web cameras, lack of staff training, staffing levels recruitment practices, record keeping and excessive hours worked by staff. The second was made on the 28th November 2008 to check compliance of immediate requirements made at the random key inspection. As part of the inspection the inspector used the short observational framework for inspection assessment tool (SOFI) to look at the well being and communication needs of people using the service. The information gathered is used in support of other evidence gathered at the time of the inspection. The observation lasted for two hours. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 6 We issued two Code B Notices to gather evidence as there was a suspicion offences had been committed. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments for manual handling, falls, nutritional needs, aggression and pressure care need to be in place to support care plans & ensure that the needs of people using the service are met. Care plans need to be updated to ensure that the current needs of people using the service are shown. Carers need to follow the care plans to ensure that individual needs are met. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 7 Ensure that there are sufficient staff on duty to meet the current needs of people who live at the home and minimise loss of dignity. Individual files must contain evidence that individual choices and personal preferences are being adequately managed and that consents for care staff to administer medication have been obtained. The registered person must ensure that all bedrails that are fitted are safe, risk assessments are in place and are maintained to ensure the safety of people using them. An immediate requirement was made at the inspection. Accurate, complete and up to date records must be kept relating to medication. The registered person needs to install a controlled medication cabinet in the locked storage area to comply with new legal requirements. Sufficient staffing levels need to be employed to meet the needs of people using the service at key times within the home. The registered person must ensure that carers undertake training that meets the National training Organisations workforce targets. Recruitment procedures within the home must be robust and protect people using the service. Carers should not work excessive numbers of hours and that there should be sufficient bank staff to cover absences. The provider must confirm that a bacterial analysis of water test has been completed All accidents/incidents relating to people using the service need to be notified to the CSCI. The registered person must provide assurances that the newly appointed manager makes an application to be registered in a timely manner. The registered person must review the policy for charging for toiletries to ensure that the financial interests of people using the service are protected. The registered person needs to ensure that systems are in place for staff supervision to maintain quality in the service provided and to ensure that staff feel supported. Please contact the provider for advice of actions taken in response to this inspection. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 8 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. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 9 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 Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 10 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,Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clear information is available to people who are considering using the service. Insufficient information is sought to provide a full assessment of people needs prior to them moving into the home. EVIDENCE: A statement of Purpose and service users guide in available within the home and was found in the entrance hall along with other useful information for prospective people using the service. A copy of the last key inspection report was also available. Assessments undertaken on the needs of people who are considering moving to the home were limited for people who are self funding. Those people who were funded by social service have detailed assessments. Contracts are available and these detail the terms and conditions of the service and its related costs. Burlington Court Care Home DS0000029409.V358610.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans do not contain full details on how people’s needs are to be met. Risk assessments were found to be poor or absent. EVIDENCE: Care plans seen remain poor with a lack of guidance for staff. There was evidence that existing people using the service are not having their care plans reviewed when there is a change in their circumstances therefore their needs are not being met. Management of risk has not improved and in case tracking one resident with unexplained bruising it was evident that bed rails were ill fitting and were increasing the risk to this resident. Risk assessments are basic and consistently lack evidence of current best practice and associated control measures to reduce and manage the risks. One person that was case tracked has a risk assessment indicated that they were at risk of malnutrition requiring access to a dietician. The risk assessment was incomplete, as it did not have an outcome or action plan to minimise the risk. There was no risk assessment for the use of cot sides. These Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 12 have been removed due to risk of entrapment and no resolution has been achieved. An immediate requirement was issued on the first day of the inspection. The care plan does not have sufficient information to guide staff on how to support them with their nutrition. The waterlow risk assessment (pressure area care) has been inaccurately completed and was not updated in full. There is evidence that the individual is being weighed but there were no records of the action taken to follow this up with advice. There is a significant weight loss for this individual over the past few months. A referral had been made to the GP for fortified drinks. The medication records indicate that only one drink a day is being given. The records state that the resident says ‘they are hungry’. There is no evidence of a fluid and food intake chart. Another person resident at the home admitted late last year has no risk assessments for manual handling, nutrition, waterlow or falls. Evidence from the file confirms that they had had several falls within two days of admission and that these are continuing. The accident records confirm this fact. In reviewing files it became evident that not all accidents especially falls led to a review of the risk assessment and care plan for people using the service. It was also noted that not all accidents that related to the well being of people using the service were notified to CSCI. The inspector calculated that there had been 144 accidents within a three-month period. Many of these accident were falls and at night. The reporting system of accidents and how they are monitored needs to be reviewed to ensure that manager is fully aware of safety issues within the home. We issued a Code B Notices to gather evidence as there was a suspicion that an offence had been committed in relation to care planning and related risk assessments. During the SOFI assessment part of the inspection the inspector observed carers to be respectful and responsive to the needs of people using the service. Outcomes indicated that some carers do communicate well with people using the service, others did not and this caused confusion. For example: A member of staff was trying to encourage a resident to go over to the dining table for lunch the resident was having difficulty in understanding what the member of staff was saying. She gave up in the end and agreed to what the staff member was saying, when the staff member walked away the resident turned to the inspector and said “I didn’t understand a word of that” Several surveys confirmed that they were usually well supported whilst other stated that there is a’ shortage of staff’ and they had to wait to have their needs attended to. One person complained to the inspector that they would like to walk back to their bedroom so that they exercise and kept mobile, but staff were not available to support them. They consequently had to stay in the lounge all day. They were also concerned that at night they had to wait for a long time for Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 13 support for personal care subsequently they incurred continence accidents. This did affect their dignity. Both inspectors checked medication records. On one unit the medication records indicated that they had been administered correctly. On another unit records indicated a refusal by a resident but the medication was not in the monitored dosage system and could not be found in the system the home has for returns to the pharmacy. It was established that the person had taken the medication later in the day, but the staff member had failed to amend the record. The provider needs to ensure that the medication systems in place are reviewed to ensure the protection of people using the service. The provider needs to install a controlled medication cabinet in the locked storage area to comply with new legal requirements. Burlington Court Care Home DS0000029409.V358610.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 poor. This judgement has been made using available evidence including a visit to this service. A range of activities is available to ensure that individuals have a choice of activities throughout the day. The menu does not provide for the dietary needs of all people using the service. EVIDENCE: A part time organiser who has no formal training in meeting the needs of people who have a dementia provides the activities. The activities need to be more person centred and individual. There is a range of activities within the home but not all people are fully aware of the programme. Religious services are held on a regular basis and meet the needs of the various faiths of people who use the service. One respondent to the surveys said that ’they would like to go out and at times spend time in the garden. Carers are not available for these activities.’ Families are welcome to visit the home at any time convenient to the person they are visiting. The SOFI observation covered the lunch-time period in one of the lounge’s at the home. One person observed was at risk of not receiving adequate Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 15 nutritional intake, as they had not eaten their meal and no alternative was offered. In their file there was no record of his weight being taken on admission weight had been recorded two months after admission so it was difficult to confirm if there had been a change in the persons weight. Records of being seen by their GP, advised to ‘push fluids and encourage nutrition’. The file contained no formal food and drink monitoring tool, records in the daily notes state ‘taken a full beaker of fortisip, not eaten anything’ Another person observed during the SOFI observation was also at risk of not receiving adequate nutritional intake as they did not eat any lunch. Pre admission information identified their food dislikes and that they need help with feeding, as ‘co-ordination is gone’, uses a fork and spoon’. They were observed during SOFI to be given a knife and fork, was struggling with the knife. A nutritional assessment in their file states that ‘no problem at this time’ Oral care: Daily notes has entry that their ‘dentures seem to be missing’’ No record of action taken to resolve the problem. Another resident case tracked had incomplete nutritional assessments and an indication of weight loss. A referral for a dietician was not evident. The individual had a prescription for fortisips, but records indicate that only one was being given a day. The Medication Administration Record sheet does not indicate how many should be given a day. Most surveys indicated that meals provided were not suitable for older people with eating difficulties with one stating that ‘meals look good but older people do not like chunks of meat’ another complained that ‘the quality of the produce is poor so is the variety and the cooking of the meals’. On the first day of inspection the inspector observed that the vegetables were frozen and not fresh they also looked overcooked. On the second day the gammon had already been cooked at 10.30am to be reheated again in a white sauce that made it tough and for some people using the service inedible. Lunch and tea are prepared in the main kitchen and transported in heated trolleys to the dining areas. Staff in each unit prepare breakfast. Burlington Court Care Home DS0000029409.V358610.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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints made by people using the service are not always resolved to their satisfaction. The safeguarding procedures do not fully protect people using the service. EVIDENCE: A copy of the complaints procedure is available in the entrance hall of the home. However some people completing the surveys were unaware of the policy and procedures. Most people did confirm when asked whom they would express a concern to said the team leader or manager. Since the last key inspection the CSCI have received five complaints that have been investigated by the commission. Parts of the complaints have been upheld and at the random inspection in October 2007 seven immediate requirements were made to improve the service. The provider complied with all of the requirements, this was confirmed at the random inspection in November 2007. In case tracking people using the service concerns have been raised about the safety of two people. These concerns have now been passed to Social Services under the safeguarding protocols for further investigation. Burlington Court Care Home DS0000029409.V358610.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): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes environment is fit for purpose and provides good accommodation for people using the service. The home is maintained and provides a clean and hygienic environment. EVIDENCE: On the day of the inspection inspectors noted that housekeeping staff were available to maintain the home to a good standard. Several people using the service at the home were ill with a viral infection and it was noted that good hygiene practices were in place to minimise the risk of passing the infection onto to others. Hand washing was encouraged along with the use of hand gels. The laundry assistant was fully aware of how soiled laundry needed to be handled and that it was washed separately. The inspector found the staff member to have a clear understanding of their role and the health/safety regulations. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 18 The provider has provided additional lifting equipment for staff to use when supporting people who require assistance. This reduces the amount of time that people had to wait when the equipment was in use. Burlington Court Care Home DS0000029409.V358610.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 poor. This judgement has been made using available evidence including a visit to this service. Poor recruitment, training supervision and levels of staff place people using the service at risk. EVIDENCE: We issued a Code B Notices to gather evidence as there was a suspicion that an offence had been committed in relation to staff recruitment and training. Staffing levels remains an issue in complaints especially at night. In reviewing the rotas there has been no increase to the number of staff on duty at night. In discussion with people using the service throughout the inspection this was stated as the main issue that care was not available in a timely manner or does not carry out the support indicated in the care plan. The surveys also supported this view. ‘staff attendance seems to be a problem, the staff that are there are very good and caring but overworked’ ‘it is not always easy to get help when I need it, especially at night’ The number of staff qualified does meet the levels set out in the National Minimum Standards with several staff also holding nursing qualification. The AQAA confirms this as does discussions with several staff during the inspection. However concerns were expressed about new staff starting without completing their basic training and this placed existing staff under pressure and people using the service at risk. The training matrix provided by the acting manager also backs this up as several staff have not completed manual handling training or they need their training updated. Not all staff have received health Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 20 & safety /fire training. Most staff have completed the in house food hygiene training but none of the catering staff hold the national Food Hygiene Certificate. There was no evidence to confirm that the catering staff hold catering qualifications. In relation to meeting the needs of people using the service only nine staff have undertaken dementia care training. The inspector also found no evidence that new staff were being inducted. The AQAA states that induction training needs to be improved. Staff surveys were also confirming that they were concerned about the lack of basic training and skills in supporting people who have a dementia. The complaints received by the CSCI expressed concerns that staff were being appointed without security checks. Files reviewed by the inspection were mainly satisfactory. However one file lacked home office clearance for the staff member to stay in the country. This was later verified when the staff member brought in their passport. Another two files did not contain the required two references and one did not contain an application or a Criminal Records Bureau check. The recruitment procedures are therefore not robust to protect people who use the service. Several concerns expressed by people using the service and staff was about the difficulties arising from language barriers with so many new staff not being fully competent with written and spoken English. One staff member was unable to take required training, as they were unable to understand or write English. Consideration needs to be given about appointing staff without these basic job requirements. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Inconsistent management of the home leads to the service not being managed in the best interests of people using the service. EVIDENCE: The acting manager has resigned and the previous area manager has taken over until a new manager commences in March. Concerns have been expressed in surveys that persistent change is not good for the development of the service. One complaint was about the introduction of a standard monthly charge for toiletries. People who use the service that do not have an advocate are at risk with this system of charging. The provider must review this policy and ensure that individual accounting of purchases are in place with receipts of what has been spent. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 22 No records of regular supervision were found in staff files reviewed. The provider must ensure that a system of supervision is introduced and maintained. Staff spoken with during the inspection and in the surveys had mixed views about the service and how they were supported. Some felt quite happy with the support other less so. Generally staff would like to meet more with manager to discuss their concerns. Some staff felt bullied, they would like to be trusted and treated with respect. Some said that there is a need for team work and more information. There has been an improvement in the monitoring of health and safety systems within the home. All systems had been recently checked. However a certificate could not be found for a bacterial analysis of water test. The acting manager agreed to forward a copy. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 23 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 22323 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X X 3 Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 24 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 2. Standard OP2 Regulation 14 13,14,15 Requirement All residents must have their needs fully assessed to ensure that their needs can be met. Risk assessments for manual handling, falls, nutritional needs, aggression, bed rails and pressure care need to be in place to support care plans ensure that the needs of people using the service are met. Previous timescale of 31/12/07 not met. Enforcement action is being considered Carers need to follow the care plans to ensure that individual needs are met. Care plans need to be updated to ensure that the current needs of people using the service are shown. Previous timescale of 30/06/07 not met The registered person must ensure that suitable bedrails are supplied, fitted safely and maintained. Risk assessments must be in place to ensure the safety of people using them. An immediate requirement was made at the inspection. DS0000029409.V358610.R01.S.doc Timescale for action 30/04/08 12/02/08 OP7 3. 4. OP7 OP7 15 15(1) 30/04/08 28/02/08 5. OP8 13,15,23 31/03/08 Burlington Court Care Home Version 5.2 Page 25 6. OP9 13 (2) 7. OP27 18 (1) 8. OP30 1819 9. OP29 19 10. OP36 18 11. OP38 37 Medication records must be signed for at the time of administration to ensure that resident’s health care needs are met. Sufficient staffing levels need to be employed at night to meet the needs of people using the service and to minimise risk of falls. Previous timescale of 30/11/07 not met The registered person must ensure that carers undertake training that meets the National training Organisations workforce targets. Previous timescales of 31/12/07 not met. Recruitment procedures within the home must be robust and protect people using the service. Previous timescale of 30.11.07 not met. Enforcement action is being considered The registered provider needs to ensure that systems are in place for staff supervision to maintain quality in the service provided and to ensure that staff feel supported. All accidents/incidents relating to people using the service well being need to be notified to the CSCI. Previous timescale of 30/11/07 not met. 30/04/08 12/02/08 12/02/08 12/02/08 31/05/08 12/02/08 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 OP9 Good Practice Recommendations Individual files should contain evidence that resident’s choices and personal preferences are being adequately DS0000029409.V358610.R01.S.doc Version 5.2 Page 26 Burlington Court Care Home 2. 3. 4. OP9 OP12 OP38 5. 6. OP38 OP35 managed and that consents for care staff to administer medication have been obtained. The registered persons should have a controlled medication cabinet installed in the locked storage area to comply with new legal requirements. The activity needs of people using the service who have a dementia need to be person centred and promote their independence. It is recommended that carers do not work excessive numbers of hours and that there is sufficient bank staff to cover absences. The health, welfare and safety of people using the service and staff are being compromised by long working days and number of hours worked in a week. The provider should confirm that a bacterial analysis of water test has been completed to ensure the safety of people using the service and staff. The registered person should review the policy for charging for toiletries to ensure that the financial interests of people using the service are protected. Burlington Court Care Home DS0000029409.V358610.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Burlington Court Care Home DS0000029409.V358610.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. 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