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Inspection on 16/05/07 for Burlington Court Care Home

Also see our care home review for Burlington Court Care Home for more information

This inspection was carried out on 16th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

The atmosphere in the home was friendly and relaxed, and staff were welcoming. The complaints policy and procedures is easy to access with a copy being located in all bedrooms and reception area of the home. There are good records kept of all complaints. Staff demonstrated a good understanding of the residents` needs and were seen to have good communication with residents. Residents were able to move around the home easily within its confines. There is evidence that health care needs are being met with good access to heath care professional. Residents live in a home that has a good standard of cleanliness undertaken by a dedicated staff team. Laundry is well maintained and residents said that they were happy with the level of this service.

What has improved since the last inspection?

Storage of medication now meets standards. Dedicated space has been made available to undertake activities that ensure others in the home are not disturbed.

What the care home could do better:

Care plans need to be updated to ensure that the current needs of residents are shown. Individual files must contain evidence that service users choices and personal preferences are being adequately managed and that consents for care staff to administer medication have been obtained. Medication must be administered as prescribed and any changes made by the prescriber must be clearly documented in individual medication records. Accurate, complete and up to date records must be kept relating to medication. Suitable foodstuffs must be provided to allow residents with Diabetes Mellitus to have the same choices as the other residents. Sufficient manual handling equipment must be available to ensure residents` needs are met. Sufficient staffing levels need to be employed to meet the needs of residents at key times within the home. Recruitment procedures within the home must be robust and protects residents. Cleaning of crockery & utensils must meet environmental health standards to ensure that residents are protected and infection control is maintained. Immediate action must be taken to have the fire system tested at the home to meet Fire and Safety Order 2005 Article 17.1 An immediate requirement was made after this inspectionChange of fire doors adjacent to the Laundry to 30 minute fire resistant doors in line with the Fire Prevention Officers requirements made on 15 February 2007. An immediate requirement was made at this inspection. Medication policies and procedures should be reviewed to ensure that medication prescribed and obtained part way through a month is transferred to the medication administration record and administered and that there are not excessive medication stocks in the home. The activity needs of residents who have a dementia need to be person centred and promote their independence. Management structures within the organisation need to delegate sufficient responsibilities to enable the Registered Manager to fulfil their role.

CARE HOMES FOR OLDER PEOPLE Burlington Court Care Home Roseholme Road Abington Northampton Northants NN1 4RS Lead Inspector Judith Roan Key Unannounced Inspection 16th May 2007 09:30 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.V336507.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.V336507.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burlington Court Care Home Address Roseholme Road Abington Northampton Northants NN1 4RS 01604 250225 01604 887664 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) Burlington Care Homes PLC Adam Turvey 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.V336507.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 18th September 2006 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. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users 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 three residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by ten residents and four visitors/ relatives. The questionnaires seek to ascertain the satisfaction of residents and others visiting the home as to the standard of care and service provided. All questionnaires provided a mixed view of the quality of care and service, which is more detailed in the body of this report. The homes registered manager also completed a pre-inspection questionnaire. The inspection was unannounced and took place in the morning and afternoon over a period of 8.5 hours. This report also includes information from two random inspections undertaken, one on the 18th January 2007 to check compliance of requirements made at the last key inspection and a second on the 18th February 2007 to investigate a complaints about medication administration healthcare needs, availability of specialist diets and repairs to cooking facilities. The Pharmacist Inspector accompanied the lead inspector on both occasions What the service does well: The atmosphere in the home was friendly and relaxed, and staff were welcoming. The complaints policy and procedures is easy to access with a copy being located in all bedrooms and reception area of the home. There are good records kept of all complaints. Staff demonstrated a good understanding of the residents’ needs and were seen to have good communication with residents. Residents were able to move around the home easily within its confines. There is evidence that health care needs are being met with good access to heath care professional. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 6 Residents live in a home that has a good standard of cleanliness undertaken by a dedicated staff team. Laundry is well maintained and residents said that they were happy with the level of this service. What has improved since the last inspection? What they could do better: Care plans need to be updated to ensure that the current needs of residents are shown. Individual files must contain evidence that service users choices and personal preferences are being adequately managed and that consents for care staff to administer medication have been obtained. Medication must be administered as prescribed and any changes made by the prescriber must be clearly documented in individual medication records. Accurate, complete and up to date records must be kept relating to medication. Suitable foodstuffs must be provided to allow residents with Diabetes Mellitus to have the same choices as the other residents. Sufficient manual handling equipment must be available to ensure residents’ needs are met. Sufficient staffing levels need to be employed to meet the needs of residents at key times within the home. Recruitment procedures within the home must be robust and protects residents. Cleaning of crockery & utensils must meet environmental health standards to ensure that residents are protected and infection control is maintained. Immediate action must be taken to have the fire system tested at the home to meet Fire and Safety Order 2005 Article 17.1 An immediate requirement was made after this inspection Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 7 Change of fire doors adjacent to the Laundry to 30 minute fire resistant doors in line with the Fire Prevention Officers requirements made on 15 February 2007. An immediate requirement was made at this inspection. Medication policies and procedures should be reviewed to ensure that medication prescribed and obtained part way through a month is transferred to the medication administration record and administered and that there are not excessive medication stocks in the home. The activity needs of residents who have a dementia need to be person centred and promote their independence. Management structures within the organisation need to delegate sufficient responsibilities to enable the Registered Manager to fulfil their role. 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. Burlington Court Care Home DS0000029409.V336507.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 Burlington Court Care Home DS0000029409.V336507.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have good information on which to base their choice of home. A thorough assessment of need ensures that resident’s needs are met. EVIDENCE: Information about the home can be found within the statement of purpose and service users guide that are available to everyone within the lobby of the home. The information provides all the information required to assist prospective residents and their families in making a choice as to whether the home can meet their needs. Prior to admission a needs assessment is completed to confirm whether the skills within the staff group at the home can meet a residents needs. These assessed needs are reviewed to ensure that changing needs can still be met within the home. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all care plans reflect the changing needs of residents. There are medication management practices in the home that put service users at risk of not receiving medication as prescribed. EVIDENCE: Three residents were selected to case track from the different units within the home. Care plans were found on each file that were detailed and contained risk assessments. Risk assessments were found in place for pressure ulcers, nutrition and moving and handling. Records as to how healthcare needs were met have been inconsistent. During the investigation of a complaint in January 2007 the inspectors found that clear records were available concerning, attendance of GP and community nurses up to the end of September and from the beginning of December, but records for the intervening period could not be found. Three other resident’s records were chosen at random and in all cases, continuous, clear records of medical and nursing intervention were available. On this inspection it was found that not all records had been updated with medication changes. However there were appropriate referrals being made to Health Care Professionals where a need is identified. Residents confirmed that they are able to see a Doctor if the need arises, and community nurses visited Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 11 the home during the inspection. Records of chiropody visits were also available. Residents for dementia are cared for in two units within the home. The unit on the first floor provides for residents with a higher dependency needs. Carers have undergone training at a basic level and would benefit from extended training to ensure that a person centred approach is meeting needs of those individual residents. As a result of the random inspection carried out in February the practice in relation has improved however the resident care records do not confirm whether there has been resident choice and personal preferences in managing their own medication. Consent for care staff to administer medication is not recorded. This means that service users choices and personal preferences in the way that they have medication administered were not being managed adequately. Medication records remain inaccurate and not updated. Medication that was no longer prescribed was still recorded, prescribed medication was not being given according to the instructions and prescribed medication had not been started. Records relating to medication in individual files and care plans were not accurate and complete for example there was no information to show how a medication should be given when necessary to manage a behavioural problem and medication profiles had not been amended when medication had been stopped. Information was not always recorded following professional visits to show what medication had been prescribed and how it should be used. Inaccurate and incomplete records put service users at risk of not receiving medication as prescribed and of not having individual health needs met. The audit trail for medication received, administered and disposed of was not complete and accurate. For example the quantity of medication received was not recorded on handwritten MAR sheets, codes for non- administration were not used or explained and where variable doses were prescribed the quantity actually given was not recorded. This meant that the audit trail could not confirm that medication had been given correctly. Controlled drug records and quantities in the service were seen to be correct and there was no evidence that controlled drugs were being administered to service users but not recorded on the medication administration records. Medication storage was seen to be secure and fridges were seen not to store medication. Medication trolleys were locked away or secured to the wall when not in use. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 12 In discussion with residents during the inspection and from surveys all were in the main very positive about the support they received and the way they were treated with respect. Residents confirmed that personal care was carried out in a discreet and sensitive manner. One survey did state that response time to call bells was slow. This was checked out during the inspection with no bell lasting longer than five minutes before it was answered. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities is available for residents to choose from, but these do not fully meet the individual needs of residents with a dementia. The menu does not meet the needs of residents who are diabetic and the food is sometimes of poor quality. EVIDENCE: Personal history profiles were being developed by the activities organiser who spent time with individuals on admission to find out what their interests were and important milestones within their lives. The activities organiser arranged weekly pottery groups, bingo, garden planting, “Songs of Praise”, along with visits from outside entertainers and clothes sales are arranged. They also spend time in each unit throughout the week to undertake more individual work with resident that do not usually participate in the larger group activities. Surveys from residents commented that they would like to go out more and have more activities in the home. Several residents had visitors throughout the day of the inspection and all confirmed that they felt welcome in the home and had no concerns about what was available for the person they were visiting. One relative said that they would like to be kept more informed about their relative, as they were not always informed when they had had an accident. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 14 As training is limited to a one-day course for working with people who have a dementia there is a shortfall in what is expected of staff in meeting the wide range of needs within this group of residents. Further training is recommended in this area. Meals are served in a small dining area that is part of the lounge. Some residents choose to take their meals in their own bedrooms. The meal served was attractive in presentation and most residents said that they enjoyed the meal. Some residents however did say that there was limited choice, the ’meat was tough, not cooked enough, Brussels sprouts hard’ and ‘there was too much repetition of food like sausages’. The menus do give a choice of two main meal options per day, with the teatime being a choice of three dishes. The needs of residents requiring a specialist diet were not met in full with a limited choice of sweet dishes. The offer of yoghurt or ice cream with fruit does not meet needs. A previous requirement made at the last two inspections has not been met and it is again made in this report. In discussion with staff it was found that food orders requesting specialist products was not fulfilled. However the inspector was able to confirm that some low sugar food products had been purchased. In speaking to one resident they raised a concern over the breakdown of a dishwasher in one of the units. They were concerned that they were being placed at risk of infection as carers had to wash crockery & cutlery by hand. In discussion with the registered manager and carers it was established that an option to use the main kitchen facilities was available, but this meant a carer not being able to carry out their care duties for this period. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that complaints are taken seriously and are fully investigated. EVIDENCE: Residents and a relative spoken with during the inspection were aware of the complaints procedure and felt confident that their views were considered important and acted upon. The home has a complaints policy that is available to residents and displayed in the lobby of the home. A summary of the policy is also within the statement of purpose and service user guide. Complaints received by the home are managed in accordance with the homes policy. Two complaints received by the CSCI were fully investigated within the random inspections earlier in 2007. Carers were aware of safeguarding procedures and all had completed abuse awareness training. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 16 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s accommodation provides a comfortable environment that meets their needs. The home is clean and hygienic but the lack of safety checks place residents at risk. EVIDENCE: The home is kept clean and hygienic by a dedicated team of housekeeping staff. Positive comments were received during the inspection and within surveys stating that the home was always kept clean and tidy. Residents have good access to well-maintained gardens that are secure. Concerns were raised that lifting equipment is limited to one per floor that leads to residents having to wait for support. Each hoist only had one sling so it is not used if the sling is being washed. Carers have to transport hoists between units if required. This has an impact on the direct support for residents. It was noted in care plans that the type of sling required for individual residents was note recorded. Only one type of sling is available Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 17 within the home and it is recommended that advice be sought from the physiotherapist to have the correct slings available to meet needs. Resident’s rooms are well equipped and all have ensuite facilities with additional toilets close to lounges. Bathrooms are fully equipped with bath hoist to meet resident needs. The home is decorated to a high standard and residents were seen to have personalised their own bedrooms. Fire safety checks undertaken by the manager are recorded on a weekly basis. However a recent Fire Prevention Officers report required the provider to ensure that the fire system is checked and certificated and that the door in the corridor adjacent to the laundry are changed to 30 minute fire door. The provider has not complied with this request and the last fire test certificate was dated in 2005. An immediate requirement has been issued for the provider to action these requirements. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Not all residents can be met at meal times with current levels of staff. Recruitment checks do not fully protect residents. EVIDENCE: On the day of inspection there were sufficient staff on duty for most of the time. It was observed that at mealtime the staff team could not meet all of the residents needs that required support with their food. The manager and deputy manager were required to assist to meet residents needs if they were all to take lunch at the same time. A review of mealtime arrangements is recommended to find a resolution to this shortfall. The cook is available on site until after lunch. Carers in the afternoon are required to complete the teatime meal. This takes up the time of one carer in each unit. This practice reduces the care teams ability to meet resident’s needs during this time. The staff rota indicates that the permanent staff team cover all absences, this leads to several staff working up to and in excess 70 hours a week. This practice makes for unsafe working and places residents at risk. Carers receive induction and mandatory training courses were seen to be up to date. Most carers have attended a one-day training on an introduction to dementia. It is recommended that further training is completed in this area to meet the wide needs of the residents within the home. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 19 Staff files checked did not contain all of the required documents to ensure that employment checks are robust. Not all files contained two references. A requirement is made for the procedures to be reviewed so that errors to not occur in the future. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The best interests of residents are not always fully met as the registered manager has limited delegated responsibility over management functions. The lack of some health & safety checks does not fully protect residents. EVIDENCE: The Registered Manager attempts to meet the needs of residents within their limited delegated management responsibilities. Poorly kept Health & Safety records places residents at risk. The manager recorded the fire system testing on a weekly basis, but no evidence could be found that a competent engineer had checked the system and issued a fire certificate. (see environment section) Records in other areas were up to date. Records of maintenance requests made did not confirm that the issue had been dealt with and failed to provide an audit trail. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 21 Residents and or their realtives complete satisfaction surveys. This information is available within a quality assurance report produced by the company. Resident’s monies are well maintained with the administrator at the home ensuring that correct records are maintained. Resident’s monies were checked and found to be accurate. Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 1 3 2 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP7 OP9 Regulation 15(1) 13 (2) Timescale for action Care plans need to be updated to 30/06/07 ensure that the current needs of residents are shown Individual files must contain 18/06/07 evidence that service users choices and personal preferences are being adequately managed and that consents for care staff to administer medication have been obtained. Previous timescale 12/04/07 not met Medication must be administered as prescribed and any changes made by the prescriber must be clearly documented in individual medication records. Previous timescale 08/03/07 not met Accurate, complete and up to date records must be kept relating to medication including: Records of all medication received. Records of all medication administered including the dose where variable doses are prescribed. Records of all medication DS0000029409.V336507.R01.S.doc Requirement 3. OP9 13 (2) 18/06/07 4. OP9 13 (2) 18/06/07 Burlington Court Care Home Version 5.2 Page 24 disposed of. Records of medication in individual files including care plans. Previous timescale 12/04/07 not met 5. OP15 16 (2) i Suitable foodstuffs must be provided to allow residents with Diabetes Mellitus to have the same choices as the other residents. Previous timescale of 1/2/06 & 08/05/06 not met Sufficient manual handling equipment must be available to ensure residents’ needs are met Sufficient staffing levels need to be employed to meet the needs of residents at key times within the home. Recruitment procedures within the home must be robust and protects residents. Cleaning of crockery & utensils must meet environmental health standards to ensure that residents are protected and infection control is maintained. Immediate action must be taken to have the fire system tested at the home to meet Fire and Safety Order 2005 Article 17.1 An immediate requirement was made after this inspection Change of fire doors adjacent to the Laundry to 30 minute fire resistant doors in line with the Fire Prevention Officers requirements made on 15 February 2007. An immediate requirement was made at this inspection. 18/06/07 6. 7. OP22 OP27 13(5) 18 (1) 30/06/07 30/06/07 8. 9. OP29 OP38 19 13 (3) 18/06/07 18/06/07 10. OP38 17 (2) sch. 4 23 (4) 18/06/07 11. OP38 23 18/06/07 Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 25 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 Medication policies and procedures should be reviewed to ensure that medication prescribed and obtained part way through a month is transferred to the medication administration record and administered and that there are not excessive medication stocks in the home. The activity needs of residents who have a dementia need to be person centred and promote their independence. Management structures within the organisation need to delegate sufficient responsibilities to enable the Registered Manager to fulfil their role. 2. 3. OP12 OP31 Burlington Court Care Home DS0000029409.V336507.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V336507.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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