Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 06/08/08 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 6th August 2008.

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

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

A comprehensive "Welcome Pack", which includes a Service User Guide, a Statement of Purpose and guidance on making comments and complaints, is available to prospective Users. Undertakes an assessment of people`s need prior to admission. Provides good training to carers. Carers feel supported. Has a clear complaints procedure that is proactively managed.

What has improved since the last inspection?

The care plan format is clearer and more accessible in plans that have been completed. All people using the service have their needs fully assessed prior to admission. All accidents/incidents relating to people using the service well being are now being notified to the CSCI. Medication records are now signed for at the time of administration to ensure that resident`s health care needs are met. Recruitment procedures within the home are robust and protect people using the service. Training systems are in place to inform, supervise and develop competence of staff with the changing support needs of people who use the service. Carers are now receiving regular supervision and support from the management team. Staffing levels at night have improved. A new management structure with the appointment of Managers in most units has been introduced and improved the day to support to people using the service. The management team have been meeting with people using the service and staff to improve communication within the service.

CARE HOMES FOR OLDER PEOPLE Burlington Court Care Home Roseholme Road Abington Northampton NN1 4RS Lead Inspector Judith Roan Unannounced Inspection 6th August 2008 08:00 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.V370073.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.V370073.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 adam.turvey@rochmills.co.uk Burlington Care Homes PLC Manager post 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.V370073.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 February 2008 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.V370073.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 who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved an expert by experience. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The views and experiences of people who use services are central to helping us make a judgement about the quality of a service so they should be fully involved in the inspection process. We use information from experts by experience to help us triangulate evidence and verify any issues. The primary method of inspection used was ‘case tracking’ which involved selecting 3 people who use the service 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 13 people who use the service, 2 relatives, 1 health care professional and 7 staff. The questionnaires provided varied views but gave good feedback that the quality of care and service was improving. Comments received in the surveys included ‘I received a Brochure and visited for lunch’ in response to information about the home. ‘More then looked after’ in response to receiving care. ‘I would like more support with the mental side of my illness’ in response to the question what more could the home do. I know who to complain to if I had one’ ‘Activities are there if you want them’ ‘The food is sometimes tough, the soup watery’ ‘Would like the menu to change from time to time’ ‘Sometimes there are lots of staff and other times not so many’ in response to staff availability. Others said ‘There lovely, they really are’ and ‘the staff are very good and helpful’ All the staff on my unit are very pleasant’ ‘The manager comes around every day to see us’ Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 6 The homes acting manager also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and was undertaken during the morning/afternoon and lasted 9 Hours. Since the last key inspection we have visited the home on several occasions to undertake random inspections the outcome of these are include in the main body of this report. We issued a Statutory Requirement Notice in relation to care planning and risk assessments in June 2008. On the 9th July we visited and found that the service had complied with this notice. What the service does well: What has improved since the last inspection? The care plan format is clearer and more accessible in plans that have been completed. All people using the service have their needs fully assessed prior to admission. All accidents/incidents relating to people using the service well being are now being notified to the CSCI. Medication records are now signed for at the time of administration to ensure that resident’s health care needs are met. Recruitment procedures within the home are robust and protect people using the service. Training systems are in place to inform, supervise and develop competence of staff with the changing support needs of people who use the service. Carers are now receiving regular supervision and support from the management team. Staffing levels at night have improved. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 7 A new management structure with the appointment of Managers in most units has been introduced and improved the day to support to people using the service. The management team have been meeting with people using the service and staff to improve communication within the service. 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. Burlington Court Care Home DS0000029409.V370073.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.V370073.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is good. Good information and pre-admission assessment ensures that the needs of peoples using the service can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide has been reviewed and updated to ensure that information remains current. The documents state clearly the service available. The terms and conditions of residing at the home are contained in the contract that is issued to all residents and their families. Not all people that replied in the surveys were sure about receiving a service users guide. It is recommended that the management team need to review how people using the service have access to the information. The AQAA states that ‘People viewing the home are issued with a statement of purpose, brochure and service user guide which enables them to be informed of information relating to the home’. Copies can be found in the entrance hall at the home. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 10 The report from the expert by experience made the following comments after reviewing the information available and in discussion with people living at the home: A comprehensive “Welcome Pack”, which includes a Service User Guide, a Statement of Purpose and guidance on making comments and complaints, is available to prospective Users. Residents/Relatives are given a choice of rooms when they are admitted. Relatives are aware they are able to visit at any reasonable time. Assessments are completed prior to admission and carers confirm that they ‘receive more information that is accurate’. In reviewing files it was clear that assessments had been completed and that all people using the service had a contract. Burlington Court Care Home DS0000029409.V370073.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. Not all people that use the service have a care plan developed in a timely manner on admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This outcome area has been the main area of random inspections since February 2008. On these visits we have seized documents as evidence that the service continues to fail some people using the service in meeting their health and personal care needs. In June 2008 we decided to issue a Statuary Requirement Notice, as improvements had not been maintained. In the random inspection in July 2008 the service had met the requirement and we were assured that the work undertaken by the acting manager had achieved compliance. On this visit we found that the atmosphere was relaxed and carers were seen to be communicating positively with people in the lounge area. People remaining in their own room were being discreetly supported with personal care needs. It was observed that senior carers were proactive in assessing the health care needs of people receiving the service. On this visit we looked at the care plans and supporting risk assessments for the people we case tracked and there has been significant improvement in the information they contained. The care plans being developed in one unit demonstrated a Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 12 good understanding of care planning and the manager was able to demonstrate how the information was being conveyed to carers to ensure continuity of support. They also evidenced how they took action to minimise the risk of falls for one person by instructing the staff to support the person in bed until additional staff came on during the morning thus reducing the risk. At this key inspection however we found that two new residents at the home had poor care plans developed on admission and that supporting risk assessments were not in place. The assessments indicated needs in the area of manual handling, pressure area care and nutrition. Information in the care plans did not direct carers on how these needs were to be met. The service failed to gain healthcare support for one person using the service in the supply of nutritional supplements. In discussion with the deputy manager it was established that issues with some staff had led to these not being completed on admission. In meeting with the carers the inspector was informed that it was not their role since they were not the unit manager. A change in the management structure of the home has resulted in some people not continuing in their role. Employee relationships have been a challenge. However in four units within the service positive changes have led to good outcomes for people who use the service. In the remaining care plans case tracked we found that were clear instructions on how carers were to support individuals with good information on personal choice and preferences. These issues were discussed with the acting manager during feedback who will look at how the continuity of management support can be achieved when they area on leave. The notes received by the Expert by Experience supported this view and they state that ‘they observed positive care and consideration towards Residents in all Units except in one, where the care administered seemed “passive” rather than “proactive”.’ Carers were seen to be more positive during this inspection. Comments from staff within the surveys confirmed that they had more support from management Good administration of medication was noted and that people receiving the service are supported well at these times throughout the day. The recommendation for the provider to review the storage of controlled drugs within the home to meet new regulation has not been undertaken. A requirement is therefore made for the provider to comply. Burlington Court Care Home DS0000029409.V370073.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. That activities available need to be more person centred and meet personal preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The appointment of an activity organiser has improved the daily lifestyles of people using the service. People spoken with during the inspection and in comments made within the surveys confirmed that they had choice from a range of activities. Care plans could be improved by noting noted peoples preferences in this area. The expert by experience comments provided good feedback to the management team. In general good interaction was observed between staff and residents. The staff attitude towards residents is firm but sensitive. Residents have a choice of a daily newspaper. Activities being lead by the Activities Co-ordinator (colouring of pictures and passing of a soft ball) were being undertaken by some of the Residents in two units and either a television was on or music was being played. Residents were given the choice whether they wish to take part or not. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 14 Some residents seemed to be dozing most of the morning. There was no evidence of a programme of activities for this group. In the afternoon “Bingo”, using large playing cards, was taking place when several residents (12) from various Units attended. Residents had the choice to attend this activity, sit in their lounge or return to their rooms after lunch. A suggestion was made to staff that “life histories” of the residents was a useful tool in applying the need for appropriate activities. One Unit manager is currently in the process of developing paperwork with management to aid this process. Evidence of this was produced during the inspection. In conversation with some of the Residents in all Units the following are some comments: “The food is good but with little choice”, “The staff are good and respond to my needs quickly”, “I do not know of any activities that I can do”, “I am happy with everything, the staff are lovely and the food is good”, “I take part in everything if I can”, “My relatives can visit at any time”. There is no a “Relative’s Forum” for input from/on behalf of residents to feedback joint concerns (or positive comments) to the management. There is however a regular meeting with Relatives. Comments reported by a visiting relative interviewed: “We have reported items of clothing going missing”, “We are aware that we can visit at any reasonable time”, “There was a “relatives forum” at the beginning, but it fizzled out due to a lack of interest”. Note: this was a social/fund raising type group”. Hot/cold drinks were served at 10.15am and at 2.30pm and tea/coffee was served at 11.00am and after lunch in all Units. Meal choices are made the day before. Lunch was served between 12.20 and 1.10pm. I observed part of the meal in two units. There was soup to start and a choice of two mains and one pudding. The meals were served from a trolley delivered from the kitchen and were well presented. Residents seemed to enjoy the meals. A soft food option is given to residents who require this type of meal, and I observed one meal, which was served on a plate in separate portions. The Carer then mashed it all together before feeding the Resident. These comments were reflected within the feedback to the management team who confirmed that they would take them into consideration within the ongoing improvements and training for the service. Relatives comment received through surveys were generally positive saying that improvements had been made since the acting manager had returned to the service. Burlington Court Care Home DS0000029409.V370073.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 adequate. People using the service feel that they are listened to but are not always protected by practices within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is available and people spoken with during the inspection were aware of whom to complain to. In discussion with the expert by experience they received the following comments from people using the service. “I have no cause to complain”, “I would complain to the management but not sure whether it would do any good”, During the inspection ‘No abuse, verbal or otherwise was observed on the day of inspection’. The expert by experience did witness one incident during the afternoon where the Bingo activity was about to commence when one resident had a fall while trying to go to the toilet. Two Care staff handled them well with firmness, sensitivity, lifted them up in the correct way and checked their condition. The resident normally uses a walking frame but on this occasion moved off without it. In discussion with the manager it was established that relatives had supported the individual to the activity and no staff from the unit has been present. It was agreed to review the practices of supporting people with activities. The manager would ensure that the activity organiser has important information about risks so that potential accidents can be minimised. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 16 Comments reported by a visiting relative interviewed: ‘we have no problems with my mother’s care here”, “We would complain to the management if we had any issues we were unhappy about”. Since the last inspection the CSCI have received three complaints two of which have been referred to the Safeguarding team to investigate. The outcomes of these have resulted in the provider tightening up the procedures in relation to call bell systems, care plans and healthcare referrals. One investigation has led to the dismissal of a member of the staff team. A further safeguarding issue was reported by the homes acting manager that has now been fully investigated with a member of the staff team receiving a warning. The number of accidents at the home has substantially reduced since the last key inspection, with management being proactive in their analysis of incidents. The increased staffing levels at night has also played a part in this reduction Carers are fully aware of the safeguarding procedures and they all receive training in abuse awareness. Burlington Court Care Home DS0000029409.V370073.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): 19.26 Quality in this outcome area is adequate. The homes environment is not totally safe and in need of refurbishment to minimise the risk of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Expert by experience reported that Burlington Court is a modern well designed home on two floors with six “Units” each with a central lounge/dining room and kitchenette, with en-suite bedrooms and bathrooms off a connecting corridor. There are security doors, accessed by codes, between the Units. Some people said “ I do not like the lock-in” when asked about the home. There is a central administration section with offices and the stores, main kitchen, laundry and a common room are contained within the complex on the ground floor. Some of the lower Units have access to the landscaped gardens, which has seating and are enclosed by safe boundaries. The Home is generally well presented, clean but showing some signs of wear. Some Bedrooms are personalised and residents are able to bring in their own possessions and small items of furniture if desired. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 18 There was no evidence of odours in any part of the Home on the day of the inspection. Cleaning of common areas and bedrooms was observed in the morning. The furniture in the lounges/dinning areas and common room was functional and appropriate. The kitchen is off a main corridor and seemed well organised. I visited the kitchen where two members of staff were preparing the lunch. I was not invited to wear any protective clothing. All main meals are prepared here and delivered in hot trolleys to the Units where care staff serve meals to the residents. One item of equipment (a hot cabinet) was out of use awaiting spare parts. On a brief visit to the laundry, I was informed by the member of staff that there is no lost property box as all residents clothing is marked and no loses take place. This was later reported to be incorrect as indicated by the manager. We toured the building and found that the toilet areas were not well maintained with several walls in urgent need of repair. The homes manager was unaware that the provider was arranging for these areas to be tiled to ensure that they could be easily cleaned. This lack of knowledge clearly demonstrates the need for improved communication and involvement in decisions about the home between the manager and the provider. Several toilets did not have refuse bins or incontinence waste containers. The subject of management and storage of incontinence waste containers is to be discussed at the next management team meeting as a proposal by one of the new Unit mangers would reduce the cross infection risks and minimise any odours that are so common in toilet areas storing the bins. We also observed a carer dragging a heavy laundry sack as there are insufficient laundry trolleys to meet the need within the units. We visited the laundry and found that some bedding and towels provided at the home is in need of renewal. The service needs to ensure that a system is in place to ensure that quality is maintained within housekeeping supplies. The staff member spoken with who was temporary was not aware that ironing of clothing was part of their role. Clothes were being sent back to the units for them to iron, which would place unnecessary pressure on the busy care staff team. Comment made by some people using the service, relatives and staff said that they is often a lack of cleaning staff within the service. Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. That staffing levels at times do not ensure that the needs of people who use the service are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection four of the units had a unit manager and three/four carers supporting people resident in the home during the morning over the lunch period and in the afternoon. There were male care workers on two of the three Units visited. One unit remains without a unit manager, which is supported by the Deputy manager on day-to-day basis. These levels were meeting the needs of people using the service at the time whilst they were in the units. In the afternoon the expert by experience noted that ‘the activities co-ordinator had to call for assistance during the “Bingo” session as she was on her own (with two relatives) to start with’. A review of how carers in units are deployed when activities occur in the activity room needs to take place to ensure that people using the service are protected. Comments received from people using the service said that ‘There lovely, they really are ‘the staff are very good and helpful’. One person spoken to during the inspection was unhappy about the support they received at night but wished to take this up themselves with the managers. Another person said to the expert by experience. “The night staff are not so good, they are slow to respond” and a relative said, “We think the staff are lovely and we have no problems with my mother’s care here” but “Sometimes there does not seem to be enough care workers on duty” Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 20 The recruitment procedures have been improved and the service is now meeting national minimum standards in this area. Three carer’s files were seen during the inspection and found to contained all of the relevant employment checks. Supervision is taking place on a regular basis and there is on the job training being undertaken by the new unit managers. One comment received from a visiting healthcare professional is that language is sometimes an issue and they are concerned that mistakes could arise. A programme of English education is available to all overseas staff employed at the home. One carers states in a survey that’ the company provides regular training, we have a good management team that I feel I can go to if I have any concern or problem and they will listen’. Other carers were not as positive and are concerned about levels of sickness especially at weekends creating staff shortages. One also said that communication could be improved. Meetings are being held and is apparent over the many inspections that staff morale has greatly improved as changes that improve the service take place. There is positive support for the manager now in post. Burlington Court Care Home DS0000029409.V370073.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): 31,38 Quality in this outcome area is adequate. The delegation of management tasks needs to ensure that in the absence of the manager the home continues to be run safely and protects people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was not possible within the inspection to look at all of the standards in this outcome area. A new manager has been appointed since the last key inspection. They had previously been the registered manager at the home and will be making an application to become registered. They have introduced new systems in care planning with the support of an external consultant and implemented a new staff structure that is bringing about the required changes in practice and meeting the needs of most people using the service. The unit that is without a unit manager is not demonstrating the same improvements as the others and continues not to run in the best interest of people in this area of the home. Whilst the acting manager was on leave care practices failed to protect two people who had been newly admitted into the home. A review of Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 22 how management tasks are delegated in their absence needs to be undertaken to ensure that equity in the provision of the service is maintained. It is notable that accidents have been reduced throughout the home and that management continue to analysis and be proactive in minimising risks for the future. Regulation 26 reports are available and undertaken by the area manager. These highlight areas of good practice and those that need addressing. Arrangements are in place to cover this member of the management team when they take leave of absence to ensure that an overview of the service is being maintained. There is a need to review the current level of laundry trolleys available for staff to use to prevent accidents. Burlington Court Care Home DS0000029409.V370073.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 30/09/08 2. OP8 12 13 3. OP10 13(2) 4. OP27 18 A detailed care plan must be in place for each person that uses the service to ensure that his or her needs are identified and met by care staff. Risk assessments for manual 30/09/08 handling, falls, nutritional needs, aggression and pressure care need to be in place to support care plans to ensure that the needs of people using the service are met. The registered persons should 30/09/08 have a controlled medication cabinet installed in the locked storage area to comply with new legal requirements. Staffing levels must be 30/09/09 maintained during periods of absence to ensure that the needs of people are met. Burlington Court Care Home DS0000029409.V370073.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 OP1 Good Practice Recommendations It is recommended that the management team need to review how people using the service have access to the information to ensure that there is ongoing accessible information. A review of how carers in units are deployed when activities occur in the activity room needs to take place to ensure that people using the service are protected. A review of how laundry is transported in a safe manner within the homes needs to address the insufficient number of trolleys available to minimise risks to carers. 2. 3. OP27 OP38 Burlington Court Care Home DS0000029409.V370073.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V370073.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. 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!