Inspection on 18/01/06 for Burlington Nursing & Retirement Home

This inspection was carried out on 18th January 2006.

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

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

Other inspections for this house

Burlington Nursing & Retirement... 18/03/08

Burlington Nursing & Retirement... 17/09/07

Burlington Nursing & Retirement... 26/09/06

Burlington Nursing & Retirement... 05/09/05

Burlington Nursing & Retirement... 17/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Burlington Nursing & Retirement Home 109-111 Victoria Drive Bognor Regis West Sussex P021 2DZ Lead Inspector Mrs S Gawley Unannounced Inspection 18th January 2006 07:00 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 Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 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 Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burlington Nursing & Retirement Home Address 109-111 Victoria Drive Bognor Regis West Sussex P021 2DZ 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) 01243 821446 Burlington Nursing Home Limited Mrs Christine Jellett Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 Brief Description of the Service: Burlington Nursing and Retirement Home is a privately owned company providing personal and nursing care for up to forty four service users in the category of Older Persons. Burlington Nursing and Retirement Home is a detached two-storey establishment in a residential area of Bognor, a seaside town near Chichester and is situated approximately a mile from the centre of Bognor and all its amenities. It is about one mile from the sea front. Accommodation is provided in thirty six single rooms and four double rooms. Twenty of the singles and two of the doubles have en-suite facilities. A lift gives access to most of the rooms. There is a large lounge/dining room and several other small lounges and quiet areas. There is a large well maintained garden. The responsible person is Mr Mark Holden and the registered manager is Mrs Christine Jellett. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken with the Aid of the pharmacy inspector Mrs J Datoo. The home was inspected against the National Minimum Standards, residents staff and relatives were spoken to and all had positive comments to make on the home. The registered manager and registered provider were available throughout the inspection. The report will reflect these aspects of the inspection What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 6 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 Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, No resident move into the home without having had a full assessment and being assured that their needs will be met. EVIDENCE: The registered manager who is a Registered Nurse assesses all Nursing residents. One care plan inspected did not have a pre assessment for one resident admitted from hospital But the registered manager stated that detailed conversations with the doctor and nurses involved gave her the information required to decide on admission. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. Some aspects of medicine administration and record keeping potentially put residents at risk. EVIDENCE: Staff said that ordering of repeat prescriptions was routinely done, in advance of the time stated in the home’s procedure, to ensure continuous supply of medicines. It was recommended that the medication policy and procedures be reviewed. Medicines were stored in lockable cupboards, trolley and fridge. Strips of tablets not in a dispensed container were in the trolley. Medication administration record charts printed in the supplying pharmacy were in use. Initials indicating administration, in boxes on these charts, were not always clear and a significant number of boxes were blank. Five medicines prescribed to be taken four times a day, had been given morning, noon and teatime but not the bedtime dose. Two medicines prescribed to be taken at night were administered at teatime. It was agreed that an out of date oxygen should be returned to the pharmacy and further information sought on the coming change in oxygen supply. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, Resident find the lifestyle experienced in the home matches expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. 13. Residents maintain contact with family/ friends/ representatives and the local community as they wish. 14. Residents are helped to exercise choice and control over their lives. 15. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Residents spoken to stated that they were happy with the lifestyle in the home and those able to are free to come and go as they wish, others stated that the staff are very kind such as posting letters. Relatives spoken to stated that they are happy with the home and are made welcome. The kitchen was inspected and the cook was spoken to. Menus were in place and food being prepared was as stated. Cleaning schedules and temperature charts were available and up to date, however re was not any provision for deep cleaning the floors and the floor of the wash up room and the sink area needed cleaning. The practice of soaking dirty crockery in the sink was questioned. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 10 The cook and the kitchen assistant have basic food and hygiene training. Residents spoken to stated that they are happy with the food served. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, will 17, 18, Residents and their relatives and friends are confident that their complaints be listened to, taken seriously and acted upon. Resident’s legal rights are protected. Residents are protected from abuse EVIDENCE: Relatives spoken to stated that they felt confident complaints would be listened to and acted on, as did relatives. There is a complaints procedure in place and on display. Relatives know how to access this. Residents are protected from abuse by the provision of policies and procedures on abuse and training in adult protection is on the training programme. Not all staff spoken to had accessed this as yet. Residents are enabled to vote either by going to the polling station or by postal vote. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, Residents live in a mostly safe and fairly well maintained environment. 26, the home is clean, pleasant and hygienic EVIDENCE: The home was neat, clean and apart from a general stuffiness in the entrance hall the rooms were odour free today. The requirement that the carpet be renewed is ongoing but not yet complete due to supply problems. The registered provider has kept the Commission updated on this situation. New areas of carpeting were observed. Door wedges were seen in use in some bedrooms. This was discussed with the registered provider who stated that most communal doors are hard wired into the fire alarm system and some rooms have door guards- self-closing devices in the event of fire. He stated that the installation of these is ongoing on a risk-assessed basis. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 13 There is a routine maintenance programme in place and the maintenance man was spoken to who confirmed that rooms are decorated as they are vacated. There is also a maintenance book which is signed off as jobs are completed. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, the numbers and skill mix of staff meets resident’s needs. Residents are in safe hands at all times. Residents are protected by the homes recruitment policy and practices. Staff now receive training to ensure competency in doing their jobs EVIDENCE: The registered manager is confident that staffing levels meet resident’s needs. She was the only registered nurse on duty the morning of the inspection and felt that she met the needs of the nursing residents. Recruitment files inspected were up to date thus ensuring residents are protected. The home has worked hard to update the training programme and it continues to be developed. All staff in the home need to complete the Adult Protection training including ancillary staff. This will ensure that residents are in safe hands at all times. This was discussed with the manager Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33. The home is run in the best interests of service users. 35. Residents’ financial interests are safeguarded. 36. Staff are appropriately supervised. 38. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The proprietor is making the investment in the home to enhance residents experience. Monies are held securely and accounted for. Supervision has now commenced. The manager is putting new documentation in place, which will be more comprehensive. The issue of doors wedged open was discussed with the proprietor. The communal doors are hard wired into the alarm system and he will continue to purchase and install automatic door closures for bedroom doors. The health safety and welfare of residents is protected by policies and procedures and a Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 16 training programme, which is to be rolled out to all staff. The home works with the Commission to meet requirements. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 17 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 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 3 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 3 Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 18 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. Standard OP16 Regulation 19,24 Requirement Timescale for action 31/03/05 2 OP30 13 3 OP9 13(2) The registered persons must renew, replace or repair communal and room carpets and chair coverings as needed to maintain the establishment to satisfactory standard. This was a requirement of the previous inspection and a new timescale has been agreed. 31/03/06 The registered person ensures that there is a staff training programme which meets the National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. This was a requirement of the previous inspection and a new timescale has been agreed. Medicines must be administered 15/02/06 according to the prescribers directions. Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The time of day that medicines are administered to individuals should be confirmed with the prescriber. For medicines prescibed to be taken regularly, records should show the reason for any non-administration. The homes medication policy and procedures should be updated and should include receipt, recording, storage, handling, administration, self-administration and disposal of medicines. All areas of the home to be clean and hygienic 4 OP15 Burlington Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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 Nursing & Retirement Home DS0000024125.V276327.R01.S.doc Version 5.1 Page 21 - 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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