Inspection on 18/03/08 for Burlington Nursing & Retirement Home

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Good 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.

Other inspections for this house

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

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

Burlington Nursing & Retirement... 18/01/06

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 PO21 2DZ Lead Inspector Ann Peace Unannounced Inspection 18th March 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burlington Nursing & Retirement Home DS0000024125.V359191.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 Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burlington Nursing & Retirement Home Address 109-111 Victoria Drive Bognor Regis West Sussex PO21 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 01243 830960 Burlington Nursing Home Limited Post Vacant Care Home 44 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users to be accommodated at any one time must not exceed 44. 17th September 2007 Date of last inspection Brief Description of the Service: Burlington Nursing 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 Home is a detached two-storey establishment in a residential area of Bognor, a seaside town in West Sussex. The home 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 thirtysix 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 Mrs C Jamieson, the registered manager’s post is vacant at present but the home does have a new manager. Fees are between £400.00 to £650.00 per week. Burlington Nursing & Retirement Home DS0000024125.V359191.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 2 stars. This means the people who use this service experience good quality outcomes. Mrs Ann Peace, Regulatory Inspector, carried out the unannounced visit at 9.00am on Tuesday 18th March 2008. To prepare for the visit the last report was looked at along with other information we had received from the service. At the last key inspection the service was rated as poor, this key inspection was planned to monitor the requirements made at the last inspection and what quality of care service users are now receiving. Also since the last key inspection where it was highlighted that Service users were not safeguarded by the medication procedures in the home, a Pharmacy inspection was carried out and the outcome from this was also poor. An improvement plan was submitted by the home and part of this visit was to monitor the actions taken. A manager has been appointed who has improved the home significantly and all the outstanding requirements have been met. The Providers need to ensure that they are complying with the law the Care Standards Act 2000 (CSA 2000) requires any person or organisation that carries on or manages a service to apply to be registered with us. The providers should ensure that the manager has the appropriate documentation to be able to apply to be registered by the Commission a requirement has been made in respect of this. We met people in the communal areas of the home and in their bedrooms, we observed service users and staff interactions throughout the day and we spoke to as many service users as we could to gain an insight into life at the home. We observed that service users were comfortable and relaxed in the home and had friendly but professional relationships with the staff who look after service users in a caring way. We looked at a selection of records, both care records, medication records and records related to the general running of the home and in the majority of cases these are in good order, where there were some gaps, but we could see this is because the Provider and the new manager are re organising all records into better systems. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 6 Some comments from Service users were: “We are cared for very well”. “Staff are approachable and listen to us”. Staff are lovely and we could not ask for more”. “Nothing is too much trouble for the staff”. What the service does well: What has improved since the last inspection? There is a new manager in post who has improved the standard of care and has implemented practices to make the home a safer place for service users. Good wound care practices and procedures has improved the health of some service users. The medication procedures in the home have been completely changed to ensure the safe administration and storage of medication. A staff supervision program is in place and the staff have been provided with more training. The record keeping throughout the home has improved and when completed there should be good systems which will be able to be audited. A quality assurance system has been formalised and some results were available for us to see. Monthly service user’s and staff meetings are held to gain feedback about the home. The storage of hazardous substances is now safe. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 7 The home has discontinued the use of wedges to keep the bedroom doors open which was a fire safety hazard. The Provider is in the process of fitting automatic closures which will enable service users to have their doors open but that would close automatically in the event of a fire. 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 Nursing & Retirement Home DS0000024125.V359191.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 Nursing & Retirement Home DS0000024125.V359191.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): 1,2,3,4,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given the information they need to make an informed decision about the home. Each service user has a written contract/statement of terms and conditions with the home. Service users are admitted on the basis of a full assessment. Service users have an up to date plan of care for daily living and prospective service users are able to visit the home for a trial stay. Burlington Nursing Home does not provide Intermediate Care; therefore Standard Six does not apply. EVIDENCE: Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 10 We saw the Statement of Purpose and Service User Guide which is available in the hallway of the home. We were told that the new provider is currently updating the Statement of Purpose and Service User Guide to reflect the changes to the management of the home. People considering moving into a care home and their relatives are encouraged to come and look around and can go into the home for a trial stay. During our visit to Burlington Nursing Home we looked at the needs assessments of four people living at the home. They did have pre assessments completed and risk assessments and care plans formulated following admission. The manager is in the process of changing the care records and we saw that the new ones are of a good quality and will inform staff of the needs of service users and how the care should be given. The homes own needs assessment is supported by a care management assessment carried out by a Social Services Care Manager when applicable. Staff training records show that collectively staff have the skills and experience to deliver a service to service users accommodated and staff have all had training in understanding Dementia following a variation to the home’s registration. Burlington Nursing home does not provide intermediate care. Burlington Nursing & Retirement Home DS0000024125.V359191.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): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the majority of cases there are plans of care in place that set out individual personal, health and social needs. Service users benefit from a caring team of staff and service users have access to additional health services to meet their assessed needs. Medication policies and procedures are in place and staff follow safe administration practices. Service users feel that they are treated with respect, their right to privacy is upheld and are assured that at the time of death staff will treat them and their families with care sensitivity and respect. EVIDENCE: Since early February a new management system has been in place and the manager is still trying to update records and get them into a more organised system which when completed should promote better health care. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 12 A new assessment and care planning system is being compiled and the new ones seen are comprehensive. With the changeover a number of the records are not fully complete however we could see this does not affect the outcomes for service users as the old records can still be referred to if necessary. There are still numerous separate books documenting and monitoring certain aspects of service users health, however the manager told us that they will be incorporated into one file which will be more person centred. We are told that a new system of key worker groups has been implemented, this means that qualified nurses will have a group of service users they are responsible for and they will be responsible for updating care records as needs change, we are told that this will improve continuity of care. Risk assessments are compiled and updated and include nutrition, falls and risk of pressure sores. The social care plans are presently being compiled and we are told that they will contain a précis of the previous lifestyle and routines of service users so that the home can continue where possible these routines, such as bathing/showering routines and social interests. We noted and were told that personal support is responsive to the varied and individual needs and preferences. Ten service users were spoken to during the visit and all said the care was very good and the staff were friendly and caring. One service user said that nothing was too much trouble for the staff. They all said staff listen to them and support them. Service users have access to healthcare and remedial services as required. On the day of the visit the tissue viability nurse came in to monitor one service user who had wounds that need a lot of care. The tissue viability nurse was very complimentary about the way the wounds had recently been managed in the home and said the result was very good. Looking at wound records there were no pressure sores recorded, there had been one but this had recently been healed. All ten service users spoken to said staff do respect their privacy and dignity and we could confirm this because during the visit we observed a service user being taken in a wheelchair for a bath, the service user had slippers and a dressing gown on while being taken between their room and the bathroom. In relation to dying and death, from what was seen on the day of the visit and what we were told, we concluded that staff would treat service users and their family with care sensitivity and respect. At a recent staff meeting, staff had asked if they could have training in this subject and the manager is arranging this. She also said that she plans to review policies and procedures for palliative care as she has experience in the Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 13 “Liverpool pathway” and wants to improve care given to service users at the end of their lives. Following the last key inspection and from a following pharmacist inspection the home was rated as poor for medication procedures. Since the new manager has been in place safer systems are operating, the home has changed to a new supplier and further training is being arranged. Only qualified nurses administer medication and new policies and procedures are in place. Medication records are up to date and a random check was made of the controlled drugs kept in the home and these were correct. Service users are able to self medicate if they are able to and up to date assessment records in the medication charts confirmed this. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find that the lifestyle they experience in the home matches their expectations and meets their needs. There is a good activity programme in the home and service users are supported in maintaining contacts with family and friends and are able to exercise choice and control over their lives. They enjoy the food provided at the home and special diets, likes and dislikes are catered for. EVIDENCE: There is an activity co-ordinator employed in the home who works 40 hours a week. There is an activity programme available for service users which includes arts and crafts, bingo and exercise to music. The activity co-ordinator also carries out individual activities for those service users who either wish to stay in their rooms or those who have individual social care needs not met by the group activities. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 15 The co-ordinator also carries out small tasks for other service users such as shopping and will take them out to various appointments etc; Service users told us that they appreciate this. A number of service users were taking part in a game of magnetic darts and another resident was washing various ornaments which she enjoys. One resident who is interested in cooking also has individual sessions. There are various photographs around the home of recent gatherings and birthday parties and we were shown some that had not yet been printed. There is a table in the dining room set out with various books on the Royal family with old photos for the service users to look through. Playing cards and draughts are also available as was a box of Newspaper front pages from earlier years to help with reminiscence. Future events planned include: An Easter tea, a cheese and wine party and a summer garden party. There are also plans to involve those service users who are interested in gardening activities. There are various homely furnished comfortable lounges around the home but service users tend to use the ones near the dining room. There is a safe and pleasant rear garden laid to lawn with shrubs and pots of plants. There is also garden furniture and a gazebo for service users to be able to sit out. One service user was sitting in the garden smoking during part of the visit. All service users spoken to expressed satisfaction with what activities were offered. At a recent service user and relatives meeting it was decided that the home would look into hiring a minibus for outings. We noted and were told by service users that daily routines in the home are flexible and they told us that visitors are welcomed into the home and they are able to see their visitors in private. They also told us that they are helped by staff to exercise choice and control over their lives and they are able to bring personal possessions into the home. Service users are offered well-balanced home cooked food, from minutes of meeting seen and by taking to service users we concluded that they are satisfied with the food served. Menus are available and on the day of the visit, cod in parsley sauce with potatoes and vegetables was the main meal, although five people who do not like fish were able to have an alternative. The dining room is homely and the tables were nicely set, service users are offered sherry with their meals. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 16 The manager has started a system which will give service users more choice and will also record what food service users are eating to help with monitoring their nutritional intake. Service users manage their own finances as long as they are able to do so. Relatives and solicitors handle the finances of those who are unable to do so themselves. The manager does hold money for one service user this was looked at and we confirmed that safe systems are in place to protect residents. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 17 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): 16,17,18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Training sessions for staff, a complaints record, staff meetings, Service User meetings plus policies and procedures ensure that, as far as is possible the service users who live at Burlington Nursing Home are safeguarded. EVIDENCE: A complaints procedure is available to service users and is displayed in the hallway of the home, service users told us that they knew how and who to complain to. They also said they felt safe and listened to and able to speak to staff if they had a problem. No complaints have been received by CSCI, one was recorded in the home’s records and this was seen to have been addressed correctly by the providers to the satisfaction of the complainant. Service users are able to vote by post which they confirmed and we were told that if any wish to go out to vote then the home would support them to do this. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 18 Staff did confirm training in safeguarding adults but induction records should be more comprehensive to evidence this. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained, clean and homely environment, they have access to safe and comfortable indoor and outdoor communal facilities. There is sufficient toilet and bathing facilities and they have specialist equipment to meet their needs. There is an ongoing programme of decoration and refurbishment. EVIDENCE: Burlington Nursing home is situated in a residential area of Bognor Regis. The property is detached with single and double rooms available. Communal areas include lounges and a dining room. The grounds are pleasant, tidy, safe and accessible to service users. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 20 The home is clean and tidy and there is a rolling program of decoration in place. Service user’s rooms have been personalised with small pieces of their own furniture and personal possessions and are homely and nicely furnished. On arrival at 9am there was an unpleasant odour in a corridor and in one bedroom, during the visit the corridor was freshened and we were told that the bedroom is in the process of being redecorated and new mattress is being purchased. Although there is an ongoing programme of decoration, some areas are looking shabby and are in need of attention we are told that these are due to be done in the near future. Aids and equipment is available to meet the needs of the service users presently accommodated and windows have restrictors fitted. Radiators have covers fitted and water temperatures are tested to prevent accidents. On the day of the visit we observed a member of staff running a bath and taking the temperature of the water to make sure it was a safe before helping the service user into the bath. The maintenance and servicing records for the home are well organised and so we were able to confirm that equipment and procedures are in place the safeguard service users. The Environmental Health Department (EHO) have recently visited the home and reported that good standards are maintained. There were some recommendations, have these have been carried out and a letter sent to the EHO Dept to confirm action had been taken. There are locks fitted to service user’s bedroom doors which they can use if they wish, these can be opened from the outside if an emergency should occur. Although many of the bedrooms have en-suite facilities there are some communal bathrooms and toilets and it was noted that these cannot be locked, the providers and the manager told us that they would look into this. It is recommended that an infection control audit be carried out as part of the quality assurance system to ensure that all areas and equipment are as safe as possible to prevent the spread of any infection and to minimise any risk to service users. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 21 Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 22 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. Service user’s needs are met by the number and skills mix of staff on duty at Burlington Nursing Home. The home has achieved a staff ratio of 50 trained to NVQ Level two. There is a thorough recruitment process in place and in the majority of cases this is followed. New staff receive basic induction training, but this does need to be more comprehensive. The manager is aware that there are gaps in the training programme and plans to deal with this. EVIDENCE: The staff rota seen during the inspection showed that there are enough staff on duty over a 24-hour period to meet the needs of the service users presently accommodated. Service users told us that they thought there is enough staff on duty to meet their needs. To support nursing and care staff, Burlington also employs a cook, a kitchen assistant, housekeeping staff, an activity co-ordinator and a maintenance man. Burlington Nursing Home employs Registered Nurses and has achieved the ratio of over fifty per cent of care staff with an NVQ Level two. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 23 Since the arrival of the new manager we could see that more training has been arranged by notices on the board and what staff told us. Staff now have an organised system to track their training which is kept with their supervision files. The manager is aware that there are gaps in the training programme and plans to deal with this. Case tracking showed that in the majority of cases the home operates a thorough recruitment process that includes obtaining two written references, (although one new member of staff only had one) a Criminal Records Bureau check and a POVA check prior to staff commencing work. We are told that there is an induction in place for new staff, however this is very basic and needs to be recorded formally. We were shown a new induction package that is being bought into place and will meet National Guidelines. By talking to service users on the day of the visit and by observing staff we concluded that the staff team are well trained, respectful and caring in their approach to service users. Staff meetings are held and minutes were available, for a forthcoming meeting there is an open agenda form displayed on the notice board so that staff can openly request issues they want to discuss. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 24 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): 31,32,33,35,36,37,38. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. There is a new manager in post who has already made improvements in the home to the benefit of service users and staff. The outcomes for service users have improved. The providers should to comply with the law to ensure that an application to register as the manager of the home is submitted. There is a quality assurance system in place to ensure the home is run in the best interests of service users. Service user’s financial interests and health and safety are safeguarded by the homes policies, procedures and record keeping. EVIDENCE: Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 25 Since the last inspection there has been a management change in the home. There is a new manager in place and already has made improvements in the home. The manager plans to undertake The Registered Managers Award in the near future and will be applying to CSCI to become registered manager. She is experienced in the management of a care home and has the skills and experience to benefit service users and staff. It is the duty of the providers to ensure that there is a registered manger in respect of The Burlington Nursing Home who is a person of integrity, good character and is physically and mentally fit to manager the and that all necessary information is available as required under paragraphs 1 to 5 and 7 of Schedule 2 of the Regulations. The manager is improving and developing systems that monitor practice and compliance with the plans policies and procedures of the home. For example we found that she and the Provider are trying very hard to organise the records into a more systematic order and when this is completed the home should have good systems. Burlington has a quality assurance and monitoring system in place consisting of service user meetings that are held, staff meetings, comprehensive Regulation 26 visits to monitor the conduct of the home, a maintenance plan, a rolling program of redecoration and refurbishment, and an audit preformed related to The National Minimum Standards. We could see that the recommendations from the latest Regulation 26 visit had been acted on and completed. Service users told us that the manager and the staff do listen to them and act on what they say, they also told us that there is an open atmosphere and they could speak to the manager at any time. Service users are able to control their own finances if they are able and wish to. Relatives and solicitors look after the finances for those residents who are unable to do so themselves. The manager does not have control of any service user’s finances but may hold amounts of money, the system for this was checked and we concluded they operate a safe procedure. Following a requirement made at the last inspection a staff supervision system is now in operation although this was not started until the new manager came into post. We saw that at least 75 of the staff have had a good supervision session with the new manager and other staff have dates planned. Staff records show that staff receives training in Health and Safety. Policies, procedures and risk assessments were seen to be in place regarding Health and Safety. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 26 A requirement was made at the last inspection that substances hazardous to health should be stored safety out of reach of service users. We are able to confirm that safe storage procedures are being carried out and that service users are now safeguarded. Fire safety training is carried out for staff and automatic closures are being fitted to bedroom doors so that service users are able to have their doors open, but that they would close in the event of a fire. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 27 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 28 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 Reg 8 To submit an application to the Commission is the registered manager of the care home. Requirement Timescale for action 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations An infection control audit should be undertaken as part of the quality assurance system. Burlington Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Nursing & Retirement Home DS0000024125.V359191.R01.S.doc Version 5.2 Page 30 - 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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