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Inspection on 05/09/05 for Burlington Nursing & Retirement Home

Also see our care home review for Burlington Nursing & Retirement Home for more information

This inspection was carried out on 5th September 2005.

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.

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

What the care home does well

The residents and relatives spoken to all expressed satisfaction with the home, saying it is a very caring and homely place. A great deal of satisfaction was also expressed with the food.

What has improved since the last inspection?

The last inspection report highlighted an issue of malodour. This has been addressed by the provision of new flooring.

What the care home could do better:

Induction, training and supervision although partially in place need to be developed and well documented. Recruitment procedures need to be strengthened and staff files need to be more comprehensive.

CARE HOMES FOR OLDER PEOPLE Burlington Nursing & Retirement Home 109- 111 Victoria Drive Bognor Regis West Sussex PO21 2DZ Lead Inspector Sheila Gawley Announced Monday 5 September 2005, 9:30am th 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 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 H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 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 Care Home with Nursing - 44 places registration, with number of places Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/08/04 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 H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 05/09/05 and was facilitated by Mrs Jellett. The home was inspected against the National Minimum Standards. The requirements of the last report were considered as were recommendations from an additional visit made to the home on 25/07/05. A pre inspection questionnaire was submitted prior to the inspection. The inspection report is reflective of all of these issues. The home today was found to be neat, clean and free from offensive odours. Residents, relatives and staff were spoken to and all spoke highly of the home. 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 H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 standard(s) 1, 3 Prospective residents have the information they need to make an informed choice about where to live. No resident moves into the home without having had his/her needs assessed and been assured that these will be met. EVIDENCE: Prospective residents have the information they need to make an informed choice about where to live. The information required is contained in the Statement of Purpose. This is displayed in the hall. All residents receive a service user guide. The complaints procedure needs to be included in the Service User Guide. Residents moving into the home have their needs assessed by the funding authority. The needs assessment carried out by the home is somewhat limited and need to be developed. It also needs to be carried out by staff qualified to do so. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 standard(s) 7-10 The resident’s health, personal and social care needs are set out in an individual plan of care. Residents make decisions about their lives with assistance as needed. Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy is upheld. Resident’s are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: Care plans inspected showed assessment of all aspects of residents needs and showed evidence of monthly review. Health professionals are called in as required. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 9 The need for nursing staff to be competent in all aspects of care, for example catheter care, to meet their registration responsibilities was discussed and this is to be met by the training programme. All residents spoken to stated that they are treated with respect with only one comment on occasional abruptness when call bell is answered. Medication policies and procedures are in place and only staff trained to do so administer medicines. Medicines are appropriately stored and Medicine Administration Charts were up to date. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 15 Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: All residents spoken to stated that they are very happy with the food served. The meal seen prepared and served during the inspection was plentiful, well presented and was enjoyed by the residents. Those requiring pureed died or assistance received this in an appropriate manner. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 standard(s) 16,18 Residents and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. 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; it does need to be added to the Service User Guide. Residents are protected from abuse by the provision of policies and procedures on abuse however training in adult protection needs to be put in place as is not currently up to date. A resident was seen being moved in a wheelchair without footplates and this was pointed out to the manager as a risk to health and safety to the resident. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 24, 25, 26 Residents live in a safe and fairly well maintained environment. Residents have access to safe and comfortable indoor and outdoor communal facilities. Residents live in safe, comfortable bedrooms with their own possessions around them. Residents live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. EVIDENCE: The home was neat, clean and odour free today, however the requirement that the carpet be renewed was not met. The proprietor stated that this work has commenced and some rooms inspected did have new carpeting or flooring appropriate to the needs of the resident. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 13 There is a routine maintenance programme in place and some areas of chipped paintwork were highlighted during the inspection. The proprietor stated that this is what the maintenance man was next to work on. Evidence of this was seen. There was discussion with the manager on hygiene matters such as the storage of mops and the signing of cleaning schedule to ensure all tasks are completed and to prevent the spread of infection in the home. One toilet was soiled and this was pointed out to the manager. The sitting of the cat food in the pot washroom adjacent to the kitchen was said to have been cleared by the environmental health officer although this is no stated on the report. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The numbers and skill mix of staff mostly meets resident’s needs. The home’s recruitment policy and practices need to be strengthened to ensure residents are supported and protected. Staff need further training to ensure competency in doing their jobs. EVIDENCE: Staff rota were perused. The pre inspection questionnaire showed forty-one bank/agency shifts in the past eight weeks. This high usage was discussed with the manager. She stated that the homes own bank staff covered the majority of these shifts. She is to address staff sickness in supervision. Four staff files were inspected and none contained the documentation as required by schedule 2 of the National Minimum Standards. Furthermore it was apparent that the homes registered manager is not involved in all staff recruitments. It important that she is involved in this process to ensure the competency and relevancy of experience of all nursing and care staff. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 38 Residents 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. Staff do not receive formal supervision. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager is a Registered General Nurse and maintains her registration with the Nursing and Midwifery Council. She is in the final stages of completing the Registered Managers Award. Staff, residents and relatives stated that she is approachable and that complaints or problems could be taken to her. Her involvement in recruitment and the organisation and delivery of training was discussed with her and with the registered provider. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 16 Clinical supervision is not currently in place and the registered manager stated that she will put this in place. There are not any outstanding requirements from the last fire and environmental health inspections. Some infection control issues were discussed with the manager and consideration may be given to the home requesting a further inspection. Staff records of employment, training and supervision were not complete and mandatory training of fire; health and safety, food hygiene, moving and handling, infection control and first aid are not in place at present. Discussion was held with the registered manager and provider on the importance of putting these in place and the requirements of this report indicate that. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x 1 x 1 Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 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 16 Regulation 19,24 Requirement 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. Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed needs of the service users, the size, layout and the purpose of the home at all times. The registered person operates a thorough recruirtment procedure based on equal opportunities and ensuring the protection of service users. The registered person ensures that there is a staff training programme which meets the National Training Organisation workforce training targets ans ensures staff fulfill the aims of the home and meet the changing needs of service users New service users are admitted only on the basis of a full assessment undertaken by Timescale for action 05/11/05 2. 27 18 05/11/05 3. 29 19 05/11/05 4. 30 13 05/11/05 5. 3 14 05/11/05 Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 19 people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 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 26 Good Practice Recommendations Consideration to be given to requesting an Environmental health Inspection with regard to adopting practices to prevent the spread of infection in the home. Burlington Nursing & Retirement Home H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 H60-H11 S24125 Burlington Nursing Retirement Home V240144 050905 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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