Inspection on 23/06/05 for Burnham

This inspection was carried out on 23rd June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burnham 28/10/06

Burnham 17/01/06

Burnham 17/11/04

Burnham 08/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Burnham 19 Julian Road Folkestone Kent CT19 5HW Lead Inspector Susan Hall Announced 23 June 2005 at 09.30 rd 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burnham Address 19, Julian Road, Folkestone, Kent, CT19 5HW 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) 01303 221335 MNP Complete Care Group Miss Debbie Beer Registered Care Home 5 Category(ies) of Young Adults with a Physical Disability x 5 registration, with number of places Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One Service User with a Physical Disability who is over 65 yrs. of age, and whose date of birth is 20.07.1939. Date of last inspection 17th November 2004 Brief Description of the Service: Burnham is a large detached Victorian-style building, and is situated in a pleasant residential area of Folkestone. It is near to a public park, a leisure centre, the town and shops, and the sea. Burnham is owned by the Company MNP Complete Care Group, who are experienced Providers for Service Users with physical and learning disabilities. They have several other care homes in this area, and one of these is within a few minutes walking distance of Burnham. There is a good rapport between these 2 Homes, and this provides the opportunity for Service Users to share in a wider range of activities, and to get to know a wider range of people. Accommodation is provided on 2 floors, in 5 single bedrooms. All of these have en-suite toilet, and shower or bathing facilities. Access to the first floor is via a passenger lift, which was newly installed in 2003. One of the bedrooms has its own front and rear access to the building. All rooms are fitted with call bells. A variation on the registration was agreed with CSCI for one Service User who has lived at the Home for several years, and is now aged over 65years. It has been agreed that the Home remains a suitable venue for him at this time. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 09.30, and the Inspector stayed in the Home until 4.30pm. The inspection included a tour of the premises, reading care plans and documentation, talking with the Manager and staff, and meeting Service Users and relatives. She saw all 5 Service Users and was able to speak in some depth with 2 of these, and to have limited conversation with another 2, who had less verbal communication. The other Service User was sound asleep in his chair, when the Inspector went to chat with him before lunch. She was also able to speak at length with 2 relatives, and this was most helpful. CSCI comment cards had been completed by 3 Service Users and 3 relatives, and these indicated that Service Users were generally content, and felt well cared for. All Service Users were well groomed and the Home was clean and in good order. The inspection took place on a hot day, and the Home was airy and well ventilated. 2 Service Users were out in the garden, and enjoyed much of the day spending time outside. These had been risk assessed as safe to go out in their wheelchairs for short distances unattended, and adhered to their guidelines by not crossing any roads. New paving in the rear garden facilitated access, and a temporary ramp had been put in place to enable them to use a side pathway and access the front of the property. Another Service User was able to walk outside, and was appropriately supervised; and a fourth Service User was accompanied by his brother, who took him out in his wheelchair to visit the doctor. The Inspector talked with one carer who had been working at the Home for about a year, and who said that she appreciated the levels of staff training in place. The Inspector also spoke briefly with 2 other care staff. What the service does well: There is a friendly and homely atmosphere, and friends and relatives are welcome to visit at any time. As there are only 5 Service Users, their needs are clearly identified, and it is easier to ensure that staff are aware of their specific and individual needs. The house is well maintained, and each Service User has a room which is suitable for their needs. Attention has been paid to fitting individual shower or bathrooms, and to widening doorways and fitting any necessary grab rails. The rear garden was very well maintained, and has paths and lawns which all Service Users could enjoy. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 6 The Manager showed a concern to ensure that medical and health needs are properly met. This had proved quite difficult for one Service User, and it was encouraging to hear a relative praise the Home for their commitment in continuing to work at this situation. Documentation was in good order, and care plans and daily records contained detailed and accurate information. What has improved since the last inspection? What they could do better: One Service User identified some small changes which could be made to his room, which would make him feel more comfortable with his care. These included having his curtains re-hung – which had come off their hooks at one side – and having a window adjusted so he could open and close it himself. The Manager asked a staff member to hang the curtains properly while the Inspector was in the Home, and said she would ask the maintenance man to attend to the window which was permanently shut. This had been because it had previously opened wide, adjacent to the front door, and could have caused an injury. The Inspector made a recommendation that the window should be fixed so that the Service User can open it, but with a window restrictor in place so that it does not cause any dangers. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 7 The same Service User had to share a mobile shower chair with another Service User, and felt this could restrict him from having a shower when he wanted. He was also concerned about the height of the shower. There is a recommendation for the Company to purchase another shower chair, and to ensure that the shower is fitted appropriately for his needs. Documentation was well maintained, but some of the Medicine Administration Records (MAR charts) did not contain photos. There is a recommendation to ensure that this task is completed. A new key worker system had been implemented, but some aspects of how this should be outworked had not been made clear to all staff, and had caused some tension in the Home – particularly in regards to the key workers’ responsibilities with the care of clothing. The Inspector recommended that the Manager should address this specific situation, and this may be helped by implementing a clothing list - especially for 1 identified Service User. 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. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 The Home has a well-produced Statement of Purpose and Service User Guide which enable prospective Service Users to make an informed decision about admission to the Home. Individual contracts contain adequate information regarding the agreed terms and conditions of residency. EVIDENCE: The Statement of Purpose is written according to Schedule 1 of the Care Homes Regulations, with each of the 18 points clearly identified. The Service Users’ Guide is presented in a presentation pack, which includes the Statement of Purpose, coloured photographs of the different MNP Homes, the complaints procedure, and terms and conditions of residency. These state the house rules about smoking and alcohol, bringing in of personal possessions, arrangements for having a telephone line fitted, fire precautions, and transport arrangements. The Home has access to the house vehicle at another nearby MNP Home, and there is a signed agreement on admission for Service Users to pay a small amount for the use of this vehicle. All transport for medical or health appointments is provided by the Company. Fees are specified, and include items such as hairdressing, chiropody and laundry. Service Users (or their next of kin) sign the contract with the Home’s Manager, and each retain a copy. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 10 Service Users are invited to visit the Home prior to moving in, and there is a trial period of 4 weeks. This may be extended if required. Detailed pre-admission assessments were viewed for 2 Service Users in their care plans. These had been carried out by the Home Manager and an Area Manager, and included all relevant assessments and required information. Rooms and equipment had been prepared as far as possible prior to them moving into the Home. Specific arrangements (such as the correct height or positioning of grab rails) is achieved as soon as possible after admission. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6-10 Service Users and their relatives are included in formulating care plans which will meet the assessed needs of the Service User. The staff actively encourage Service Users in pursuing their choice of activities, within a risk management framework. EVIDENCE: An initial plan of care is instigated after pre-admission assessments have been completed, and care plans are than adapted as appropriate. They are reviewed weekly and monthly at first, and when they have been correctly implemented, are reviewed at 6-monthly intervals. Service Users are reviewed by their Care Managers every 6 months, and this often coincides with recognising if changes to the care plan are necessary. The format includes detailed information about personal hygiene needs, mobility, health needs, continence, skin integrity, communication skills, nutrition, medication needs and psychological profiles. Service Users are encouraged to make their own decisions about their care where they are able to do so, and about the type of activities they wish to pursue. These are dependent on risk assessments, which show their ability for Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 12 such items as going out unaided, managing their own personal hygiene, and going in the garden unsupervised. Satisfactory systems are in place for the management of personal finances on a day to day basis. Only pocket monies are retained in the Home, and these are kept individually and all receipts are retained. Service Users records are stored confidentially in a locked cabinet, and Service Users (or their next of kin if indicated) are able to access their records on request. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11-17 Service Users are encouraged to maintain and develop independent living skills, and to follow their preferred choice of lifestyle. Meals in the Home offer sufficient choice and variety to provide a nutritious diet. EVIDENCE: Service Users are enabled to manage as much of their personal hygiene as possible, including using the toilet and showering unaccompanied. Each of the Service Users had their own routines, and are able to get up or go to bed as they wish. It is not possible to always carry out same gender care, as there are female staff as well as male staff, and all Service Users were male at this time. This had been discussed with Service Users prior to admission. Some Service Users prefer to spend more time in their own rooms than others. One is unsighted, and likes to spend most time in his room, and to have visits from his wife. 2 Service Users had been residents in the Home for some time, and 3 had moved into the Home since the last inspection. The Inspector noted that their rooms were personalised according to taste, and décor had been Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 14 changed with their agreement. The Service Users are of different ages, but seemed to get on well with each other and accept each other. A new master key system was in the process of being fitted, with new locks for 2 rooms. Service Users are able to access different training courses and leisure pursuits, and 2 of them told the Inspector that they like going to nearby “car boot fairs” most weeks. One of these particularly enjoys buying old records, tapes and CDs, and listens to them frequently. He was heard singing happily in the garden during the afternoon. Another had bought a picture, which his brother was going to hang for him. Activity records had been commenced in the Home for each Service User, showing daily reports for mornings, afternoons and evenings. One of these showed a range of activities from playing games (eg: skittles in the garden), visiting the local park, and going to an exercise class, to helping in the kitchen, or going out bowling with another MNP Home. Some Service Users are interested in activities such as sport, swimming, hydrotherapy, football and computer courses. The Manager and staff were looking at enabling Service Users to develop these interests wherever possible. Some had not been in the Home long enough to establish what they would be able to do within the confines of health needs. The Home has a clause in their terms and conditions that they do not pay for holidays for Service Users, but they will assist Service Users in finding holidays appropriate to them and in helping with staffing needs. As there are only 5 Service Users, likes and dislikes with food can easily be ascertained. Menus are discussed together, and Service Users are able to choose an alternative course if they change their mind on the day. The kitchen was only viewed briefly on this occasion, and was clean and tidy. Lunchtime food was seen to be well presented. The Environmental Health Officer had visited the Home in April 2005 to carry out a spot check on prepared sandwiches. These were taken away for analysis, and the results were satisfactory. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18-20 Good systems are in place to ensure that Service Users medical and health needs are being properly provided for, and the Manager had involved other health professionals to ensure that assessed needs are met. EVIDENCE: Care plans confirmed that staff give attention to detail in assisting with personal care and hygiene needs. Specific details are recorded to show individual routines for day and night care. Detailed mobility assessments ensure that staff know how much Service Users are able to help themselves, or where they need specific assistance. There was good evidence of assistance from other health professionals. This included a physiotherapist for one – (who had taught staff how to do leg exercises with this Service User); an Occupational Therapist (who ran an exercise class which 1 attended); a nutritionist, and a Speech and Language Therapist. There was ongoing involvement with these health professionals as needed. Visits to the GP and other medical advisors were detailed in Service Users’ reports. One relative expressed concern about his brother’s medical needs, as it seemed that he had been discharged from hospital and rehabilitation care Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 16 much too soon. He stated that he was impressed with the way in which the Manager and the staff in the Home had supported his brother during this time, and that it was their vigilance and input which had ensured that his brother was having his health needs identified and acted on. None of the Service Users were able to administer their own medication, and only staff who had attended a satisfactory course were assessed as suitable to administer this. There had been a change of Pharmacy since the previous inspection, and this had been a positive change. Medication is administered using the nomad cassette system where possible, and these cassettes were properly sealed, and changed over by the Pharmacist if there was any error or changes of medication during the week. Storage of tablets was in locked metal cupboards, and there was separate locked storage for creams and lotions. The Inspector did not find any out of date medication, and eye ointments and creams had been dated on opening. Medication is usually checked in by the Manager, and is receipted in on the Medication Administration Records (MAR charts.) A record is kept of any returns to the Pharmacy. There was a list of staff signatures in place, and MAR charts had been neatly and accurately completed. There was a satisfactory system in place for taking medication out of the Home when Service Users are going out. The Inspector noted that some of the MAR charts did not have photographs of the Service Users with them. The Manager was already aware of this, and was dealing with it. There is a recommendation to ensure that this is completely carried out. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The Home has a satisfactory complaints procedure in place. This was mostly working well, but one concern raised had not been satisfactorily resolved. Staff have an understanding of adult protection issues, which protects Service Users from possible risk of harm or abuse. EVIDENCE: The complaints procedure was on display, and was included in the Service Users’ Guide. The Manager stated that this was also put inside the wardrobe of each Service User’s room. She had recognised that the current ones in rooms needed to have some wording altered from “National Care Standards Commission” to “Commission for Social Care Inspection”, and this was being done. There was a correct version in the Service User’s Guide, but she was waiting for access to a laminator to change the other ones. No formal complaints had been raised with the Home or with CSCI, but several concerns had been raised, and the Manager had thought that all of these had been satisfactorily resolved. However, when the Inspector was talking to a relative, she realised that one of these issues had not been properly resolved. This concerned the level of responsibility which is given to key workers, and how clothes are maintained. The Inspector suggested that a separate clothing list may help to handle this situation more appropriately in the future, and staff awareness of their levels of responsibility must be made clear. Staff had good training records, and these included records of updated training for all staff in awareness and recognition of adult abuse, and how to prevent Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 18 this. An Area Manager has a certificate in adult abuse awareness, which entitles her to teach this subject to staff. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 The standard of the environment is excellent, providing Service Users with an attractive and homely place in which to live, and showing attention to detail for individual needs. EVIDENCE: The Inspector was able to view the entire Home, and noted that improvements with structural changes and décor were of a good standard. Individual Service Users’ needs and preferences had been taken into account, ensuring that there was wheelchair access to their rooms, and satisfactory toilet and bathing facilities. The main lounge and conservatory had been redecorated, as well as several bedrooms. En-suite toilet and shower facilities had been completely refurbished into “wet rooms”, making showers a lot easier to access. One Service User was concerned that his shower facility was a bit high for him to use unaided, and the Manager was addressing this issue immediately. He also said that he would prefer his own mobile shower chair, and there is a recommendation for the Company to consider this. (NB. The Company carried this out after the inspection.) Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 20 A requirement from the last inspection about radiator covers had been carried out. This was for 2 identified radiators. There was a controlled maintenance programme to fit all radiators with covers, and this was in the process of being done. The Home was well ventilated, and windows on the first floor had been fitted with window restrictors for safety. One Service User with a bedroom on the ground floor wished to be able to open a window in his room which opens near to the front door. There is a recommendation to have this window readjusted, providing it does not compromise safety of people entering the building. (NB. This work was carried out shortly after the inspection.) All bedrooms and communal rooms were fitted with suitable furniture and soft furnishings, and individual equipment (such as grab rails) where needed. A new locking system was being fitted to bedroom doors, and a master key system was being implemented. Doors were fitted to comply with fire regulations. There is a beautifully maintained rear garden, which includes newly paved areas, lawns and flowerbeds. One of the staff had also started to grow some vegetables, and one of the Service Users was enjoying helping her to water these. There were further plans to re-pave an area at the side of the house; this was already accessible to Service Users in it’s current state, but this action would improve it. A summerhouse in the garden had been out of use for some time as it had been used as a storage area. This had mostly been cleared, and the staff and Service Users were discussing the best possible use for this additional space. Laundry machines are situated in a separate area on the first floor. This is a small room with a washing machine and tumble dryer, which is adequate for the needs of the Home. Hand washing facilities are situated in an adjacent area. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 There is an effective staff team, and staff have a good understanding of Service Users needs. This was demonstrated by good relationships between staff and Service Users, and by positive comments from Service Users and relatives. EVIDENCE: A new system of key workers had been introduced, and was beginning to work well. (One aspect of this which needed addressing has already been commented on in the section which includes standard 22.) The Home has 2 staff on duty each day, and this is usually sufficient as Service Users have different preferred times for getting up and going to bed. Additional staffing is arranged if all of the Service Users join in with outings, or if needed to assist them with medical appointments. The Manager works some hours giving hands-on care, and some where she is supernumerary and can concentrate on management issues. Night duties are covered by 1 staff member, who has access to the Manager or Deputy for assistance with any night emergencies. One Service User has 10 hours per week of one to one care, which is paid for as an extra by his funding authority, and is to meet specific needs. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 22 Staffing files showed good recruitment procedures, which included the documentation required for new employees. A staff member who had transferred from another Company Home, had been re-interviewed to ensure that he was suitable for working in this Home and with the current Service Users. The Inspector checked with the CSCI office that his CRB (Criminal Record Bureau) check was still in order, and did not need to be re applied for, as he had the same employers. All CRB checks and POVA First checks had been completed, and the Inspector viewed some of these. The Home has a good induction procedure, whereby staff from different Company Homes go through the induction process together. This enables them to discuss different aspects of staff responsibilities together. All Managers take part in the induction process, teaching different subjects on one day each over several weeks. Staff training records showed that mandatory training (eg: moving and handling, basic food hygiene, fire awareness), were being kept up to date for all staff. 65 of staff are trained to a minimum of NVQ level 2, and all senior care staff are trained to NVQ level 3. Staff supervision was being carried out on a 2-monthly basis, and self appraisals and joint appraisals were being done yearly. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 -43 The Manager provides clear leadership in the Home to other staff, and demonstrates a good understanding of how to ensure continually improved levels of care for the Service Users. Systems are in place to ensure that policies and procedures reflect the current practices in the Home, and are properly recorded; and to ensure that health and safety matters are attended to promptly. EVIDENCE: The Manager had completed training for the Registered Managers’ Award (RMA), and NVQ level 4. The Inspector was able to view the certification verification for NVQ 4. It was clear that the Manager had settled well into running the Home, and had more confidence in her understanding of the best ways to ensure effective care for these Service Users. She had completed a detailed assessment record for the Inspector, which was helpful in clarifying different parts of the inspection. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 24 Service Users are included in discussing plans for changes in the Home, outings and menus, and are invited to complete questionnaires every 6 months. These do not have to be named, and give an opportunity for Service Users and relatives to express their views. The generally friendly environment of the Home, and the commitment of the Manager, usually encourages Service Users and relatives to speak freely with her about any concerns. Policies and procedures had been reviewed during the year, and had been amended where indicated. The Inspector viewed additions to one policy, and 2 new extra policies. These were set out in a straightforward format which was easy to follow. Policies are stored in the office, and are always accessible to staff. The Inspector viewed health and safety records for hot water temperatures (recorded weekly in different areas); meat temperatures (recorded for large joints of meat); gas, electrical, PAT testing, and fire records. These were all up to date and in good order. Accident records had been accurately maintained, and the Inspector discussed auditing of accident records with the Manager. Satisfactory systems are in place for maintaining budgets and financial planning. The Head Office manages accounts, and equipment is provided to the Home as needed. An Insurance Certificate was displayed and up to date. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burnham Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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. 4. 5. Refer to Standard YA20 YA22 YA22 YA26 YA27 Good Practice Recommendations To ensure that each medication administration record is accompanied by a photograph of the Service User. To implement a separate clothing list for Service Users (at least for main items.) To ensure that staff are trained in their individual responsibilities as key workers. To arrange for a specified bedroom window to be readjusted, so that the Service User can open and close it. To purchase an additional mobile shower chair, so that each Service User has their own. Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Burnham H56-H05 S23122 Burnham V224023 230605 Stage 4.doc Version 1.30 Page 28 - 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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