Inspection on 13/02/06 for Burnham Lodge Nursing Home

This inspection was carried out on 13th February 2006.

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

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

Other inspections for this house

Burnham Lodge Nursing Home 14/08/07

Burnham Lodge Nursing Home 30/05/06

Burnham Lodge Nursing Home 23/08/05

Burnham Lodge Nursing Home 01/11/04

Burnham Lodge Nursing Home 29/04/04

Burnham Lodge Nursing Home 17/11/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Burnham Lodge Nursing Home Parliament Lane Burnham Bucks SL1 8NU Lead Inspector Joan Browne Unannounced Inspection 13th February 2006 09:30 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 Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address Parliament Lane Burnham Bucks SL1 8NU 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) 01628 667345 Burnham Lodge Ltd Catherine Mary Bronock Mrs Jo Davidson Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. General Nursing Care maximum 46 Personal Care maximum 6 One service user under the age of sixty five as identified in the Application for Variation Form, Section 4.2, signed and dated 5th May 2004. 23rd August 2005 Date of last inspection Brief Description of the Service: Burnham Lodge is a care home providing nursing and personal care for residents who are elderly and physically frail. The home has 32 single rooms and 7 shared rooms, which are situated on three floors. Access to floors can be gained via a passenger and stair lift. The home is a large country house set in tranquil surroundings backing on to woodlands situated at the edge of Burnham Beeches. Public transport and other amenities are not easily accessible. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 13 February 2006 from 09. 45 am to 16.00 pm. The lead inspector was Ms Joan Browne who was accompanied by Mr Mike Murphy (Inspector). The inspection consisted of meeting with residents and staff, examination of care documentation, records and a tour of the building. The requirements and recommendations from the previous inspection were discussed. The manager did not submit an action plan to the Commission in relation to these requirements and recommendations. She explained that it was an oversight and has agreed to forward one to the Commission. Feedback was given to the manager on the findings the inspection. What the service does well: What has improved since the last inspection? What they could do better: Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 6 Care plans need to be reviewed monthly. Residents’ Waterlow assessments and weights must be reviewed monthly. Trained nurses’ practice in the administration and recording of medication must take account of guidelines published by the Nursing and Midwifery Council. Medication administration record (MAR) sheets should be monitored regularly. Details of outcome of complaints investigated need to be recorded in the complaints folder. An up to date photograph must be kept on staff members’ files to confirm proof of identity. A supervision framework needs to be developed. Generic risk assessments need to be updated. Residents’ bedroom doors must not be kept open with door wedges or other obstacles. A protocol for the administration of Fosamax medication needs to be developed. The home’s application form needs to be reviewed to ensure that it conforms to current guidelines. 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 Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 7 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 Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed at the previous inspection. Standard 6 is not applicable because the home does not provide intermediate care. EVIDENCE: Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 &10 Standards of care planning are uneven and inconsistent. Weaknesses in current practice may increase the risk of a failure in communication leading to a failure in the provision of care to residents. There are still inconsistencies in the administration and recording of medication identified in the body of the report, which have the potential to place residents at risk. Arrangements were in place to ensure that residents’ privacy and dignity are being respected. EVIDENCE: The home uses the Standex care planning system. Photographs of residents are held on the medicine charts. Three care plan records were examined. The results were uneven. The long- term assessment form was well completed. Care plans were generally well formulated. It was evident that some nurses set a very good standard in this respect. While assessments and care plans were generally of a good standard; the standard of their implementation, monitoring and review were very much more variable and significant deficits were noted. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 10 In the care plans examined, residents’ weights were not being maintained. Waterlow (pressure sore risk indicator) assessments were not updated, and there was no evidence of the agreement of the resident to the care plan. In the case of one resident who was receiving anti-depressant treatment there were no references to the resident’s mood, thought or interactions recorded in the daily log. However, there was a care plan to meet the identified need, which included personal support. Daily records were generally confined to recording the physical care given. Reviews were infrequent. These findings were discussed with the manager during the inspection. To some extent the decision of the home not to have a key worker (key nurse) for each resident may be a contributory factor. Responsibility for maintaining the care plan appeared to lay entirely with the manager and deputy manager. Corrective action is required and this might include setting clear standards for all aspects of care planning, staff training, staff supervision, periodic audit, and management review of conformance to the home’s own standards - as well as to those of other bodies. The medication administration record (MAR) sheets were examined. It is acknowledged that there has been an improvement in the presentation of the MAR sheets’ folder. Gaps were noted on some sheets these included controlled drug medications, which were Ora-Morph and MST for two particular residents. The controlled drug register was checked. Information recorded in the register indicated that two staff members had signed and witnessed for the administration of the medications. However, the MAR sheets for these individuals were not signed. It is required that the practice in place for the administration of controlled drug medication be reviewed to ensure that it is administered in accordance with the Nursing and Midwifery (NMC) Guidelines. Trained nurse should be reminded of their accountability. Some entries were written over. Inconsistencies in staff’s recording were noted. For example, when antibiotic treatment was completed or medication stopped by the general practitioner (GP), the staff member recording the entry did not always record a short note for example, ‘course completed’, ‘stopped by the GP’, and date and sign the entry. It is required that regular auditing of the MAR sheets are carried out. Records of auditing undertaken should be kept for inspection purposes. It is further required that the manager should regularly assess staffs’ competencies in the administration and recording of medication. Records of assessments undertaken must be kept for inspection purposes. It was noted that a bottle of eye drops that was in use did not record the date when it was opened. It is recommended that individual protocols be developed for those residents who have been prescribed for Fosamax medication to ensure that it is appropriately administered by all staff. There was a list with staff’s names and initials who were authorised to administer medication. This is deemed as good practice. However, not all staff Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 11 had recorded their initials. It is recommended that all staff record their initials on the list provided. Staff were observed knocking on residents’ bedroom doors and waiting for a reply before entering. Staff ensure that residents’ privacy is respected when providing personal care. Residents can receive and make telephone calls in private. All bedrooms are fitted with telephones. The laundry facility provided ensures that residents’ personal clothing is well maintained. Medical examinations and treatments are carried out in residents’ bedrooms. Appropriate screening is provided in shared rooms to ensure that privacy is not compromised. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14 Visitors are welcome to visit at anytime this ensures that residents maintain contact with their family and friends. Satisfactory arrangements were in place to support residents to exercise choice and control over their lives. EVIDENCE: Residents are able to choose whom they wish to see and receive visitors in private in their bedrooms or in the communal areas. Residents spoken to confirmed that relatives and friends are able to visit them at anytime and there were no restrictions on visiting. The manager stated that there were no volunteers currently visiting the home. Residents are encouraged to handle their own financial affairs for as long as they are able to with support from relatives. The home’s staff prior to admission would make residents aware that they are able to bring in small items of personal possessions such as furniture if they wished to. Personal items were noted in some residents’ bedrooms. The home’s staff would advice residents and their relatives on how to contact the services of an advocate if such a service was required. There were no residents receiving the services of an advocate at the time of the inspection. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 13 Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home keeps a record of complaints made. However, more detail of the outcome of complaints is needed. This would ensure that residents and relatives’ complaints are taken seriously and acted upon. EVIDENCE: The complaints record folder was examined. Since the last inspection the home had received one complaint. There was no record of the outcome of the complaint investigated. It is required that details of outcome of complaints investigated are kept in the complaints record folder. Residents spoken to were aware of whom to speak to if there was a problem. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 & 26 The home is well maintained, pleasantly decorated and furnished. It provides residents with an attractive, safe and homely place to live in. EVIDENCE: The home is situated in large grounds at the edge of Burnham Beeches. It is close to the village of Burnham. The home is well furnished and provides a comfortable welcoming environment. The location and layout of the home is suitable for its stated purpose and meets the needs of residents. Residents spoken to on the day of the inspection felt that the building was safe, and well maintained. On the day of the inspection one bedroom was being refurbished. Residents’ bedrooms were personalised with family pictures, mementoes and personal furniture. Daily monitoring on the standard of cleaning in residents’ bedrooms, bathroom and toilets takes place. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 16 The floors and walls in the laundry room were clean and free from dust. It was evident that a cleaning schedule was in place and being adhered to. On the day of the inspection the home was bright, clean and free from offensive odours. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 Care Staff are working towards acquiring the NVQ qualification. This would ensure that qualified and competent staff care for residents at all times. Some minor amendments are needed to the home’s application form to ensure that it conforms to current guidelines and good practice. Arrangements were in place to ensure that staff are trained to do their jobs. EVIDENCE: The home is a care home providing nursing which has a number of registered nurses on its staff. It has 15 care staff of whom one has acquired National Vocational Qualification (NVQ) 3, three have acquired NVQ 2, and one is on the point of completing the NVQ 2. It also has a number of nurses who are qualified and registered in Eastern Europe but not with the Nursing and Midwifery Council (NMC) in the United Kingdom. It is considered that the knowledge, skills and experience of such nurses may be equal to NVQ 3 although it may not be possible to demonstrate strict equivalence. To do so would require such staff to undertake the NVQ 3 course, acquiring credit for prior experience while doing so. Applicants for positions in the home are required to complete an application form, supply two references and have Criminal Records Bureau (CRB) Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 18 clearance. The files of three staff appointed since the announced inspection were examined. It was noted that the home’s application form does not require a statement as to why the applicant left a previous care position. Since July 26 2004, with the introduction of the Protection of Vulnerable Adult (POVA) list, employers have been required to acquire such information where applicants have worked for more than three months in a care position. Evidence of medical fitness is assessed through the answers to two questions on the application form. In the absence of a medical report, in addition to the current two questions, conformance to Schedule 2 might be more closely achieved by a signed declaration by the applicant that she or he is fit for the job. Files contained relevant information on personnel. Two references had been received in all cases. A POVA first check had been received in all cases before the person started work. Enhanced CRB certificates had been obtained. Photographs were black and white photocopies of passport photos and may not have been recent. A recent colour photograph would be better. All had contracts of employment. Checks had been made with the Nursing and Midwifery Council (NMC) with regard to the current registration status of nurses. A relatively new member of staff reported that she had almost completed the NVQ 2 in her first ten months. Managers were reported to be approachable and supportive. Training is co-ordinated by an experienced registered nurse. The training programme from April 2005 to January 2006 included; fire safety (4 two and a half hours), moving & handling (2 three and a half hour sessions), manual handling (1 half day), POVA (2 half days), POVA ‘train the trainer’ (1 day), dementia care (4 whole days), falls and fall prevention (1 half day), infection control (2 half days), and, health & safety (1 half day). The home plans to cover training in first aid and MRSA in 2006. Training in food hygiene was not included in the programme in 2005. The manager said that new staff are provided with a copy of the TOPSS (now ‘Skills for Care’) induction programme and are required to complete it during their induction period. Training is carried out by a range of providers. Bucks Social Services provide training on POVA with the home now having its own trainer. A care home with City and Guilds accreditation, provides training in manual handling, dementia care, falls and infection control. Another care home and domiciliary care agency provide training in manual handling. An external consultant provides training on fire safety. From the records available it was not possible to say whether training events were at induction, basic or update level. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 The manager and deputy manager are working towards achieving the required level of formal professional qualification. This would enable them to demonstrate that they are fit to discharge their responsibilities fully. The home has a positive and caring ethos however, there are no direct means through which residents can influence the service delivery. Audits systems need to be developed and formalised further to ensure that residents are consulted regarding all aspects of the service delivery. A formal supervision framework needs to be in place to ensure that all staff are appropriately supervised. Satisfactory record keeping is in place to ensure that residents’ financial interests are safeguarded. Improvement in the home’s safety records and practice are needed to ensure that residents’ safety is not compromised. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 20 EVIDENCE: The registered manager is an experienced registered nurse who has worked at Burnham Lodge for fifteen years. She is supported by a deputy manager who is also an experienced registered nurse. Both the manager and the deputy manager are pursuing the NVQ 4 Registered Managers Award with the ‘Care in the Shires’ training agency. The registered manager is not responsible for any other registered service. Over the previous twelve months, in addition to the NVQ course, the manager attended update training in dementia, fire safety, tissue viability and wound care. The manager’s job description has not been reviewed over the last two years and an appraisal has not taken place within that timescale. Managerial lines of accountability are clear: the manager is accountable to one of the proprietors (not the registered provider). The home has a positive and caring ethos. The registered manager likes to be out ‘on the floor’, setting direction, monitoring the service and leading by example. Residents and relatives may influence the service indirectly but there are no formal direct means through which they have influence. Some meetings have taken place over the last two or three years but were judged not to be constructive and were discontinued. The most recent staff meeting was in November 2005. The manager, deputy manager and one of the proprietors are round and about the home every day and are available to residents, relatives and staff. Staff have been provided with the General Social Care Council (GSCC) Codes of practice. The home does not have a development plan. Developments are decided by the proprietors, decisions being informed through discussion with the manager and others. A stakeholder survey has not been conducted since 2005 and there were no plans to conduct a survey of the quality of the service at the time of the inspection. The intellectual, practical and social skills of residents are maintained through reading, discussion, board games and activities organised by the activities co-ordinator. The home does not have a system for periodically updating policies. The home does not meet timescales set by the Commission for Social Care Inspection (CSCI) for requirements and recommendations. A system of personal supervision of staff is not in place. The home has consulted a Human Resource consultant with regard to establishing a system but the subject has not moved forward since then. Small amounts of cash and valuables such as credit and debit cards are held in the safe for some residents. The home has developed a system to ensure that all incoming and outgoing transactions are recorded. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 21 There was evidence that the fire panel is checked weekly. There was a valid electrical hardwiring certificate of the premises in place. The portable appliance test for the electrical equipment in the building was up to date. The water system had been checked and regulated to control the spread of Legionella bacteria and an up to date certificate was in place. There was evidence that the mobile hoists were serviced on the 13 January 2006. The generic risk assessments in place needed to be updated. COSHH sheets were in place for all hazardous solutions that were being used in the home. The requirement made by the fire officer to replace fire exit signs in areas of the building had been actioned. The updated fire risk assessment of the building was not accessible on the day of the inspection. The manager has agreed to forward a copy of the assessment to the Commission. During a tour of the building it was noted that two bedroom doors on the lower ground floor were wedged open with a plant pot and a footstool. The appropriate door holding devices must be fitted to doors to keep doors open after consultation with the fire officer. A bottle of shampoo and bubble bath were observed in a bathroom on the second floor. Leaving toiletries in bathrooms could pose a safety hazard for residents and could be perceived as toiletries were being shared. The manager confirmed that toiletries were not being shared. Staff are reminded of their responsibility to return residents’ toiletries to their bedrooms after use. Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 2 Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15(2)(b) Requirement The registered manager must ensure that care plans are reviewed monthly. Waterlow assessments and residents’ weights must be maintained monthly. The registered manager must ensure that trained nurses administer medication in accordance with the Nursing and Midwifery Council guidelines. All staff must have their competencies assessed regularly. Regular monitoring of MAR sheets must be carried out. (Previous timescale of 30/11/05 not met). The registered manager must ensure that details of outcome of complaints investigated are kept in the complaints record folder. The registered manager must ensure that an up to date photograph is kept on staff members’ files to confirm proof of identity. The registered manager must develop a supervision framework DS0000019186.V280545.R01.S.doc Timescale for action 30/04/06 2. OP9 13(2) 30/04/06 3. OP16 22(3) 30/03/06 4. OP29 Schedule 2 30/03/06 5. OP36 18(2) 30/04/06 Burnham Lodge Nursing Home Version 5.1 Page 24 6. 7. OP38 OP38 13(4)(c) 13(4)(a) to ensure that all staff receive 6 supervision sessions yearly. (Previous timescale of 31/01/05 not met). The registered manager must ensure that generic risk assessments are kept updated. The registered manager must ensure that residents’ bedroom doors are not kept open with door wedges or other obstacles. 30/05/06 14/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations It is recommened that the registered manager should ensure that regular monitoring of care plans take place. It is recommended that the registered manager should develop a protocol for the administration of Fosamax medication. It is recommended that the registered manager should ensure that all staff authorised to administer medication record their initials on the list provided. It is recommended that the registered manager should review the home’s application form to ensure that it conforms to current guidelines as detailed in the body of this report. 4 OP29 Burnham Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Lodge Nursing Home DS0000019186.V280545.R01.S.doc Version 5.1 Page 26 - 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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