Inspection on 13/09/05 for Burnham Lodge Nursing Home

This inspection was carried out on 13th September 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 Lodge Nursing Home 17/09/08

Burnham Lodge Nursing Home 27/11/07

Burnham Lodge Nursing Home 05/04/07

Burnham Lodge Nursing Home 19/06/06

Burnham Lodge Nursing Home 04/01/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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 147 Berrow Road Burnham-on-Sea Somerset TA8 2PN Lead Inspector Caroline Baker Announced 13 September 2005 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. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address 147 Berrow Road, Burnham-on-sea, Somerset, TA8 2PN 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) 01278 783230 01278 781249 Elderly Medicare Ltd - Mr Lingajothy Mrs Patricia Cox Care home with nursing 21 Category(ies) of Old age (21) registration, with number of places Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Rooms 7, 8 and 14 must only be used for ambulant service users once the service users in those rooms have moved on. 2. 3. Room 9 must be used for persons requiring minimal moving and handling once the service user in that room has moved on. Communal space must be increased to at least 4.1 sq m of space per service user to include a dining area within two years of registration. Date of last inspection 29th November 2004 Brief Description of the Service: Burnham Lodge Care Home is situated on the outskirts of Burnham-on-Sea. It is registered with the Commission for Social Care Inspection (CSCI) for 21 people over the age of 65yrs that require general nursing care. The providers are Elderly Medicare Ltd - Mr Lingajothy. The registered manager is Mrs Patricia Cox. The home has a level patio area for sitting or walking, with a large rear garden where a summerhouse is located. The home has a passenger lift that allows access to the first floor. There are 13 single bedrooms of which 7 have en-suite facilities. There are 4 double bedrooms of which 1 has an en-suite facility. Downstairs there is a lounge and a sitting area with a dining table for service user use. There is a pay phone for service users to use and a cordless phone to receive incoming calls. The home has a nurse call system throughout. Bedrooms have locks on the doors for extra privacy, which are accessible in an emergency. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first announced inspection since Elderly Medicare Ltd purchased the home in July 2005. Mr Lingajothy is the registered individual and Patricia Cox continues to be the registered manager. This inspection took place over one day (6.5 hours) and was conducted by Caroline Baker. Twenty service users were residing at the home. Staffing levels were adequate on the day of inspection. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least eleven service users were spoken with. All the staff on duty during the morning were consulted. Three relatives were spoken to. Patricia Cox, the registered manager, was available throughout the inspection. Mr Lingajothy was available from lunchtime onwards. Throughout the day the inspector was able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. The inspector would like to thank service users and staff for their time and help during the inspection. What the service does well: Burnham Lodge provides a well-maintained, secure and environment, which meets the needs of the current client group. comfortable Service users were observed using the communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Service users were well attired and looked well cared for on the day of inspection. Service users nursed in bed looked comfortable and well cared for. Service users praised the food. A good choice of wholesome food was given. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 6 Service users praised the staff. One comment received was “they are all kind and caring”. Relatives spoken to indicated their satisfaction at the provision of care at the home. Staffing numbers and the skill mix of staff were sufficient to meet the dependency needs of current service users on the day of inspection. Staff spoken with stated that they felt well supported and happy working at the home. Staff consulted confirmed receiving induction and health and safety training. Staff looked and acted in a professional manner. What has improved since the last inspection? What they could do better: Communal space is minimal for service users and there is a condition to the current registration that communal space be increased within 2 years. Service users should have more dining room tables provided to allow them to have a choice of where they sit at meal times. Staff training and induction should be recorded with evidence of staff input. Staff recruitment systems must improve. The present manager should have more support and time allowed to enable her to continue to effectively manager the home and maintain standards. The inspector was satisfied that the provider has taken these matters seriously and that action will be taken within given timescales, therefore feels that the home remains suitable for its stated purpose. 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 D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, and 5. NMS 6 is not applicable to the home. Service users are provided with the information they need to enable them to make an informed choice about moving to the home. Terms and Conditions of stay are issued to service users. The home was not fully able to demonstrate that service users are fully assessed prior to admission to ensure their needs can be met. The home would be able to introduce prospective service users to the home prior to admission. Staff individually and collectively have the skills to deliver the care. EVIDENCE: The home had a current Statement of Purpose at the home for service users and visitors to access. All service users are given a copy of a guide to the home. These were seen in the rooms sampled during the inspection and service users spoken with at inspection confirmed this. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 9 The manager informed the inspector that pre-admission assessments were generally carried out prior to admission. Evidence was seen in the most recently admitted service user’s care plan sampled that a pre-admission assessment had been gained to ensure the home could meet their needs, however as discussed should be dated on the day the assessment takes place, not after admission. Service users are able to visit the home at any time prior to admission. The inspector saw evidence that contracts of the homes terms and conditions were given to service users with their room number reflected. From the sample of service user plans inspected it was confirmed that specialist practitioners advise on some aspects of care in the home, for example, physiotherapy. It could also be seen from this sample, that service users are being admitted according to the home’s admission criteria. The home has a Registered Nurse on duty 24 hours per day supported by care staff. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 10 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, 8, 9 and 10. Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under constant review. Service users have access to health care professionals expertise to meet their individual needs. Service users were protected by the homes procedures in regard to the receipt, administration, recording and disposal of medications. Service users were treated with kindness and respect. EVIDENCE: Three individual service users care plans were examined and the individual service users were met as part of a case tracking process. The care plans were comprehensive. Individual care needs plans contained detailed actions to be taken by care staff to assist with or deliver the care. All care plans reflected current individual care needs. Generic, falls, pressure sore, nutritional and manual handling risk assessments were in place. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 11 Evidence was seen that individual service users had been seen by and had access to a chiropodist, optician, dentist, and GP. Pressure relieving equipment was being used appropriately. Wound care was well detailed. Medication systems were examined to include records of receipt, administration, recording and disposal. Good practice was seen throughout. Service users were treated and addressed appropriately by staff. Care plans reflected preferred names. Service users can lock their bedroom doors from the inside if they wish for extra privacy, and staff would be able to access the rooms from outside in an emergency. Staff were seen and heard to knock on doors before entering service users rooms. Service users spoken to indicated that the staff always treated them with respect. They indicated that they felt well cared for, liked living at the home, that the staff treated them well and that their privacy was respected. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, and 15. Service users at this time do not benefit from a range of activities to suit their individual choices and needs. The home is open to visitors at any time and encourages service users to access the local community. Service users individual choices and needs dictate the routine of the home. Service users are offered a choice of nutritious well-balanced menus promoting their health and well being. EVIDENCE: Activities had been provided at the home however at the time of this inspection there was no activities co-ordinator in post. The manager told the inspector that the home was going to advertise. Trips are organised on a regular basis and a mini bus is hired. Service users spoken to at inspection were happy with the activities that had been provided. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 13 The service user plans showed an assessment for social care and a record each month of the involvement the service user has had in activities. There was a plan of activities on the notice board and service users who were asked said that they had been out in trips, which they had enjoyed. The home has a visitor’s book, which indicated many visitors to the home at varying times. Service users told the inspector that their families and friends were made welcome at the home. It was evident through comments received from service users that they had a choice of daily living. The manager was informed that one service user would like to be given an opportunity to wash themselves in the mornings, the inspector was satisfied that care staff would be informed. All service users were very complimentary about the food. The cook was observed to visit service users during the morning to tell them what was for lunch and offer them an alternative if they wish. A menu is on display in the lounge. The lunch looked appetising on the day of inspection. Puree food was served separately to maintain an appetising appearance. The food is served from the kitchen on individual plates. Service users either sit in the lounge and use a bed table or remained in their rooms and use a bed table. There is a small dining area, which could accommodate four or five people at a table, and this was used. It is concerning that many service users do not leave the lounge all day having to eat their meals, apart from breakfast, there too. A condition of the registration includes communal space to be increased, which will incorporate a dining area within two years. The CSCI will continue to monitor this. The provider informed the inspector that extension work at the home would hopefully commence in March 2006. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 standard(s) 16 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. Steps to reduce the risk of harm or abuse to service users needed tightening up. EVIDENCE: A complaints register is maintained and the inspector was advised that the home has received no complaints. No complaints or concerns have been received by the CSCI regarding the home. Service users consulted knew who to talk to should they have any concerns and the complaints procedure forms part of the service user guide, which is available in each bedroom. The POVA list is now operational. Please see standard 29 where recruitment of staff systems at the home identified some omissions. The majority of staff spoken to on inspection were aware of the Whistleblowing Policy and what to do if they suspected abuse. As discussed ancillary staff must also be made aware. Formal abuse awareness training is recommended for all staff before the end of April 2006. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Service users live in a homely, clean environment where they can enjoy the privacy of their own bedrooms or socialise in communal areas. EVIDENCE: Communal areas and at least fourteen bedrooms were seen at this inspection. The service users are mainly accommodated in single bedrooms, there are shared rooms x four at the home, which are fitted with a wash hand basin, and some have en-suite toilets. Bedrooms are situated on the first and second floor and are accessed by a passenger lift and stairs. Service users are encouraged to personalise their rooms and staff ensure that the privacy and dignity of service users is respected. This was evident at inspection. All service users had accessible locks on their bedroom doors. Service users spoken with informed the inspectors that they were happy with their rooms. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 16 Equipment such as walking aids, grab rails and wheelchairs were available to assist with maintaining independence. During the inspection, service users were observed utilising the communal areas, of a small lounge, and larger TV lounge. As discussed it would have been pleasant for service users to be outside on such a warm sunny day, the manager informed the inspector that service users at the home on the whole did not like going outside. One service user was seen outside with their relatives during the afternoon. The home had adequate specialist bathing and toilet facilities for service users. The home appeared well maintained. Maintenance records were kept, which included routine maintenance. Environmental Health last visited the home in January 2005 when a hygiene award was granted. The Fire Officer visited last in September 2004. The cleanliness of the home was very good at this inspection. There were no offensive malodours. Hand washing facilities were available for staff throughout and included the provision of liquid soap and paper towels. Resources were available to aid in infection control such as aprons and gloves. The laundry area is off the staff recreational area and equipment was adequate. Hand washing facilities for staff are outside the laundry room but close by. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 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, 28, 29 and 30. The home’s recruitment procedures for staff were not robust and did not fully protect service users from the risk of abuse. The numbers and skill mix of staff were appropriate to meet the needs of current service users. Staff morale was good. Recorded evidence of induction and on-going training was poor. EVIDENCE: As part of the inspection process seven staff recruitment files were sampled and examined. The following issues were identified which led to an immediate requirement notice: • • • • • • On four occasions written references were either not signed and/or dated On five occasions there was no photo ID On five occasions there was no copy of a passport or driving licence On six occasions there was no evidence seen of any qualifications gained e.g. any certificates Only one induction programme was seen which had not been completed Staff spoken to confirmed they had received induction and mandatory training however there was no recorded evidence seen Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 18 • • • There were no medical details seen to determine whether the person was fit to undertake the job they were employed to do (these were held in the office upstairs – the manager informed the inspector) There was no recorded evidence of interviews And only one person had a POVAFirst check completed at the time of employment and all had commenced before an enhanced CRB had been returned. As discussed, recruitment of staff must be more robust for the protection of vulnerable adults. The home records a duty rota of staff on duty at all times on a weekly basis. Copies were sent to the inspector as part of the inspection process. These indicated that staffing is set within minimum staffing levels set by the old health authority. Staff and service users spoken to indicated that the staffing levels were always adequate. Evidence was seen that agency staff are used to cover any shortfalls. Regular checks of water temperatures are maintained. Warning signage has been fitted to wash hand basins to reduce the risk to service users from scalding. Emergency lighting was tested monthly, according to current guidance. Staff training at the home is on a rolling programme and includes, for example, NVQ 2 and 3 in care and health and safety training which includes: • • • • • Manual handling Infection control First Aid Basic and Advanced Food Hygiene And Fire Awareness training. 30 of staff had gained an NVQ in care. Staff spoken to confirmed the training they had received. The home is on track to have at least 50 of the staff enrolled for training in NVQ level 2 in care or above by end of 2005. The staff consulted, confirmed induction training, however the inspector only saw incomplete evidence of induction recorded for one domestic. Staff appeared relaxed and happy on the day of inspection and told the inspector that they enjoyed working at the home. Service users complimented the staff group. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 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 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, 32, 33, 34, 36, 37 and 38. The registered manager continues to work very hard to effectively manage the home. The systems in place for 1:1 supervision had not been implemented. The systems in place for ensuring the health and safety of service users and staff were good. EVIDENCE: The registered manager is Patricia Cox and she is a Registered General Nurse. At present Mrs Cox is only managing to have some supernumerary hours and this makes it difficult for her to fulfil the role as thoroughly as she would like, for example staff training, supervision and recruitment. Looking at more support for the manager was discussed with the provider who is taking the matter seriously. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 20 Staff confirmed that the manager of the home was approachable and they would have no problems in discussing any issues. On the day of this inspection, staff appeared happy and a good team spirit was evident. The atmosphere of the home appeared happy and relaxed. The provider had completed his first Regulation 26 visit and had recorded a comprehensive report. A copy was given to the inspector on the day of inspection. Service users and visitors were made aware of the inspection by a poster being displayed on the main notice board. A service user questionnaire format to was seen at inspection. This was yet to be implemented and will be followed up at the next inspection. Formal 1:1 supervision of staff had not yet commenced and this will be followed up at the next inspection. The records seen at inspection were up to date and in line with current legislation. The manager informed the inspector that many policies and procedures were due to be reviewed and this will be followed up at the next inspection. A current Employers Liability Insurance certificate was displayed. The current provider submitted business and financial plans as part of their registration, which evidence financial viability at this time. The service records were as follows: • • • • • • • The hoists had been serviced last on 21/07/05. The passenger lift was last serviced on 24/06/05. PAT records were current. The fire records were examined, the home conducts weekly fire checks the last recorded check was on 08/09/05 The emergency lighting and fire equipment was last serviced on the 16/08/05. Emergency lighting was tested on a monthly basis. The Electrical Hard Wiring was checked 16/11/00 – Due this year. Gas servicing was last done on 18/02/05. Records indicated that staff attended regular fire training. There were a total of 4 accidents recorded since the last inspection. COSHH records were maintained. There have been six deaths at the home in the past 12 months. The home has informed the CSCI of any serious incidents. The kitchen was clean and well organised on the day of inspection and kitchen records were maintained. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 21 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 3 2 3 3 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 3 x 2 3 3 Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 22 NA 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 OP29 Regulation 17(2) Schedule 4(6) and 19, Schedule 2 Requirement The registered person must not allow a person to commence employment until satisfactory checks have been completed in regard to their fitness for the protection of vulnerable adults. An immediate requirment notice was issued. The registered person must maintain induction and training records, signed by the staff and the inductee, in respect of all staff at the care home Timescale for action 13 September 2005 2. OP30 19 15 October 2005 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 OP3 OP12 OP15 Good Practice Recommendations Pre-admission assessments should be dated prior to the admission date. A programme of in-house activities should be implemented as soon as possible. Service users should have a choice to eat at a dining room table and thought should be given to perhaps adding a further table to the small lounge or the large lounge at D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 23 Burnham Lodge Nursing Home 4. 5. OP18 OP31 meal times. The registered person should implement the provision of formal abuse awareness training for all staff by end of April 2006 It is strongly recommended that a deputy manager be appointed to facilitate the development and strengthen the management structure within the home. Burnham Lodge Nursing Home D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL 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 D53-D02 S64241 Burnham Lodge Nursing Home V241845 130905 Stage 4.doc Version 1.40 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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