Inspection on 19/06/06 for Burnham Lodge Nursing Home

This inspection was carried out on 19th June 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 17/09/08

Burnham Lodge Nursing Home 27/11/07

Burnham Lodge Nursing Home 05/04/07

Burnham Lodge Nursing Home 04/01/06

Burnham Lodge Nursing Home 13/09/05

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 David Kidner Key Unannounced Inspection 19th June 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 DS0000064241.V296833.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 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 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) 01278 783230 01278 781249 Elderly Medicare Limited Mrs Patricia Cox Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Rooms 7, 8 and 14 must only be used for ambulant service users once the service users in those rooms have moved on. 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 metres of space per service user, to include a dining area within two years of registration. 4th January 2006 Date of last inspection 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. 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 6 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. All bedroom doors have automatic fire door closures to allow service users to leave their doors open should they wish to do so. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted by one Inspector and lasted one day (9hrs). Nineteen service users were residing at the home. Staffing levels appeared adequate on the day of inspection. The Registered Manager was available throughout the day. The Inspector viewed records in relation to health and safety, staff recruitment, care plans, medicines and staff training records. Most areas of the home were viewed including the kitchen, laundry, dining room and the majority of bedrooms. The Inspector spent a period of time sitting in the lounge area talking to service users and observing care practices and met and spoke to the relatives of four service users. A small number of staff were also spoken to in private and in small groups. The feedback that the Inspector received from all service users was that they were very happy with the care that they received. There were very positive comments about the care team and how well the service users feel supported. As part of the Inspection process the Inspector sent 10 Relative/Visitors Comment Cards and 9 were returned. This is an excellent response. The feedback received from all of the comment cards was that the relatives/visitors were satisfied with the overall care provided and that they are welcome at the home at anytime. All but one comment card stated that they are kept informed of important matters that affect their relative. The vast majority of the comments received were very positive about the care that their relative receives. The Inspector also sent comment cards to the entire care manager/social work team as provided by the Registered Manager. 6 comments cards were sent and three were returned, however other comments were also received from other members of the team. Again, comments were very positive and all returned comment cards stated that they were satisfied with the overall care provided. Three comment cards were sent to the three GP who attend the home. One comment card was returned. The comments again were very positive about the home. The Inspector would like to thank service users and staff for their time and help during the inspection. As a result of this inspection the home has seven requirements and five recommendations. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that staff receive training in dementia awareness, abuse and diabetes and they should receive regular 1:1 supervision. Staff must be offered access to formal qualifications. Care plans are detailed but must be reviewed monthly. The home must provide service users with meaningful activities. The home must ensure that the recruitment process is robust so as to protect vulnerable people. The home must develop quality assurance and quality monitoring systems. The Registered Manager should forward a copy of the homes planned maintenance and refurbishment programme to the CSCI. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 7 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 DS0000064241.V296833.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 4 5 NMS6 is not applicable The outcome for this group is Adequate Service users are provided with information they need to enable them to make an informed choice about moving to the home. The home ensures that service users are fully assessed prior to admission. Staff individually and collectively had the skills to deliver general nursing care but the home currently does not provide staff with training in dementia awareness. Wherever possible service users and their representatives are invited to visit the home before admission. EVIDENCE: The home has Statement of Purpose at the home for service users and visitors to access. All service users are given a copy of a Service User Guide to the home. These were seen in the rooms viewed during the inspection. The Service Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 10 User Guide has been updates to reflect the recent change in provider. This was a requirement at the last inspection and has been met. The home has not admitted any new services users since the last inspection that was conducted on the 4th January 2006. At that inspection the Inspector viewed four care plans and noted that the home had pre-assessed the service users prior to admission to ensure the home could meet their needs. As part of the inspection process and through the case tracking process, the Inspector noted that the care plans viewed also contained detailed pre-admission assessments. Registered Nurses staff the home 24 hours per day. From the records seen and speaking with care staff it was evident that for general nursing needs the staff are collectively skilled to deliver the care. At the previous inspection the Inspector identified and discussed with the Registered Manager the need to provide staff with training in dementia awareness and diabetes, as the home provides care to a number of service users with such needs. This would ensure that the care team would have the skills to meet the physical and mental health care needs of the service users. A Requirement was made at the last inspection to address this need. This requirement has not been met and remains a requirement. Further discussions in relation to this were held with the Registered Manager. The Inspector spoke to a number of relatives at the time of the inspection. One relative stated that they were able to visit the home prior to admission and another stated that they were familiar with the home and were very happy for their relative to move to the home. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 The Outcome for this group is Good. Each service user had an individual plan of care. Some care plans viewed had not been updated. Service users have access to health care professionals to meet their individual needs. The management of medicines at the home has improved. Service users are treated with kindness and respect. Systems were in place to ensure that staff treat service users and their families with care and respect when a service user is very ill. EVIDENCE: The home has detailed care plans that are user friendly and accessible. The Inspector viewed two care plans. Both care plans contained detailed information including waterlow assessments, moving and handling risk Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 12 assessments, nutritional risk assessments, bedrails risk assessments, records of visits by healthcare professionals, weight and day to day running records detailing the care and support provided. However, it was noted that both care plans had not been formally reviewed since March 2006. This was discussed with the Registered manager. The home must ensure that the home formally records that the care plans are reviewed regularly. On the day of the inspection the chiropodist was visiting the home and a number of service users were accessing this service. The Inspector also spoke to a number of service users and relatives who confirmed that they have access to a variety of health care professionals as and when needed. Two GP’s also visited the home on the day of the Inspection. As part of the inspection process the Inspector sent General Practitioners Comment Cards to three of the GP’s that visit the home. The Inspector received one completed comment card. The GP is satisfied with the overall care provided at the home and was complimentary of the services provided. The Inspector viewed the medication systems including the records of receipt, administration, recording and disposal of medicines. At the last inspection conducted on the 4th January 2006 a requirement was made in relation to the management of medicines at the home and following this the Pharmacy Inspector visited the home on the 9th February 2006 and made a number of requirements and recommendations. The Registered manager provided an action plan to address this. At this inspection it was noted that the home has considerably improved in the management of the medicines at the home and had met the requirements and recommendations that were made. On the day of the inspection the Inspector noted that 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 that the Inspector spoke to stated 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. The Inspector also spoke to a number of relatives who also stated that they feel that the care staff treat their relative with dignity and respect. The home has policies and procedures in place for staff to follow when service users are dying to ensure they are cared for with dignity and respect and with sensitivity. Care plans viewed contained information in relation to the service users and their families’ wishes for funeral arrangements. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 13 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): 12 13 15 The outcome group Adequate Service users do not benefit from a range of activities to suit their individual choices and needs. Families are welcomed to the home. Service users are offered a choice of nutritious well-balanced menus promoting their health and well being. EVIDENCE: At the previous inspection conducted on the 4th January 2006 the Registered Manager stated that the home been actively trying to employ an activities coordinator. This has proved unsuccessful. The Inspector spent time sitting in the main lounge area at various times of the day. There were no organised activities taking place and service users were not offered any individual/group activities. The service user guide lists a number of activities that occur it was evident that this is not happening. Some service users stated that they do not wish to take part in organised activities, others commented that they would like more organised activities. Some relatives that the Inspector spoke to commented that there are no activities at the home, other than monthly day trips out in the minibus. On the day of the inspection it was noted that in the Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 14 main lounge area the television was on and one service user was reading the paper. Other service users were occupying their time in their own room by watching television and reading a paper. The home keeps records of activities undertaken but records contained very limited information. The service user guide has a plan of activities reflected which needs reviewing, as the home is not providing in-house social activities at this time. There was no written plan or recorded evidence of any in-house activity provided since the last inspection. It was evident through comments received from service users that they had a choice of daily living and that service users dictated the routine of the home depending on their needs and choices. The Inspector spoke to a number of service users and their relatives. All service users were very complimentary about the food. They told the Inspector about the cook visits them daily for their choice of meal and all those asked and able knew what they were having for lunch. A daily menu is on display in the lounge. The Registered Manager has confirmed that previously the dietician has approved the four-weekly menu. 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. Supplementary fluids were available and given to those service users assessed as high risk of loss of weight or poor appetite. It is very pleasing that the home encourages relatives to support their relative in their eating and drinking needs if so desired. Relatives that the Inspector spoke to were very pleased that they are able to contribute to their relatives care needs in this manner. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 15 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 18 The outcome group for this is Adequate The Complaints procedure has now been updated and included in the service user guide. Staff have not received appropriate training in relation to abuse. EVIDENCE: The home maintains as complaints register. The home had one recorded complaint since the last inspection. The complaint was substantiated. The Registered Manager has taken appropriate action to address the nature of the complaint. The Commission for Social Care Inspection (CSCI) has not received any complaints or concerns regarding the home. The complaints policy has been included in the service user guide. Four of the eight Relatives/Visitors comment cards stated that they did not know how to make a complaint. It is recommended that the Registered Manager ensure that all interested stakeholders are aware of the homes complaints procedure. Service users that the Inspector spoke to were able to say how and whom they would speak to if they had any concerns or worries. Relatives that the Inspector spoke to were clear about who they would speak to if they had any concerns about the care of their relative. The home has a Whistleblowing Policy and policies in relation to abuse. At previous inspections it has been recommended and required that staff must receive training in abuse awareness. This requirement has not been addressed and therefore remains. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 16 Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 17 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 22 23 24 25 26 The quality outcome of this group is adequate The service users live in a safe environment. Some areas of the home would benefit from updating and refurbishing. The home provides adequate bathing, showering and toilet facilities. However, the use of bathing facilities needs to be reviewed. The home provides adequate aids and adaptations. Bedrooms are comfortable and most are personalised. On the day of the inspection the home appeared clean and hygienic. EVIDENCE: The Inspector viewed the lounge area, dining room, kitchen, toilet and bathing facilities, laundry facilities and a number and service users bedrooms. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 18 The home has two bathrooms. One is an assisted bathroom on the ground floor and the other bathroom is on the first floor. The shower facility is also on floor. The Registered Manager stated that the first floor bathroom is very rarely used. The Inspector noted that the record of the hot water temperature in this bathroom was last recorded in September 2005. It is assumed that service users have to use the lift to the ground floor to access bathing facilities. This should be reviewed to ensure that the bathing facilities are easily accessible to service users and that the home has adequate bathing facilities that meet the needs of the service users. The Inspector recommends that the Registered Manager forward a copy of the homes planned maintenance and refurbishment programme to the CSCI. The home has a number of aids and equipment to meet the needs of the service users. These include hoists, pressure relieving equipment, assisted bathing facilities, grab rails and wheelchairs. The Inspector noted that on a couple of occasions footplates were not in situ when service users were using the wheelchair and being escorted by staff. It was also noted that a sling being used to hoist a service users did not appear to be used correctly. The Inspector raised these concerns with the Registered Manager at the time of the inspection. The Registered Manager stated that this would be looked into immediately and then wrote to the Commission for Social Care and Inspection to state that these matters has been addressed with the care team. At the previous inspection the home had a requirement to ensure that service users had easy access to a call bell. Service users the Inspector spoke to stated that they have access to a call bell and staff respond quickly when they are called. Following a requirement at the previous inspection the home has developed a checklist in relation to the maintenance of bed rails and a person is responsible for these checks. It was noted that monthly checks had been conducted in April, May and June 2006. At the previous inspection an Immediate Notice was issued at the home had admitted a service user who had manual handling needs into a room for ambulant people. The home has now made alterations to this room to increase its size. All service users spoken to stated that they were happy with their bedrooms. The Inspector spent a considerable amount of time talking to service users in their bedrooms. The bedrooms were personalised and contained many personal possessions such as photographs of loved ones, soft furnishings, television, radio, flowers, greetings cards, personal furniture and personal furniture. However, it is the Inspectors opinion that some bedrooms are in need of redecorating. The home maintains records of hot water temperatures. The home has formulated a chart to record the cleaning regime to prevent the build up of Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 19 bacteria in the taps and showerheads. This is following a visit from Somerset County Council following a Legionella inspection. On the day of the inspection the home appeared clean and hygienic. There were no offensive malodours. Hand washing facilities were available for staff throughout and included the provision of liquid soap, alcohol gel and paper towels. Resources were available to aid in infection control such as aprons and gloves. There were no changes to the laundry systems. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 20 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): 27 28 29 30 The outcome group is adequate Staffing levels appeared adequate at the time of inspection. The home needs to ensure that care staff obtains appropriate qualifications. The home’s recruitment process needs to be more robust to ensure that vulnerable people are protected. EVIDENCE: The Inspector viewed the rotas provided and noted that the home has a Registered Nurse on duty 24hrs a day. There are usually four care assistants on duty of a morning and three care assistants on duty of an afternoon/evening. There is a qualified nurse and one care assistant on duty at night. The home has been using agency staff consistently for night duty. The home employs 14 care staff. The Registered Manager has advised that the home has two care assistants qualified to NVQ2 and there are three care assistants currently undertaking this qualification. This equates to 15 of the care assistants. The Registered Manager must develop an action plan to ensure that 50 of care staff are trained to NVQ Level2 or equivalent. The Inspector sampled the recruitment files of four of the most recently appointed staff. POVA First checks had been completed and Enhanced CRB obtained. The Inspector had discussions with the Registered Manager in Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 21 relation to the documentation that needs to be in the recruitment files and checks that need to be made. These included: • • • • • • • References should be dated Employment history gaps explored and reasons recorded. Education history should be completed Copies of formal qualifications held on file. Risk assessments conducted if needed. Health declaration forms completed by all applicants and dated. Written references obtained following verbal reference. The Registered Manager must ensure that the recruitment files contain all appropriate documentation as listed in Schedule 2 of the Care Homes regulations 2001. The Registered Manager confirmed that all newly appointed staff receive a period of Induction with records kept. A previously mentioned the home must arrange specific training for staff including dementia awareness and diabetes training. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 22 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 33 36 38 The outcome group is adequate. The Registered Manager works hard to manage the home. The home does not have an effective quality assurance and quality monitoring systems. The systems in place for 1:1 supervision had still not been implemented. The home strives to promote health and safety. EVIDENCE: The Registered Manager is Patricia Cox and is a Registered General Nurse. At present Mrs Cox is only managing to allocate minimum hours of supernumerary time and this makes it difficult for her to fulfil the role as thoroughly as she would like. This may be of detriment to staff training, Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 23 supervision and reviewing of care plans. The Registered Manager appears very committed in ensuring service users receive a quality service. It was a requirement at the last inspection that consideration is given to appointing a deputy manager. Discussion took place in relation to this, as this has not been pursued as yet. A requirement was made at the last inspection that the Responsible Individual visits the home at least once a month, unannounced and compiles a report of their findings. Copies have been sent to the CSCI. It is requested that these continue to be forwarded to the CSCI each month. The home has not developed formal methods of seeking the views of service users and other interested stakeholders as part of the home’s quality assurance and quality monitoring systems. The home does not conduct service user meetings, service users satisfaction surveys and surveys to carers/relatives and health care professionals. This must be addressed. At the previous inspection the Inspector examined the systems in place at the home for service user monies and personal allowances. Records are kept on the homes computer database with individual records and receipts kept on file. The Inspector did not view such records at this inspection. Discussions took place in relation to staff receiving formal 1:1 supervisions with records kept. These are still not happening and were raised at the previous inspection. Again this may be due to the Registered Manager not being able to allocate time to address this. This should be addressed without delay. The Inspector viewed a number of records in relation to health and safety. The service records were as follows: • • • • The hoists had been serviced last on 19/01/06. The passenger lift was last serviced December 2005. The fire records were examined, the home conducts weekly fire checks the last recorded check was on 28/12/05. The emergency lighting and fire equipment and fire system were last serviced on the 01/03/06. The home also conducts monthly checks on the emergency lighting system with records kept. Staff receive fire training. The Electrical Hard Wiring was checked 03/03/06. The Registered Manager must ensure that any recommendations identified at that inspection are addressed. The Gas servicing was last done on 18/02/05. The Registered Manager advised that the next service visit has been arranged for 26/06/06. • • Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 24 As previously stated the home now keeps records of the maintenance checks on bedrails and the action taken if needed. Records are maintained of fridge and freezer temperatures and a cleaning rota had been developed. The home has recently purchased two new fridges. Accident records were not viewed at this inspection. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 2 X 3 Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation 12(1) 18 (a) Requirement Timescale for action 31/08/06 2. 3. OP7 OP12 15 (2) (b) 16(m) (n) 4. OP28 18 (1) The Registered Manager must arrange specialist awareness training for staff in Dementia and Diabetes to ensure the home can meet the current service users health care needs. (Previous timescale of 20/03/06 not met) The Registered Manager must 31/07/06 ensure that all service users care plans are kept under review. 30/09/06 The Registered Manager must ensure that a programme of planned activities and one-one social care is implemented in consultation with service users and/or their representatives without delay to satisfy individual service users social and recreational interests and needs. (Previous timescale of 30/01/06 not met) The Registered Manager must 31/08/06 develop an action plan to ensure that 50 of care staff are trained to NVQ Level2 or equivalent. Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 27 5. OP29 19 6. OP33 24 7. OP38 13(4) The Registered Manager must 31/07/06 ensure that the recruitment files contain all appropriate documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The Registered Manager must 31/10/06 develop effective quality assurance and quality monitoring systems. The Registered Manager must 31/08/06 ensure that the recommendations made at the time of the electrical hardwiring being checked are addressed. The hardwiring certificate was issued and dated 03.03.06. 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 OP16 OP21 OP24 Good Practice Recommendations It is recommended the Registered Manager should ensure that all interested stakeholders are aware of the homes complaints procedure. The Inspector recommends that the Registered Manager should forward a copy of the homes planned maintenance and refurbishment programme to the CSCI. It is recommended that the Registered Manager should take into consideration the redecoration of service users bedrooms as part of the refurbishment and redecoration programme. It is recommended that the Registered Manager should record the identified employment history gaps and ensures that the author dates references received. It is strongly recommended that the Registered Manager should introduce formal 1:1 supervisions with records kept. 4. 5. OP29 OP36 Burnham Lodge Nursing Home DS0000064241.V296833.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor 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 DS0000064241.V296833.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!