Inspection on 23/08/05 for Burnham Lodge Nursing Home

This inspection was carried out on 23rd August 2005.

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 13/02/06

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 Announced 23rd August 2005 9:30am 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address Parliament Lane, Burnham, Bucks, SL1 8NU 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) 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2004 Brief Description of the Service: Burnham Lodge is a care home providing nursing and personal care and accommodation for residents who are elderly and physically frail. On the day of the inspection there were 46 residents living in the home. 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 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 23rd August 2005 from 09.30 am to 18.00 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 and records. The lunchtime meal was observed and a tour of the building was carried out. Nine residents completed comment cards. Overall they were very happy with the care provided and felt that staff respected their privacy and dignity. The following positive comments were noted: “Everybody is very nice, caring and very helpful.” “The home is always clean and smells fresh.” “I could not have chosen anywhere better to live”. Relatives, care managers, and health and social care professionals also completed comment cards. Overall they were happy with the care provision. They felt that the manager and her staff team were sensitive to residents’ needs, and were helpful and supportive. Feedback was given to the manager at the conclusion of the inspection. What the service does well: The home provides a pleasant and comfortable environment in which residents can live. There is a caring staff team who ensure that residents’ care needs and appearance are well maintained. Interaction between staff and residents was noted as kind and caring. This was reinforced through residents’ comments. The home has an excellent chef who provides a good choice of meals. Fresh fruit, home made biscuits and cakes are readily available daily. The home employs a dedicated activity organiser and there is a daily activity programme in place. Residents’ birthdays are celebrated. Visiting is ‘flexible.’ The home maintains a good relationship with the general practitioner. Residents and staff benefit from a supportive manager who assists in providing hands on care. The home has a stable senior staff team. Burnham Lodge Nursing Home Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burnham Lodge Nursing Home Version 1.10 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 Version 1.10 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 &5 The home has a concise and informative statement of purpose but it does not include information on how to contact the local social services. This could be improved to fully meet the standard if it includes the list of current staff and room sizes. Information relating to ‘Terms and Conditions’ of residence is in place to ensure residents are clear about the range of services offered. However, the document could be improved further by including fees payable and the room number residents would be occupying. EVIDENCE: The home revised its statement of purpose in June 2005. This concise and informative two-page document includes most of the information required under Schedule 1 of Regulation 4. If the list of ‘current staff’ and ‘room sizes and details’ as supplied for the inspection (and available from the administrator as stated at the end of the document) were attached as appendices the document would fully meet this aspect of the standard. Burnham Lodge Nursing Home Version 1.10 Page 9 It is recommended that the list of staff names and room sizes should be attached as appendices this would ensure that the document meets the standard. The home does not have a service users’ guide. It has a brochure, which outlines its philosophy, former use and location. There is a brief description of the accommodation, staffing, services provided, special facilities, safety precautions, recreation and general care. The document does not state the number of places, inspection reports, the complaints procedure or service users’ views of the home. The statement of purpose and the brochure do not provide contact information for the local social services or health services authorities. The document entitled ‘Terms and Conditions of Residence’, includes information on medical services, medication, times of meals, advice on marking property and obtaining insurance for personal valuables, the arrangements for dry cleaning, telephones, visitors, and finally the terms and conditions which are outlined in thirteen paragraphs. The document does not state the room to be occupied or the fees payable. Referrals to the home may be made direct by individuals or through health or social services agencies. Referrals through health or social services will include an assessment of the needs of the person. Private referrals will require further enquiry in order to assess whether the home can meet the needs of the person. In all cases the manager or deputy manager conducts an assessment prior to admission. A form, which structures the process, is completed. On admission a more detailed assessment of needs is carried out using the relevant section of the Standex care plan. The assessments on care plans examined were thorough and of a very good standard. The assessment forms the basis of a plan of care, which, as indicated above, is recorded on the Standex system. Those examined were generally of a good standard but it was noted that in one case the use of the term ‘confusion’ was not explained (in terms of the nature and presentation of the ‘confusion’) and that the care plan of a resident prescribed Prozac (Fluoxetine – an antidepressant drug) did not include reference to monitoring of mood. The range of needs met which are briefly outlined in the statement of purpose, the pre-admission assessment and liaison with other professionals (where involved) aims to ensure that the home does not admit someone whose needs it cannot meet. General and specialised healthcare is accessed either through the general practitioner (GP) or through direct contact with the practitioner. Prospective residents may visit the home prior to admission and both the statement of purpose and the terms and conditions include reference to a stay for a trial period. Burnham Lodge Nursing Home Version 1.10 Page 10 Burnham Lodge Nursing Home Version 1.10 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 standard(s) 7, 8 & 9 Care plans are in place however, they need to be more detailed and kept under review to ensure that staff are meeting residents’ identified needs. Care plans examined indicated that residents’ health care needs were being met appropriately. However, care plan protocols relating to diabetes, catheter care, warfarin and wound care treatment could be developed further. 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. EVIDENCE: Care plans for three residents who were suffering from tissue ulcers were examined. It was noted that changes in the treatment of ulcers were not always reflected in the care plans. Progress on individual’s ulcers was not always recorded in the daily report. For example, it was noted for a particular resident that the treatment regime of a pressure ulcer was reduced to weekly. However, this information was not reflected in the care plan. Information recorded in the daily report sheet read as follows: ‘Dressing changed.’ Staff Burnham Lodge Nursing Home Version 1.10 Page 12 were not recording the size and colour of the ulcers and were doing themselves a disservice by not detailing more detailed information. Waterlow assessments were in place and appeared to be regularly updated. It was noted that several residents were suffering with incontinence and management plans were in place. It is required that the manager develop protocols for individuals relating to diabetes, warfarin, catheter and wound care treatment. A PRN medication management plan should also be developed. The medication administration record (MAR) sheets were examined. Ten gaps were noted on sheets. Staff were not using the codes recorded on the MAR sheets to denote the reason for not administering medication. Some entries were scribbled over. Inconsistencies in staff’s recording were noted. 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 complete’, ‘stopped by the GP’, and date and sign the entry. Not all nursing staff were recording individuals’ pulse rates when administering Digoxin medication. However, it was noted that a particular resident was prescribed for Amitryptiline medication which is an antidepressant one or two tablets at nights and staff recorded on the MAR sheet the number of tablets administered. It was noted that some staff were recording a tick instead of their signatures when administering creams. The manager is required to carry out regular auditing of the MAR sheets. 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 also be kept for inspection purposes. The controlled drug register was examined. The stock levels of drugs in the cupboard corresponded to balances in register. Burnham Lodge Nursing Home Version 1.10 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 standard(s) 12 & 15 The home has a varied activity programme in place to ensure that residents’ social and recreational interests are catered for. The presentation and quality of the food was of a high standard. This ensures that residents’ dietary needs are catered for. EVIDENCE: Residents have a choice as to how they spend their day. A daily selection of activities is provided for residents. A list of the week’s activities is circulated to all residents. Each month a professional entertainer performs to residents and a cultural lunch is prepared by the chef. Residents and staff were complimentary of the recent African lunch that the chef had prepared. On the day of the inspection residents participated in a newspaper discussion in the morning and a game of scrabble in the afternoon. Some residents chose to sit in the garden and enjoyed the warm sunshine. Residents spoken to were complimentary about the activity organiser’s dedication and felt that adequate provision was being made to ensure that their social needs were being met. Unfortunately, the home is no longer able to provide shopping trips. Some residents who have no relatives miss this valuable service. Burnham Lodge Nursing Home Version 1.10 Page 14 The lunchtime meal was observed. There are two sittings at lunchtime. Residents who need assistance or prompting are served at the first sitting and staff were seen assisting them in a discreet manner. The choices on offer at lunchtime were grapefruit segments for starters. Chicken casserole or fivespice rice with prawns and peas were on offer as the main course with parsley potatoes, carrots and spring greens. Dessert was semolina pudding or ice cream. Residents were complimentary about the quality and presentation of the food. The following comments were noted: “The food is excellent”. “We are offered a wide variety of choices, the portions are very large”. “We are well fed.” “The chef is excellent and would always provide us with an alternative if we do not like what is on offer.” Lunch was sampled, and it was tasty. Tables were appropriately set with colour co-ordinated tablecloths, napkins, cutlery and condiments. There was a good ambience. Residents were observed talking to each other and lunchtime appeared an enjoyable and social occasion. Burnham Lodge Nursing Home Version 1.10 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 standard(s) 16, 17 & 18 The home home’s complaints policy and procedure need to be improved to ensure the views’ of residents would be heard and acted upon. Staff have undertaken training in adult and abuse awareness. With clear guidelines and adoption of procedures this should ensure that residents are protected from any potential abuse. EVIDENCE: Since the last inspection the Commission for Social Care Inspection received a complaint about the home. The home was given the opportunity to investigate and the manager responded to the complaint. The complaints policy includes reference to a complaints book but this appears to refer only to complaints received in writing. The home does not retain a record of oral complaints. The complaints procedure is displayed on a notice board in the home, and is outlined in the statement of purpose and in the ‘terms and conditions of residence’. The reference in the last named should be amended when the document is reprinted. It says ‘If the complaint is unresolved then the Resident and/or relative must refer the matter to the Registration Authority’. There is no obligation on a complainant to refer the matter to the Commission for Social Care Inspection (CSCI) if unresolved with in the home. At the same time, however, a complainant may refer the matter to Commission for Social Care Inspection at any stage (standard 16.4) if they wish. The reference in the statement of purpose to the Commission for Social Care Inspection is correct. The policy states that complaints are to be audited Burnham Lodge Nursing Home Version 1.10 Page 16 yearly by the Matron but records of such an audit were not available. The home’s procedure and associated documents would benefit from review All residents are registered to vote and some did so in recent elections by opting for a postal vote. The home does not publicise details of an advocacy organisation. The registered manager said that, through social services, they have used Age Concern in Slough in the past. The home has policies on the Protection of Service Users, Abuse and on the application of the Protection of Vulnerable Adult (POVA) register. While there is a degree of overlap between these policies and some scope for rationalisation and updating they are also evidence that the home does take the subject seriously. At the time of this inspection it did not have a copy of the current Buckinghamshire joint agency guidelines or details of the ‘Careline’ confidential reporting telephone line. The subject of abuse is covered in the induction of new staff to the home although the registered manager said that there is not a specific reference to it in the ‘TOPSS’ (now ‘Skills for Care’) induction, which the home has now started to use. The home has a policy, which provides guidance to staff on dealing with aggression. There are policies and procedures governing the management of residents’ monies Burnham Lodge Nursing Home Version 1.10 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 standard(s) 19, 24 & 26 The home is well maintained, pleasantly decorated and furnished to meet the needs of the frail elderly. This provides residents with an attractive, safe and homely place to live. 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. The premises were recently inspected by the local fire service and some requirements were made and they were being addressed by the proprietor. The home has had a new pitch roof erected on the right hand side of the premises. Several bedrooms had been refurbished and floor coverings replaced. A footpath for wheelchairs had been developed in the grounds and fruit trees planted along the edges. Burnham Lodge Nursing Home Version 1.10 Page 18 Six residents’ bedrooms were examined. Some minor alterations were carried out to two of these bedrooms. The shower facility in one en suite had been replaced with a wash hand basin and water closet. Some bedrooms had been redecorated and floor coverings replaced. Bedrooms were personalised with family pictures, mementoes and personal furniture. Residents stated that their bedrooms were cleaned daily and smelt fresh and, they felt safe and comfortable with their own possessions around them. 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 adhered to. On the day of the inspection the home was clean and free from offensive odours. Residents spoken to confirmed that the communal areas are cleaned twice daily. It was noted that in some areas of the home waste bin covers were missing. It is required that waste bins are replaced with the foot pedal type to prevent the spread of cross infection. Burnham Lodge Nursing Home Version 1.10 Page 19 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 & 30 On the day of the inspection an appropriate number of staff were on duty to meet the needs of residents. The home’s procedure for the recruitment of permanent staff needs to be more rigorous to ensure that residents are protected. Arrangements are in place to ensure that staff have access to training. This would ensure that staff have the skills to care for residents. EVIDENCE: In its pre-inspection papers the home reported that it had 29 residents with medium needs and 6 residents with low needs. The registered manager said that dependency is based on RNCC (Registered Nursing Care Contribution) input and the home’s own assessment processes. Current staff numbers are based on historical assessments of the number of staff required but are considered adequate. The home aims to have 8 care staff (including 2 registered nurses) in the morning, 5 or 6 care staff (including 1 or 2 registered nurses in the afternoon) and 4 care staff (including 1 registered nurse) at night. In addition to care staff the home employs catering, administration, laundry, domestic and maintenance staff. At the time of this inspection the home employed 10 registered nurses. As far as National Vocational Qualification NVQs are concerned, one member of day staff had NVQ 3 and three had acquired NVQ 2. Three staff were pursuing NVQ Burnham Lodge Nursing Home Version 1.10 Page 20 2. The registered manager estimates that 33 of staff are qualified to NVQ 2 or above. Staff vacancies are advertised in local newspapers. Applicants are required to complete an application form, supply the names of two referees, and attend an interview. Successful applicants are required to have an enhanced Criminal Record Bureau (CRB) certificate obtained through an ‘umbrella organisation’ (i.e. an organisation authorised to process such applications to the CRB). Nurses’ qualifications are checked with the Nursing and Midwifery Council. The home’s application form should be updated because applicants are not required to state why they left their last job. This is now a requirement where an applicant has previously been in a care position for more than three months. The home is now starting to use the TOPSS induction. The probation period for new employees is one month. Four staff files were examined. In three of the four files an application form had been completed. In one case the status of open references did not appear to have been verified. CRBs were generally in order although in one case the member of staff appeared to have worked in the home for three days before a ‘POVA first’ was received and in another the member of staff appeared to be working under ‘POVA first’ arrangements for some months. This appears to have been due to an oversight on the part of the umbrella organisation and the CRB was faxed on the day of the inspection and was in order. Details of the induction process for new staff were not on file. The quality of notes taken by a member of the interviewing panel was good. The registered manager should establish a system of close monitoring of procedures in order to ensure full compliance with this standard and in particular that staff files contain the information currently required under Schedule 2. Arrangements for the organisation of staff training appeared to be in a state of change and have improved since the last announced inspection. One of the registered nurses was assuming a lead responsibility for some aspects of training and was building up information on training needs, records of training carried out or planned and of training providers. Buckinghamshire social services had recently circulated details of a five-day induction programme and the home expressed interest in using this. Recent training had included moving & handling, protection of vulnerable adults, training the trainer in the protection of vulnerable adults, dementia care and fire awareness. The programme for the autumn included medicines, falls management, moving & handling, protection of vulnerable adults and dementia. Three staff were pursuing NVQ 2. Burnham Lodge Nursing Home Version 1.10 Page 21 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) 35, 36 & 38 Arrangements need to be put in place to ensure that residents’ financial interests are safeguarded by good record keeping. The home needs to develop a robust supervision framework to ensure that staff are supported and supervised in providing quality care to residents. Overall systems are in place to protect residents’ safety. However, fire risk assessments and procedures need to be reviewed. EVIDENCE: Burnham Lodge Nursing Home Version 1.10 Page 22 The administrator confirmed that small amounts of cash are held in the safe on behalf of some residents. However, the system needs to be developed further and records kept of all incoming and outgoing payments. To date the home has not progressed in establishing a programme of regular supervision for all staff. The manager is required to develop a supervision framework. All staff should receive formal supervision at least six times yearly. There was evidence that the boilers and the central heating system were serviced regularly. A recent service took place on the 20/8/05. There was a valid electrical hardwiring certificate of the premises in place. The cold water system had been regulated to control the spread of Legionella bacteria. This was completed in April 2005. The Stannah chair lift and moving and handling hoists were serviced in April 2005. There was evidence that the Portable Appliance Testing for all electrical equipment in the building had taken place recently. There was evidence that the fire panel, fire appliance and call bell system are regularly serviced. Records indicated that window restrictors are visibly checked weekly. The local fire service department recently inspected the home and it was noted that the current fire certificate risk assessment for the premises required updating. There were also a number of fire exit signs that did not display the ‘running person’ pictogram. It was also noted during the inspection that some confusion could arise with the exit procedures from the area at the top of the staircase adjacent to the lift, at both first and ground floor levels. To avoid confusion signage should be provided to indicate the shortest of travel to a place of safety. The manager is required to ensure that all staff undertake a minimum of two fire drills yearly. Burnham Lodge Nursing Home Version 1.10 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 x x x x 2 1 x 2 Burnham Lodge Nursing Home Version 1.10 Page 24 YES 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 1 Regulation 4&5 Schedule 1 Requirement The registered manager must amend the Statement of Purpose and Brochure as outlined in Standard 1 in this report (Previous timescale of 31/01/05 not met) 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. The registered manager must develop the homes complaints folder to ensure that all verbal complaints are recorded with satisfactory outcomes. The registered manager must ensure that records are kept of all incoming and out going payments relating to residents money. The registered manager must develop a supervision framework to ensure that all staff receive 6 supervision sessions yearly. (Previous timescale of 31/01/05 not met). The fire risk assessment for the Version 1.10 Timescale for action 30/01/06 2. 2 13(2) 30/11/05 3. 22 16 30/11/05 4. 35 10(1) 30/11/05 5. 36 18(2) 30/11/05 6. 38 13(4)(a) 30/11/05 Page 25 Burnham Lodge Nursing Home building needs to be updated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations It is recommened that the registered manager should ensure that care plans inter-relate with health intervention sheets. Daily report writing should reflect detailed information of the care that is being provided. It is recommended that the manager should develop protocols relating to diabetes, warfarin, catheter care and wound care. It is recommended that the manager should develop a PRN pain management plan. It is recommended that the manager should review the homes application form as outlined in standard 29 It is recommended that the manager should ensure that staff undertake a minimum of two fire drills yearly. 2. 3. 4. 5. 8 9 29 38 Burnham Lodge Nursing Home Version 1.10 Page 26 Commission for Social Care Inspection Cambridge House, Smeaton Close 8 Bell Business Park, Aylesbury Buckinghamshire 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 Version 1.10 Page 27 - 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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