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Inspection on 30/05/06 for Burnham Lodge Nursing Home

Also see our care home review for Burnham Lodge Nursing Home for more information

This inspection was carried out on 30th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home 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. Comments received from residents and relatives and other health care professionals indicated that they were satisfied with the provision of care. Interaction between staff and residents was noted as kind and caring. This was reinforced through residents` comments. The home`s chef provides a good choice of meals. Fresh fruit and vegetables, home made biscuits and cakes are readily available daily. The home employs an activity organiser. Residents` birthdays are celebrated. Visiting is `flexible.` The home maintains a good relationship with the general practitioner. The home`s domestic supervisor carries out daily checks on the standard of cleaning in residents` bedrooms and other areas in the building. Residents and staff benefit from a supportive manager who assists in providing hands on care.

What has improved since the last inspection?

Generic risk assessments have been updated. Dor-gards have been fitted to those residents` bedroom doors who wish to keep them open during the day. A protocol for the administration of Fosamax medication had been developed. The home`s application form had been reviewed to conform with current guidelines. Several bedrooms have been refurbished. The chef carries out a monthly safety check on the kitchen and a service manager carries out a three-monthly audit check. Additional bench seats have been purchased for the garden. Lighting in public areas has been upgraded. Brambles in the gardens have been cleared thus reclaiming further areas of grass.

What the care home could do better:

Copies of residents` pre-admission assessments must be available and confirm that residents` needs have been assessed before admission and that the home is able to meet the individual`s needs. The prospective resident and his or her representative have been involved in the process. Care plans must be reviewed monthly. Waterlow assessments and residents` weights must be maintained monthly. Any change to the frequency of medication must be reflected on the medication administration record sheet and signed by the general practitioner. Regular monitoring of the medication administration record sheets must be carried out. Two staff members should check and sign for the receipt of controlled medication. All staff should be consistent and date and sign the medication administration record sheet when antibiotic treatment has been completed. The drug fridge temperature record should be maintained. Tippex correction liquid and written over entries on the medication administration record sheets must cease. An up to date photograph must be kept on staff member` files to confirm proof of identity. Missing covers on general waste bins must be replaced to prevent the spread of infection. The clinical waste bin must be fitted with a lock to prevent the spread of infection and vermin gaining access. Restrictor valves on hot water taps in bedrooms in the basement must be adjusted to ensure the temperature in hot water outlets remain close to 43 degrees Celsius.

CARE HOMES FOR OLDER PEOPLE Burnham Lodge Nursing Home Parliament Lane Burnham Bucks SL1 8NU Lead Inspector Joan Browne Unannounced Inspection 30th May 2006 09:45 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 DS0000019186.V290130.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000019186.V290130.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address Parliament Lane Burnham Bucks SL1 8NU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01628 667345 Burnham Lodge Ltd Catherine Mary Bronock Mrs Jo Davidson Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places DS0000019186.V290130.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. General Nursing Care maximum 46 Personal Care maximum 6 One service user under the age of sixty five as identified in the Application for Variation Form, Section 4.2, signed and dated 5th May 2004. 13th February 2006 Date of last inspection Brief Description of the Service: Burnham Lodge is a care home providing nursing and personal care for residents who are elderly and physically frail. The home has 32 single rooms and 7 shared rooms, which are situated on three floors. On the day of the inspection there were forty-two residents living in the home. Access to floors can be gained via a passenger and stair lift. The home is a large country house set in tranquil surroundings backing on to woodlands situated at the edge of Burnham Beeches. There are extensive gardens, which are well maintained. Public transport and other amenities are not easily accessible. The current scale of charges at the time of writing this report ranges from £600.00 to £800.00 weekly. DS0000019186.V290130.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 30 May 2006 from 09.45 am to 16.00 pm. The lead inspector was Ms Joan Browne who was accompanied by Mike Murphy (Inspector). The inspection consisted of discussions with residents and staff, examination of care documentation, records and a tour of the building. Comment cards were received from eight residents, eight relatives, two care managers, and two health and social care professionals and the general practitioner. Comments received were generally favourable. The following comments were noted: “I am always confident when I place at Burnham Lodge that the client will receive good care.” “Very helpful staff, good interaction with residents, key people and other professionals.” “Outstanding nursing care and recreational.” The evidence seen during the inspection and comments made by residents and staff indicated that the home meets residents’ diverse needs. For example, residents’ religious, dietary and disability needs are catered for. The requirements and recommendations from the previous inspection were discussed. An action plan (now known as an improvement plan) in relation to these requirements and recommendations was not submitted to the Commission. The manager is required to submit an improvement plan to the Commission in response to requirements and recommendations from this inspection. Feedback was given to the manager on the findings 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. Comments received from residents and relatives and other health care professionals indicated that they were satisfied with the provision of care. Interaction between staff and residents was noted as kind and caring. This was reinforced through residents’ comments. The home’s chef provides a good choice of meals. Fresh fruit and vegetables, home made biscuits and cakes are readily available daily. The home employs an activity organiser. Residents’ birthdays are celebrated. Visiting is ‘flexible.’ The home maintains a good relationship with the general practitioner. The home’s domestic supervisor carries out daily checks on the standard of cleaning in residents’ bedrooms and other areas in the building. Residents and staff benefit from a supportive manager who assists in providing hands on care. DS0000019186.V290130.R01.S.doc Version 5.1 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000019186.V290130.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019186.V290130.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were no records available to confirm that the home’s staff had carried out pre-admission assessments before admission to which residents or their representatives had been party to. EVIDENCE: Pre-admission assessments were requested for three recent admissions (the fourth resident had been admitted in 2001). The homes own pre-admission assessments could not be located on the day of the inspection. A preadmission assessment of one resident by the referring social worker was available in one case. This was comprehensive and provided sufficient information for the home to determine whether it could meet the prospective residents needs. A requirement is being made that copies of pre-admission assessments for residents are available and confirm that residents’ needs are assessed before admission. That the home is able to meet individuals’ needs and that propsective residents or their representatives had been involved in the process. DS0000019186.V290130.R01.S.doc Version 5.1 Page 9 DS0000019186.V290130.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ health and personal care needs were being met. However, care plans, Waterlow assessments, and residents’ monthly weights were not being reviewed and maintained monthly. There was no written evidence to support staff’s good practice in relation to monitoring individuals’ tissue viability and fluid balance intake. Weaknesses identified in staff’s practice in the recording and administration of medication has the potential to put residents at risk. EVIDENCE: The home uses the Standex care planning system. Four care plan files were examined. The standard of record keeping was variable. It does not operate a key worker system. Some sections of the front sheet of the record had not been completed. The long- term assessment was very well completed in three of the four records examined. In the fourth record many sections had not been completed. The particular resident had been residing in the home for seven weeks. The residents spouse had died ten days before admission. This information had, it is felt, been inappropriately recorded in the section on DS0000019186.V290130.R01.S.doc Version 5.1 Page 11 sexuality. There were no further references to the residents bereavement in the records examined. The Waterlow pressure sore risk assessment had been completed soon after admission but had not been updated. The moving and handling assessment had not been completed and the box on whether there was a history of falls had not been ticked. The record did not include weight or height. The care plan for a particular resident who was being nursed in bed was examined. There was an action plan in place detailing that the individual should be cared for in bed. However, there was no written evidence such as a turning chart to indicate that the individual was being regularly turned to prevent tissue ulcers. It was identified that the individual was prone to constipation and staff should offer 200 mls of fluids hourly. However, there was no fluid balance chart in place to support staff’s practice. It is acknowledged that the following was recorded in the individual’s daily report: ‘fluids taken well.’ This information was not detailed and there was no written evidence to indicate that the individual was having 200 mls of fluid hourly as identified in the care plan. The Long Term Assessment in the other three records examined had been well completed. These included appropriate and good quality records on mental state. Waterlow assessments had been carried out but not updated (in one case with a score of 19 (high risk). The handling assessment had been completed but the box on history of falls had not been ticked in all cases. This seems a serious omission in a home for older people. Care plans based on the assessments seemed appropriate to the residents assessed needs. Care plans did not show evidence of the residents involvement in the process or of their agreement (where possible). Daily records were predominantly orientated towards recording physical care provided. However, it was noted that this did include reference to the implementation of the care plan, which is a good practice. The home aims to review care plans monthly but had failed to achieve this in the records examined and the frequency of reviews seemed particularly variable between October 2005 and May 2006. The registered manager and deputy manager said that they were endeavouring to resume monthly reviews again from June 2006. At the last inspection a requirement was set to ensure that care plans, Waterlow, moving and handling risk assessments are reviewed monthly. This requirement had not been complied and is being repeated. Healthcare services are accessed through the general practitioner or through direct contract with a practitioner. The home has access to district nurses and to the advice of a tissue viability nurse as required. The registered manager said that there were no tissue ulcers at the time of this inspection. It has pressure-relieving mattresses if required. A specialist National Health Service nurse in continence provides advice on catheter care (eight residents had catheters). Psychological support is provided during the course of care work. DS0000019186.V290130.R01.S.doc Version 5.1 Page 12 Nutritional screening is basic - residents likes and dislikes, weight and choice of what and where to eat. One resident was obtaining nutrition through a PEG feed. An optician and dentist based in Burnham village visit the home. A chiropodist visits from High Wycombe. Other services, such as audiology, are accessed through the general practitioner (there is an audiology department at Windsor Hospital). The medication administration record (MAR) sheets were examined. Gaps were noted on MAR sheets for four residents. It was noted that a particular resident was prescribed for two Senna tablets and Lactulose solution twice daily. However, staff were administering the medications on alternate days. The manager stated that the general practitioner had amended the frequency of the medications but this was not reflected on the MAR sheet. It is required that any change to the frequency of medication must be reflected on the MAR sheet. The controlled drug register was checked. Tablets in the drug cupboard corresponded to balances in the register. It was noted that there was an entry in the controlled drug register with one signature for the receipt of Temazepam medication. As a good practice there should be two staff members’ signatures recorded for the receipt of controlled medication. Not all staff were being consistent and dating and signing the MAR sheet when antibiotic treatment had been completed. It was noted that the drug fridge temperature record was not being maintained. The last entry recorded was 30 April 2006. As a good practice it is recommended that the fridge temperature should be recorded at least once daily. Tippex correction fluid was noted on the front sheet of a particular resident’s MAR sheet and written over entries was noted on some MAR sheets. This practice is unacceptable and must cease. At the last inspection a requirement was set that regular auditing of MAR sheets must be carried out and that records of auditing undertaken should be kept for inspection purposes. There was no written evidence that MAR sheets were being regularly audited. This requirement is being repeated. The manager is advised that failure to comply with this requirement may result with the Commission contacting its legal department, with a view to considering enforcement action. Staff were observed knocking on residents’ bedroom doors and waiting for a reply before entering. Residents spoken to confirmed that staff respected their privacy and dignity when providing personal care. It was noted that residents’ preferred term of address was recorded in their care plans. Residents can receive and make telephone calls in private. All bedrooms are fitted with telephones and televisions. However, some residents choose to have their own. DS0000019186.V290130.R01.S.doc Version 5.1 Page 13 The laundry facility provided ensures that residents’ personal clothing is well maintained. Medical examinations and treatments are carried out in residents’ bedrooms. Appropriate screening is provided in shared rooms to ensure that privacy is not compromised. DS0000019186.V290130.R01.S.doc Version 5.1 Page 14 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, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents’ lifestyle experienced in the home matches their expectations and their social, cultural, religious and recreational interests. Residents confirmed that the presentation and quality of the food was of a good standard. EVIDENCE: Residents spoken to confirmed that they are able to choose how to spend their day. Some residents choose to go for daily walks in the garden. The home employs an activity organiser who works four days a week. Arrangements were being made to employ a second activity person to ensure that activities are available seven days a week. Each month arrangements are made for a professional entertainer to perform for residents. The local minister visits the home twice monthly. Residents are able to participate in a church service or Holy Communion if they wish to. Forthcoming events of activities taking place were displayed on the notice board. On the day of the inspection residents participated in a newspaper discussion, which was very well attended. Some residents chose to remain in their bedrooms or in the television room. One particular resident was able to go out for a stroll in the grounds unescorted in an electric scooter. DS0000019186.V290130.R01.S.doc Version 5.1 Page 15 Residents are able to choose whom they wish to see and are able to receive visitors in private in their bedrooms or in the communal areas. Residents spoken to confirmed that relatives and friends are able to visit them at anytime and there were no restrictions on visiting. On the day of the inspection staff were observed offering relatives tea and biscuits. Relatives spoken to confirmed that staff always made them feel welcome. It was noted that a volunteer visits the home one hour weekly to assist the activity organiser with bingo sessions. However, a Criminal Record Bureau (CRB) Clearance had not been obtained for the volunteer. It is required that a criminal record bureau (CRB) clearance be obtained. Residents are encouraged to handle their own financial affairs for as long as they are able to with support from relatives. It was noted that three residents were handling their own financial affairs. The home’s staff prior to admission would make residents aware that they are able to bring in small items of personal possessions such as furniture if they wished to. Personal items were noted in some residents’ bedrooms. One particular resident spoken to was pleased to be given the choice to move in with three bonsai trees. One of the trees was sixty years old. The resident praised staff for their support with assisting to look after the trees. There were no residents using the services of an advocate at the time of the inspection. The lunchtime meal was observed. There were two sittings at lunchtime. Residents who need assistance or prompting are served at the first sitting. Staff were seen assisting those residents who needed assistance in a discreet and sensitive manner. The choices on offer at lunchtime were: grapefruit segments for starters, chicken curry, savoury pancakes, omelette, filled jacket potato, boiled rice, sauté potatoes, baton carrots and sweet corn. Dessert was strawberry cheesecake. 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.” Tables were appropriately set with colour coordinated tablecloths, napkins, cutlery and condiments. Lunchtime appeared an enjoyable and social occasion. DS0000019186.V290130.R01.S.doc Version 5.1 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a clear complaints policy in place to ensure that residents and relatives are listened to. Policies and procedures are in place to protect residents from abuse. However, the home’s recruitment procedure needs to be strengthened to ensure that residents are protected from any potential harm. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Residents spoken to said that if they had a complaint they would report it to the manager and they were confident that it would be investigated appropriately. The home has policies on the protection of residents from abuse and on guidance for staff when dealing with aggression. Staff confirmed that they had attended training sessions on the protection of vulnerable adults and were able to demonstrate their knowledge in the different types of abuse and how they would respond if they suspected that a resident was being abused. Weaknesses identified in the home’s recruitment procedure has the potential to put residents at risk of being harm. DS0000019186.V290130.R01.S.doc Version 5.1 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home is well maintained, pleasantly decorated and furnished. It provides residents with an attractive, safe and homely place to live in. EVIDENCE: The home is situated in large grounds at the edge of Burnham Beeches. It is close to the village of Burnham. The home is well furnished and provides a comfortable and tranquil environment with interesting garden life. 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 home complies with local environmental health and fire authority requirements. DS0000019186.V290130.R01.S.doc Version 5.1 Page 18 There is an ongoing programme of refurbishment of bedrooms taking place. Residents’ bedrooms were personalised with family pictures, mementoes and personal furniture. Daily monitoring on the standard of cleaning in residents’ bedrooms, bathroom and toilets takes place. The floors and walls in the laundry room were clean and free from dust. It was evident that the cleaning schedule was being adhered to. On the day of the inspection the home was bright, clean and free from odours. DS0000019186.V290130.R01.S.doc Version 5.1 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 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s recruitment procedure needs to be strengthened to ensure that residents are not put at risk. The home need to ensure that training profiles are developed for staff members, which outline in detail all training undertaken. EVIDENCE: The present staff establishment allows for eight staff in the morning (including one Registered General Nurse), five staff in the afternoon (including one RGN) and four staff at night (including one RGN). The registered manager works on the floor as required and is not always supernumerary. The home had a vacancy for a senior sister and for two care assistants at the time of the inspection. Nursing and care staff are supported by domestic, laundry, servery and maintenance staff. Catering staff are provided by an external contractor. Two staff were pursuing National Vocational Qualification (NVQ) at level 2 at the time of the inspection and were due to complete the course in the near future. The home will meet the 50 target if the nurses who qualified in Bulgaria and who are assumed to have qualifications equivalent to NVQ level 3 are included in the calculation. Two files of staff recruited since the last inspection were examined. Both applicants had completed an application form. The homes application form DS0000019186.V290130.R01.S.doc Version 5.1 Page 20 now requires applicants to give their reasons for leaving. POVA first clearance had been obtained for both applicants prior to appointment. An enhanced Criminal Record Bureau (CRB) certificate had been received for one of the applicants prior to appointment. The supervision arrangements for the person appointed under a POVA First were not clear but the registered manager said that the person was always supervised. With regard to references the registered manager said two references had been received for both staff. It was noted that only one reference was on file for one staff member. The manager has agreed to send a copy of the second reference when the administrator returned from leave. Neither file had a recent photograph although both had black and whilte photocopies of passport photos. Nurses PIN numbers had been checked with the Nursing and Midwifery Council (NMC). Both work permits were in order. A file for the volunteer was not available for examination. Information on training was brief, consisting only of a list of training events which had taken place. The list did not indicate the level or duration of training and records on staff attendance were not provided. DS0000019186.V290130.R01.S.doc Version 5.1 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 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, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home’s supervision framework needs to be developed to ensure that staff receive regular supervision. Issues relating to infection control and safety should be addressed to ensure that residents’ safety is promoted. EVIDENCE: The registered manager is a registered general nurse with many years experience in the care of older people. Both the registered manager and the deputy manager were pursuing the Registered Managers Award and both expect to complete it by the autumn of 2006. The registered manager had not had an appraisal for over three years and her job description had not been reviewed. The home circulated a quality asurance questionnaire to relatives of residents in May 2006. 40 questionnaires were distributed and 27 returned. A full report of that exercise was not available at the time of the inspection but overall it DS0000019186.V290130.R01.S.doc Version 5.1 Page 22 appeared that there was a good level of satisfaction with the quality of the service and the exercise yielded a number of valuable additional comments from relatives and residents on a range of elements of the service. The home does not have a written development plan. A copy of the inspection report was not on display. The home has not been pro-active in submitting an improvement plan to the Commisson in response to requirements and recommendatons from previous inspections. A requirement is being made that an improvement plan must be submitted to the Commission. The home does not routinely manage monies on behalf of residents and never acts in a appointee capacity. There is a system in place for dealing with small amounts of cash which is separate from the homes own petty cash system. Written records of transactions are maintained. Receipts are not retained. The home has a policy on supervision. The system was not fully operational at the time of this inspection and the registered manager was not sure when it would be in place for all care staff. A care assistant spoken to did have supervision with the deputy manager and did value it. Fire records examined indicated that the fire panel was being maintained and staff had participated in a recent fire drill. There was a valid electrical hardwiring certificate of the premises in place. The portable appliance test for the electrical equipment in the building was up to date. The water system had been checked and regulated to control the spread of Legionella bacteria and an up to date certificate was in place. It was noted that the water temperature in wash hand basins in some bedrooms in the basement was above the normal range temperature. It is required that the restrictor valves on taps are checked and any defects identified are remedied It was noted that there were general waste bins in toilet areas without covers. It is required that covers on bins are replaced to prevent the spread of cross infection. The clinical waste bin was not fitted with a lock. It is required that the bin is fitted with a lock to prevent the spread of infection and vermin gaining access. Opened packets of food stored in the general kitchen were dated and labelled. Food temperature records and fridge and freezer temperatures were being maintained. There was evidence that the chef was carrying out monthly safety inspection checks and 3-monthly auditing of the kitchen was taking place by a senior manager from the external catering company who has overall responsibility for the provision of food. It was noted that the generic risk assessments had been updated. COSHH sheets were in place for all hazardous solutions that were being used in the home. DS0000019186.V290130.R01.S.doc Version 5.1 Page 23 There was evidence that the passenger lift, central heating, boiler, call bell system and mobile hoists were regularly maintained. DS0000019186.V290130.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 DS0000019186.V290130.R01.S.doc Version 5.1 Page 25 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 OP3 Regulation 14(1)(a) Requirement The registered manager must ensure that copies of preadmission assessments for new admissions are available to confirm that residents’ needs are assessed before admission. That the home is able to meet individuals’ needs and the prospective resident and their representative have been involved in the pre-admission process. The registered manager must ensure that care plans are reviewed monthly. Waterlow assessments and residents’ weights must be maintained monthly. (Previous timescale of 30/04/06 not met) The registered manager must ensure that trained nurses administer medication in accordance with the Nursing and Midwifery Council guidelines. Regular monitoring of MAR sheets must be carried out. (Previous timescale of 30/11/05 not met). DS0000019186.V290130.R01.S.doc Timescale for action 31/08/06 2 OP7 15(2)(b) 31/08/06 3 OP9 13(2) 31/07/06 Version 5.1 Page 26 4 OP9 13(2) 5. OP9 13(2) 6 OP13 12(1)(a) (19)(1) 7. OP29 19(1) Schedule 2 The registered manager must ensure that any change to the frequency of medication must be reflected on the MAR sheet and signed by the general practitioner. The registered manager must ensure that the use of tippex correction liquid and written over entries on MAR sheets be ceased. The registered manager must ensure that a Criminal Record Bureau clearance be obtained for the volunteer who visits the home. The registered manager must ensure that an up to date photograph is kept on staff members’ files to confirm proof of identity and that two references are obtained before appointing a staff member The registered manager must submit an improvement plan to the Commission in response to the requirements and recommendations made in this report. The registered manager must ensure that general waste bins in some areas of the building without covers are replaced to prevent the spread of infection. The registered manager must ensure that the clinical waste bin be fitted with a lock to prevent the spread of infection and vermin gaining access to its contents. The registered manager must ensure that restrictor valves on hot water taps in bedrooms in the basement must be adjusted to ensure that the temperature of the hot water outlets remain close to 43 degrees Celsius. DS0000019186.V290130.R01.S.doc 30/06/06 30/06/06 30/06/06 30/06/06 8 OP33 10(1) 31/07/06 9 OP38 16(k) 31/07/06 10 OP38 16(k) 31/07/06 11 OP38 13(4) 31/07/06 Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4 5 Refer to Standard OP7 OP9 OP9 OP30 OP36 Good Practice Recommendations It is recommened that the registered manager should ensure that regular monitoring of care plans take place. It is recommended that the registered manager should ensure that all staff are consistent and date and sign the MAR sheet when antibiotic treatment has been completed. It is recommended that the registered manager should ensure that the drug fridge temperature is recorded at least once daily. It is recommended that the registered manager should ensure that staff training files be developed for staff members detailing all training undertaken. It is recommended that the registered manager should continue to progress with the supervision framework to ensure that all staff receive regular supervision. DS0000019186.V290130.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000019186.V290130.R01.S.doc Version 5.1 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. 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