Inspection on 04/01/06 for Burnham Lodge Nursing Home

This inspection was carried out on 4th January 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 19/06/06

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 Burnham Lodge Nursing Home 147 Berrow Road Burnham-on-Sea Somerset TA8 2PN Lead Inspector Caroline Baker Unannounced Inspection 4th January 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 Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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.V271814.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address Burnham Lodge Nursing Home 147 Berrow Road Burnham-on-Sea Somerset TA8 2PN 01278 783230 01278 781249 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) 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.V271814.R01.S.doc Version 5.0 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. 13th September 2005 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 - Mr Lingajothy. The registered manager is Mrs Patricia Cox. The home has a level patio area for sitting or walking, with a large rear garden where a summerhouse is located. The home has a passenger lift that allows access to the first floor. There are 13 single bedrooms of which 7 have en-suite facilities. There are 4 double bedrooms of which 1 has an en-suite facility. Downstairs there is a lounge and a sitting area with a dining table for service user use. There is a pay phone for service users to use and a cordless phone to receive incoming calls. The home has a nurse call system throughout. Bedrooms have locks on the doors for extra privacy, which are accessible in an emergency. 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.V271814.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first announced inspection since Elderly Medicare Ltd purchased the home took place on 13 September 2005. At that inspection two requirements were identified and five recommendations were made. This inspection was unannounced and took place over one day (6.25 hours) by Caroline Baker. At the time of this inspection one requirement had been complied with and two recommendations had been actioned. Further requirements and recommendations have been made during this inspection as detailed later in the report. Not all the National Minimum Standards were assessed at this inspection and this report should be read in conjunction with the last report. Twenty service users were residing at the home. Staffing levels were adequate on the day of inspection. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least thirteen service users were spoken with. Patricia Cox, the registered manager, was available from 14:00 hrs when her shift began. Throughout the day the inspector was able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. The inspector would like to thank service users and staff for their time and help during the inspection. What the service does well: Burnham Lodge provides a warm, clean and comfortable environment. Service users were observed using the communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Service users were well attired and looked well cared for on the day of inspection. Service users nursed in bed looked comfortable and well cared for. Service users praised the food. A good choice of wholesome food was given. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 6 Service users praised the staff. Relatives spoken to indicated their satisfaction at the provision of care at the home. Staffing numbers were sufficient to meet the dependency needs of current service users on the day of inspection. Service users monies kept on their behalf were safe and secure with detailed records kept of any transactions. Staff spoken with stated that they felt well supported and happy working at the home. Staff consulted confirmed receiving induction training. Staff looked and acted in a professional manner. What has improved since the last inspection? What they could do better: The Service User Guide for the home needed reviewing and updating to reflect the current provider; activity provision at the home; and the complaints procedure. Staff at the home had not received any specialist training since the last inspection and need to be able to meet the needs of people with dementia or diabetes, for example, if service users with these specialist problems are admitted to the home. Where bedrails are used a risk assessment, consent and rationale for use must be recorded as they are seen as a potential use of restraint. All staff responsible for the receipt, administration, recording and disposal of medications must always follow the homes medication policies and be responsible for their own actions to ensure the protection of service users. The activity provision at the home is not adequate and does not meet the social and recreational care needs of the service users. For the protection of vulnerable adults the home must plan and provide abuse awareness training to staff so that all staff understand the steps to take should they suspect any type of abuse. Also the recruitment of staff must be more robust and persons must not commence work at the home until all satisfactory checks have been received in respect of them. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 7 Staff must be more vigilant and ensure that service users had access to a call bell at all times should they require assistance. The home must ensure that a person trained to do so checks and ensure bed rails are fitted correctly on a more regular basis; they were last checked in September 2005 and at least three were found to be ill fitting at this inspection. The home must comply with the Certificate and Conditions of Registration at all times and must not breach these conditions without prior discussion and agreement with the Commission. Steps must be taken to rectify the breach in condition made when admitting a service user with manual handling needs to Room 7 which is for ambulant persons only given its manual handling restrictions. Health and safety issues were identified at this inspection, which need addressing, in regard to an unguarded radiator, testing of hot water outlet temperatures and emergency lighting checks. In this regard the provider must consider increasing the maintenance hours from four per week to at least twenty hours to ensure all maintenance and health and safety checks at the home are kept up to date. The electrical hard wiring certificate was due for renewal in November 2005 and must be addressed to ensure the hard wiring is safe at the home. Consideration must be given to the management role at the home. This inspection has identified many issues of concern. The manager does not have many supernumerary hours to manage the home and ensure it is maintaining standards in line with its aims and objectives and stated purpose, and as strongly recommended at the last inspection consideration must be given to appointing a deputy manager, to give management support, and to increase the supernumerary hours of the manager. The registered provider has not supplied the manager or the Commission with a monthly written report of his visits since September 2005. These monthly unannounced visits would provide the registered provider or representative with a clear insight into what is currently happening at the home, and allow them to take action to address any issues they may find. The staff had not received formal supervision on a one-one basis in the past twelve months. This must commence to allow the management to assist and discuss with the staff on an individual basis, any training and development needs they may have. Nutritional assessments were compiled for each service user. A plan of care had not always been flagged up where service users were at high risk of loss of weight. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 8 The home had not held any staff or service user meetings since the last inspection and should do so on a regular basis as part of its quality assurance and review, to allow staff and service users to air their views on the conduct and running of the home. 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.V271814.R01.S.doc Version 5.0 Page 9 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.V271814.R01.S.doc Version 5.0 Page 10 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; 2; 3; and 4. NMS 6 does not apply to the home. Service users are provided with information they need to enable them to make an informed choice about moving to the home, however the Service User Guide was in need of reviewing and updating. Terms and Conditions of stay are issued to service users. The home was able to demonstrate that service users are fully assessed prior to admission. Staff individually and collectively had the skills to deliver general nursing care. EVIDENCE: The home had a 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 sampled during the inspection. On examination of the guide it was noted that they still had the last providers name reflected and the complaints procedure did not form part of the guide. This needs reviewing and updating as discussed at inspection. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 11 Through the case tracking process the inspector sampled two contracts service users had received from the home which outlined the terms and conditions of residence. The contract clearly states what is included in the fees and what is not included. The free nursing care element was also outlined. Four individual care plans were sampled at inspection as part of the case tracking process and evidence was seen that the home had pre-assessed the service users prior to admission to ensure the home could meet their needs. The assessments were all dated as recommended at the last inspection. It was concerning however that the home clearly breached an agreed condition of its registration by admitting a service user assessed as being ‘chairfast’ and requiring a hoist to a room that was for ambulant persons only. An Immediate Requirement notice was issued for the home to rectify the situation as this breach potentially puts the staff and service user at risk. There are Registered Nurses at 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. As discussed at inspection some of the service users admitted recently also had been diagnosed as having dementia therefore dementia awareness training must be implemented in order that the staff can fully meet the current service users needs. The home should not admit service users without the staff having the skills to meet their physical and mental health care needs. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 12 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 and 11. Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under review. Service users have access to health care professionals expertise to meet their individual needs. Service users were not protected and were put at a potential risk of harm by the homes procedures in regard to the receipt, administration, and recording of medications. Service users were 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: Four individual service users care plans were examined and the individual service users were met as part of a case tracking process. The care plans were comprehensive. Individual care needs plans contained actions to be taken by care staff to assist with or deliver the care. The care plans reflected current Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 13 individual care needs apart from one where bedrails were in use – there was no risk assessment or rationale for use. Generic, falls, pressure ulcer, nutritional and manual handling risk assessments were in place. As discussed where loss of weight has been identified then a plan of care should be reflected with the intervention and action taken. Evidence was seen that individual service users had been seen by and had access to a chiropodist, optician, dentist, and GP. Pressure relieving equipment was being used appropriately - however on three occasions where bedrails were fitted the mattresses were too high putting service users at risk, as bedrails would not serve their purpose of prevention of falling out of bed. This must be addressed as discussed at inspection. Wound care was well detailed. Medication systems were examined to include records of administration, recording and disposal. The findings were as follows: • • • • receipt, There were gaps in signatures on several occasions on all of the Medication Administration Records (MAR). Lactulose on one MAR sheet had many gaps in administration and definitions had not been recorded. Many hand transcribed medications did not reflect the prescription label; have two signatures, the maximum dose, the date or amount received, or administration route recorded. Variable doses were not reflected on three occasions making it unclear as to how many tablets had been administered. This put service users at a potential risk of harm. Agency staff are used at the home at times and the records were not always clear enough for staff not knowing the service users to deliver the correct prescribed medication. All Registered Nurses are expected to follow the NMC guidelines in regard to the receipt, administration, recording and disposal of medications. An Immediate Requirement Notice was issued in regard to this major shortfall. Service users were treated and addressed appropriately by staff. Care plans reflected preferred names. Service users can lock their bedroom doors from the inside if they wish for extra privacy, and staff would be able to access the rooms from outside in an emergency. Staff were seen and heard to knock on doors before entering service users rooms. Service users spoken to indicated that the staff always treated them with respect. They indicated that they felt well cared for, liked living at the home, that the staff treated them well and that their privacy was respected. Policies and procedures were in place for staff to follow when service users are dying to ensure they are cared for with dignity and respect and with sensitivity. There had been five deaths since the last inspection. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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; 14; and 15. Service users do not benefit from a range of activities to suit their individual choices and needs. Service users individual choices and needs dictate the routine of the home. Service users are offered a choice of nutritious well-balanced menus promoting their health and well being. EVIDENCE: The manager informed the inspector that they had been actively trying to employ an activities co-ordinator. At the time of this inspection there was no activities person in place to implement in-house activities or one-one social care. Service users spoken to had enjoyed the festivities and some had gone out on trips provided by the home. Activities records seen in the care plans sampled indicated that one of the four service users had gone to the garden centre in November 2005, the other records were blank. 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. This must be reviewed without delay, as service users social needs are not being fully met at the home. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 15 Some service users spoken to when asked what their day was like at the home stated that they did nothing all day but sit and sleep. Others enjoyed TV in their rooms or the lounge. Visitors were seen during the inspection and they informed the inspector that they were pleased with the care provision and that the staff always made them feel welcome. The visitor’s book indicated many visitors to the home. 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. All service users were very complimentary about the food. They told the inspector about the cook visiting them daily for their choice and all those asked and able knew what they were having for lunch. A menu is on display in the lounge. The lunch looked appetising on the day of inspection. Pureed food was served separately to maintain an appetising appearance. The food is served from the kitchen on individual plates. Service users either sit in the lounge and use a bed table or remained in their rooms and use a bed table. There is a small dining area, which could accommodate four or five people at a table, and this was used. Supplementary fluids were available and given to those service users assessed as high risk of loss of weight or poor appetite, however it was not clear from the care plans assessed when the service users received the supplementary fluids and if they refused what action was taken. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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 and 18. A complaints procedure is made available to service users to allow them to raise any concerns, however the complaints procedure needed updating and was not available within the Service User Guide. Steps to reduce the risk of harm or abuse to service users continued to need tightening up. EVIDENCE: A complaints register is maintained and the inspector was advised that the home has received no complaints. No complaints or concerns have been received by the CSCI regarding the home. The complaints policy and procedure must be updated as discussed and added to the Service User Guide for the home. Service users consulted knew who to talk to should they have any concerns. The POVA list is now operational. Please see standard 29 where recruitment of staff systems at the home identified some omissions as at the last inspection. The majority of staff spoken to on inspection were aware of the Whistleblowing Policy and what to do if they suspected abuse. As discussed at the last inspection formal abuse awareness training is recommended for all staff before the end of April 2006. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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; 22; 23; 25 and 26. Service users live in a homely, warm, clean environment where they can enjoy the privacy of their own bedrooms or socialise in communal areas. The home breached an agreed condition of registration when admitting a service user to a smaller room that would not meet their manual handling needs. EVIDENCE: On arrival at the home it was noted to be warm. The atmosphere was welcoming and relaxed. Some service users were having breakfast in their rooms whilst others had chosen to have breakfast in the main lounge. Staff were busy with the morning routine. The communal areas, kitchen, laundry, staff area, bathrooms and thirteen bedrooms were assessed at this inspection. It was noted that up to four service users in their own private rooms could not reach a call bell, and in the small lounge and main lounge none of the service users could reach a call bell putting service users at risk of harm. This was rectified during the inspection Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 18 by staff and the inspector. An Immediate requirement notice was issued to ensure this would not happen again. As previously mentioned a service user with manual handling needs and very poor mobility had been admitted to a room for ambulant persons only, due to the size of the room, and an agreed condition of registration with the Commission. An Immediate Requirement Notice was issued in this regard. Service users are encouraged to personalise their rooms and staff ensure that the privacy and dignity of service users is respected. This was evident at inspection. All bedroom doors were fitted with automatic fire door closures enabling them to service users to have their doors open should they choose. Service users spoken with informed the inspectors that they were happy with their rooms. Equipment such as walking aids, grab rails and wheelchairs were available to assist with maintaining independence. During the inspection, service users were observed utilising the communal areas, of a small lounge, and larger TV lounge. The home had specialist bathing and toilet facilities for service users. The home appeared generally well maintained. Maintenance records were kept, which included routine maintenance. The inspector noted a handrail coming away from the wall by Room 12 and brought it to the attention of the nurse in charge who recorded it in the maintenance book. Environmental Health last visited the home in January 2005 when a hygiene award was granted. The Fire Officer visited last in September 2004. The care staff maintain regular checks of bath hot water temperatures before a service user is bathed. Warning signage has been fitted to wash hand basins to reduce the risk to service users from scalding. There was no recorded evidence of all other hot water outlet temperatures being tested since the last inspection and this must be implemented in line with Health and Safety guidelines and Legionella testing guidelines. As discussed at inspection the unguarded piped radiator in the upstairs bathroom must be guarded and/or risk assessed. Emergency lighting was last tested in August 2005 and must be done monthly to ensure it is working in line with Fire Safety guidelines. The cleanliness of the home was very good at this inspection. There were no offensive malodours. Hand washing facilities were available for staff throughout and included the provision of liquid soap, 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.V271814.R01.S.doc Version 5.0 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): 27; 29 and 30. The home’s recruitment procedures for staff, although improved since the last inspection, were not robust and did not fully protect service users from the risk of abuse. Staffing levels were adequate. The skill mix of staff was not fully appropriate to meet the needs of current service users. Staff morale was good. Recorded evidence of induction and on-going training had improved. EVIDENCE: On sampling four staff recruitment files of the most recently employed staff including two overseas staff the following issues were identified: • The two overseas staff who commenced in November 2005 (exact date not reflected on file) only had one written reference on file, which was from the ‘internet’ and not signed by the referee. Copies of work permits were not on file. References for the other staff were not dated on receipt making it unclear as to when they were received. • As discussed at this and the last inspection, recruitment of staff must be more robust for the protection of vulnerable adults. An Immediate Requirement Notice was issued Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 20 The home records a duty rota of staff on duty at all times on a weekly basis. Copies of three weeks rotas including the Christmas and New Year rotas were given to the inspector as part of the inspection process. These indicated that staffing is set within minimum staffing levels set by the old health authority. Staff and service users spoken to indicated that the staffing levels were always adequate, and that there was always time to talk with the service users and that they did not feel rushed. Evidence was seen that agency staff are used to cover any shortfalls. At the time of the inspection the Nurse in Charge had to find someone to cover sickness for overnight and following exhausting all avenues with the homes own staff an agency nurse was booked. The staff consulted, confirmed induction training, and records had been completed to evidence this. As discussed specialist awareness training in for example Dementia, Diabetes must be planned for staff to enable the home to fully meet the needs of the current client group. Staff appeared relaxed and happy on the day of inspection and told the inspector that they enjoyed working at the home. Service users complimented the staff group. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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; 37 and 38 The registered manager continues to work hard to manage the home, but is failing to ensure that its stated purpose, aims and objectives are maintained and service users are protected, by not having sufficient management time and support to do so. The systems in place for 1:1 supervision had still not been implemented. Systems were in place to ensure any service users monies kept at the home on their behalf were safe and secure. The systems and working practises in place for ensuring the health and safety of service users and staff were not so robust at this inspection. EVIDENCE: The registered manager is Patricia Cox and she is a Registered General Nurse. At present Mrs Cox is only managing to have ten hours of supernumerary time Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 22 and this makes it difficult for her to fulfil the role as thoroughly as she would like, for example staff training, supervision and recruitment. As mentioned throughout the report there have been many issues raised and statutory requirements identified. This reflects the struggle the manager has to maintain standards and protect vulnerable service users. As strongly recommended at the last inspection the provider must consider appointing a deputy manager to assist with the every day running of the home. The home has a part time administrator. The maintenance person works only 4 hours per week. The provider should consider increasing these hours to enable maintenance work such as hot water temperature testing, emergency light testing, bed rail risk assessments, and routine maintenance to take place on a daily basis and be kept up to date for the safety of staff and service users, and not be undertaken by the manager or nursing staff. The provider had completed his first Regulation 26 visit and had recorded a comprehensive report in September 2005. The CSCI has not received any further Regulation 26 visit reports and must do so, to evidence that the provider is auditing the home on a monthly basis. The home did not have any further record on file. Formal 1:1 supervision of staff had still not commenced again evidencing the struggle the manager has to find time. The inspector examined the systems in place at the home for service user monies and personal allowances. The home holds monies for eleven service users at this time. Records are kept on the homes computer database and those sampled were detailed and individual. Any transactions were recorded and receipts kept on file. The majority of records seen at inspection were up to date and in line with current legislation. The manager informed the inspector that many policies and procedures were still to be reviewed. This was evident from assessment of the policy folder. The service records were as follows: • • • • The hoists had been serviced last on 21/07/05 – due January 2006 The passenger lift was last serviced December 2005. PAT records were current. The fire records were examined, the home conducts weekly fire checks the last recorded check was on 28/12/05 Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 23 • • • The emergency lighting and fire equipment was last serviced on the 16/08/05. Emergency lighting had not been tested since August 2005. The Electrical Hard Wiring was checked 16/11/00 – Due now. Gas servicing was last done on 18/02/05. Records indicated that staff attended regular fire training. There were a total of four accidents recorded since the last inspection, one involving a service user being found over the top of a bed rail. As discussed at inspection bed rails must be checked as to their safety and correct fitting on a regular basis by someone trained to do so. They had not been checked according to the records since September 2005, it is recommended that they be checked monthly given the findings at this inspection. The inspector agreed to send the home the MHRA guidance on the correct fittings of bedrails. The kitchen was clean and well organised on the day of inspection and kitchen records were up to date. Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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 2 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 1 1 X 1 3 STAFFING Standard No Score 27 2 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 1 2 1 Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 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 OP1 Regulation 5 Timescale for action The registered person must 20/02/06 review and update the Service User Guide. The registered person must 20/03/06 consider planning specialist awareness training for staff in Dementia and Diabetes to ensure the home can meet the current service users health care needs. 30/01/06 Requirement 2. OP4 12(1) 18(a) 3. OP8 12(1) (2) The registered person must (3) ensure that a risk assessment; consent, and a rationale for use is recorded where service users are supplied with bed rails. 13(2) 17(1)[a] In line with the Immediate Requirement Notice issued at inspection: The registered person must ensure that all staff responsible for maintaining medication systems and procedures do so in accordance with the NMC Guidelines, Royal Pharmaceutical Guidelines and the homes own medication policy. DS0000064241.V271814.R01.S.doc 4. OP9 04/01/06 Burnham Lodge Nursing Home Version 5.0 Page 26 5. OP12 16(m) (n) The registered person must 30/01/06 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. 6. OP16 22(5) (7) The registered person must 20/02/06 review and update the complaints procedure and ensure the Service User guide contains a copy. 13(6) The registered person must plan 30/01/06 awareness training for all staff in abuse and implement it by April 2006. (This was recommended at the last inspection) 7. OP18 8. OP22 12(1)[a] 13(4)[c] In line with the Immediate Requirement Notice issued at inspection: the registered person must ensure that at all times service users can reach a call bell for assistance. The registered person must ensure that someone trained to do so checks bedrails on a monthly basis as to their safety and fitting in line with the MHRA guidelines. Also all staff involved in the use of bed rails must receive awareness training as to the correct fitting of bedrails. Also consideration must be given to increasing the maintenance hours at the home. 04/01/06 9. OP22 13(4)[c] 30/01/06 Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 27 10. OP23 CSA S24 In line with the Immediate Requirement Notice issued at inspection: the registered person must not admit a person with manual handling needs to any of those rooms reflected in condition No 1 of the homes registration without prior discussion and agreement with the Commission, and steps must be taken to rectify the breach of condition. The registered person must ensure that all radiators are guarded and /or risk assessed; hot water outlet temperatures are tested on a monthly basis; legionella testing is carried out and emergency lighting is tested on a monthly basis in line with HSE guidelines and Fire Safety guidelines. 04/01/06 11. OP25 13(4) 30/01/06 12. OP29 17(2) S 4(6)19,S 2 In line with the Immediate 04/01/06 Requirement Notice issued at this and the last inspection: The registered person must not allow a person to commence employment until satisfactory checks have been completed and received in regard to their fitness for the protection of vulnerable adults. (Previous timescale of 13 September 2005 not met) The registered person must 20/02/06 consider appointing a deputy manager to facilitate the development and strengthen the management structure within the home. (This was strongly recommended at the last inspection) 13. OP31 12(1) Burnham Lodge Nursing Home DS0000064241.V271814.R01.S.doc Version 5.0 Page 28 14. OP33 26 The registered provider or a representative of the organisation must visit the home at least once a month unannounced and compile a report of their findings and action to be taken, and supply a copy of the report to the registered manager and the Commission. The registered person must ensure that staff receive formal 1:1 supervision on a regular basis to allow the home to assess for any training needs and development. The registered person must ensure that the homes electrical hard wiring is checked by end March 2006 and a copy of the certificate sent to the Commission. 20/01/06 15. OP36 18(2) 15/02/06 16. OP38 13(4) 31/03/06 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. Refer to Standard OP7 OP31 Good Practice Recommendations Care plans should reflect any intervention or action to be taken in regard to service users being assessed as high risk of nutritional problems. The registered provider should review the manager’s job description and management time allowance at the home to allow them to ensure the home is run in line with its Statement of Purpose, aims and objectives. The registered person should consider gaining views on the conduct of the home through regular staff meetings and service user meetings as part of its review of quality of care in line with Regulation 24 by end April 2006. DS0000064241.V271814.R01.S.doc Version 5.0 Page 29 3. OP33 Burnham Lodge Nursing Home 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.V271814.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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