Inspection on 08/07/08 for Burntwood Lodge

This inspection was carried out on 8th July 2008.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burntwood Lodge 09/07/07

Burntwood Lodge 07/08/06

Burntwood Lodge 19/01/06

Burntwood Lodge 21/04/05

Burntwood Lodge 16/11/04

Burntwood Lodge 26/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Burntwood Lodge Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA Lead Inspector Lisa Johnson Unannounced Inspection 8th July 2008 09:45 Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 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 Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burntwood Lodge Address Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA 01883 381692 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) burntwoodlodge@fsmail.net Mr Abdulha Aziz Coowar Sally Margaret Skinner Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (1), Physical disability over 65 years of age (2), Sensory impairment (2) Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range of those accommodated shall be 43 - 65 years of age and 2 residents over 65 years of age 9th July 2007 Date of last inspection Brief Description of the Service: Burntwood Lodge is a registered care home, providing care and accommodation for up to six adults with learning difficulties. The home is set in a quiet residential area, with shops and other amenities a short drive away. All six rooms were occupied, one single room with en-suite facilities, one double shared room, and four single rooms. Communal rooms comprise a spacious lounge, dining room, kitchen and bath/shower room. The area to the rear of the main house has a patio area and a large garden. The fees are £900 to £1000 per week. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. This site visit was part of a key inspection. The site visit was unannounced and took place over seven hours commencing at 9.45 am and finishing at 4.55p.m. Mrs. L Johnson Regulation Inspector carried out this visit. Ms. S skinnerregistered manager represented the service. Information was provided to us by the service prior to this visit in the Annual Quality Assurance Assessment. (AQAA) This is a self-assessment that focuses on how well outcomes are being met for people using the service. Reference is made to this assessment throughout this report. A full tour of the premises took place. Care plans, risk assessments, medication administration records staff personnel files, training records and policies and procedures were seen during this visit. During this visit we were able to speak to three people, and three members of care staff. The inspector would like to thank the people living in the service and staff for their time, assistance and hospitality during this inspection. What the service does well: The home provides a relaxed and friendly atmosphere. Good relationships were observed between people and staff. Staff were seen to be respectful, caring and attentive to the needs of people living in the service throughout this visit. The home has developed detailed and comprehensive person centred care plans and health action, which are completed in consultation with people, these were accessible and formulated with pictures. People living in the service attend a range of meaningful recreational and social activities. The home benefits from having their accessible vehicle and during this visit one person had been to the hairdressers and said that they had been out for a meal. Another person said, “ I like going out for a coffee and biscuits”. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Prospective people considering this service as a place to live are provided with information they need to make an informed choice about its suitability as a place to live. The needs of prospective people are assessed prior to admission to the home. EVIDENCE: The home provides a statement of purpose and service user guide, which is formulated in an accessible format with pictures. People currently living in the service have lived there for a number of years. There have been no new admissions since the last visit The home has clear procedures and protocols for admitting new people into the service and no one would move in unless their needs were assessed and the home could meet their needs. Opportunities would be taken for prospective new people to visit the home and a structured settling period would be arranged the service. Information supplied in the self-assessment states that information and discussions would also be obtained from other professionals. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with a care plan, which records their individual needs and goals and they are supported to make decisions about their lives. People using the service are supported to take risks as part of an independent lifestyle. EVIDENCE: Each person has a comprehensive person centred care plan in place which are designed to enable personal, health, communication, social, cultural and religious needs of each person to be addressed. Care plans are accessible and provided with pictures. Three person centred plans were sampled which had been implemented in consultation with people living in the service and or their relatives and had been signed by them confirming their agreement. The manager has implemented review record, which demonstrated that people’s individual goals are reviewed every four to six weeks. Information supplied in the self-assessment states that the manager has attended training in on care planning and that this information has been Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 10 cascaded down to key workers. Key workers spoken with were aware of peoples care plans and showed good awareness and knowledge of their needs. The service has systems in place to support people to make choices and decisions about their daily lives. This information is included in their care plan such as preferred times of getting up and going to bed choosing clothing and preferred meals. One person living in the service said, “ I can choose the clothes that I like”. We were informed that since the last visit people now have their own bank accounts although people currently living in the service require full support to manage their finances. It was recommended that this information be documented in the care plan. It was also recommended that where people are unable to use a key for their bedrooms this information should also be documented in the care plan. The home holds regular consultation meetings, which are documented, and two people living in the service confirmed that these take place. Pictorial feedback surveys are conducted enabling people using the service to express their views and suggestions. A range of comprehensive risk assessments were in place, which are regularly reviewed. Risk plans sampled included moving and handling, falls, epilepsy and choking. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with a range of appropriate activities and engage in a range of leisure pursuits. People are supported to take part in the local community and their rights and responsibilities are respected. The home is able to demonstrate that people are provided with a well-balanced and nutritious diet. EVIDENCE: Each person has a weekly activity plan. One person said that they go to drama. During this visit a music therapy session was being carried out where people were fully involved and were observed to be enjoying this event. The home benefits from having their own wheelchair accessible vehicle where people have the opportunity to participate in the local community. One person told us that they had been to the hairdresser and had a meal out. Due to the ageing process of some of the people and associated health needs the manager has identified in the self-assessment they are trying to arrange Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 12 more in house activities and have employed a member of staff to carry out these activities. Some people had televisions and music centres in their bedrooms. One person said, “ I like music”. Staff were aware of this persons interest in music and put the radio on for them. A member of staff acting as a key worker said that one person likes to have their nails polished and foot spas. This person showed us her manicured nails, which she said she likes. People’s religious needs are supported and links are maintained with local places of worship. Information supplied in the self-assessment identified that one person receives visits from the Roman Catholic priest where they take part in communion. People living in the service maintain links with their families and friends. Peoples care plans detailed their family contacts. One person’s plan identified that they require support to use the telephone and one person told us about their family. Choice making is considered in the person centred care plan this included peoples preferred activities. This was demonstrated in one persons plan where it is identified that that they like going shopping and having coffee and biscuits out. This person told us that this was their favourite activity. Peoples care plans demonstrated that people are supported to assist with household activities. One person said, “I make cakes sometimes”. Another person was observed being assisted to lay the table for lunch. Two people said that staff respect their privacy and knock on their bedroom doors before entering. One person said it is their preference to have meals later at lunchtime and the evening, which was observed to be respected during the lunchtime meal, although this person stated that on some occasions this is not always accommodated. This was bought to the attention of the manager who said that she would raise this with the staff team. This person also commented that they would like to spend more time in the kitchen. The homes menus were viewed which were varied and well balanced. The manager stated that meals are based on people’s preferences and had been reviewed by a dietician. We were informed that alternatives could be provided, although this is not indicated on the menu and the manager said that the menu is in the process of being formulated into an accessible format. The manager was advised to include information to highlight that choices of meals can be provided. Three people spoken with said that they enjoyed their meals. During the lunchtime meal people were provided with appropriate support and adapted plates, and cutlery, although one member of staff was observed standing feeding one, which provided this person with little eye contact. It was observed Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 13 that people were not provided with or asked if they would like any condiments with their meals such as salt and pepper or sauces. These matters were bought to the attention of the manager who said that she would discuss this with the staff team Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 19 & 20 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people living in the service receive personal support in the way they prefer. People’s physical and health needs are met and they are protected by medication administration procedures. EVIDENCE: Each person has a comprehensive health action plan in place that recorded in detail people’s health and personal needs. People’s likes, dislikes, their preferred routines and preferences as to whom they would like provide their personal care. Each persons support needs were clearly documented advising staff how this is to be supported. Information documented in one-persons care plan identified that they require support from staff when mobilising which staff were observed to carry out and were provided with specialist feeding equipment when eating. Another person’s care identified that they require a walking frame when walking, which has been provided. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 15 The service maintains records of each person’s health screen checks and appointments including general practitioner, chiropody, optician and dentist. The home also maintains close links with a range of heath care professionals including district nurses and the community team for people with learning disabilities for advice and support and referrals can be made for people to access dietician and speech therapy support through this team. The home provides a range of specialist equipment including pressure relieving mattresses and moving and handling equipment. One person is currently in hospital and is due to return to the home shortly. This person will require support with feeding using medical devise. The manager is currently making arrangements for staff to receive training in using this equipment, which will be monitored by a dietician. The medication policies and practices were examined. Medication profiles were in place, which included how medication is to be administered, any side effects and any identified allergies. Medication was stored in a locked trolley, which was fixed to the wall. Medication is dispensed in “blister packs” using the monitored dose system (MDS) system. A photograph of each person was available with their medication administration records and all medication administered had been signed for. We were informed that staff attend external medication awareness training and complete an internal assessment. Records were maintained for the receipt and disposal of medication. An item one-medication administration record had been hand transcribed by staff but had not been checked and signed by two members of staff, which was bought to the attention of the manager who attended to this matter during this visit. The home does not currently hold any controlled drugs, however there has been a change in the law and so should the care home have any controlled medication in the future they will need to ensure these are stored in a controlled drug cupboard. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. 22 & 23 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People know that their concerns will be listened to and acted upon and they will be protected from abuse. EVIDENCE: There is a complaints procedure in place, which is also available in an accessible pictorial format, which was seen on display. The manager was advised to amend and include the current contact details for the Commission should anybody wish to contact us. Since the previous visit the Commission has received no complaints or concerns. The service has also not received any complaints. Two people spoken with said that they would speak their key worker or go to the office if they had any concerns. One person said, “the staff are kind and I am happy” and another person said the staff, “Look after me well”. The service has safeguarding vulnerable adults from abuse procedure, which refers to the local authority multi agency procedures. Safeguarding alert cards were also seen on display on the notice board. Three members of staff spoken with were aware of the procedures and clear about the action they Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 17 should take if they witness or are made aware of any incident where the safety or protection of a vulnerable person is compromised. Staff receive training which was confirmed by the homes training schedule and from information maintained in staffs personal files. The manager said that they had also attended the local authority multi agency training. Since our last visit one matter was referred by the manager to the local authority in relation to person who had returned to the home after being discharged from hospital with a pressure sore. This matter is currently still being investigated by the local hospital. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Further improvement is needed to ensure that people live in environment, which is decorated, furnished and maintained to a good standard. People receiving the service have a clean and hygienic service to live in. EVIDENCE: The home provides a spacious environment suitable to meet the needs of people using wheelchairs. All ground floors are accessible and a ramp is provided to the rear of the house to enable people to access the garden and patio. There is a large lounge and separate dining room During this visit it was observed that areas of the home would benefit from being decorated and some maintenance work. The manager showed us a copy of their redecoration and refurbishment plans and currently some of the bedrooms are being redecorated. We were informed the home receives the shared services of a handy man with their sister home near by. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 19 The shower room on the ground floor needs attention such as wiring, which was uncovered and exposed beneath the sink, which could be a potential safety hazard to people using this facility. The shower curtain needs replacement and some of the tiles need cleaning in the shower, which gave a slight mouldy smell. It is required that that these matters are attended to ensuring the welfare and safety of people living in the home We viewed three bedrooms and two of these bedrooms were comfortable and personalised with people’s belongings. Two people share one bedroom, which is their preference. The home has one bedroom, which has ensuite facilities. One person’s bedroom was observed to have a broken wardrobe door and another cupboard requires attention under their sink. The person residing in this room expressed dissatisfaction that their tap was not working in their sink, which they were unable to use. These matters were bought to the attention of the manager who was aware of this. It was not clear when this work was to be carried out. Therefore it is required that these repairs are promptly attended and written evidence provided in the homes maintenance log record when this work is completed. During a tour of the home it was observed there was no radiator cover in the hallway and one was missing from one persons bedroom, which was identified as a safety hazard to people using the service. (See also standard 42) During this visit the home was observed to be clean and hygienic. Information supplied in the self assessment states the home has a cleaning schedule in place. Appropriate protective equipment is provided to staff as well as general cleaning equipment to avoid cross infection The home has an infection control procedure which the manager said is based on the Department of Health good practice guidance. The manager is in the process of arranging up to date infection control training for staff. Since our last visit the home has been visited by environmental health, which was satisfactory, and also by health and safety. One matter in relation to a window restrictor in the upstairs bedroom has been completed. At the request of the fire authority fire doors have been fitted with cold smoke seals. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are provided with appropriate support although this needs to be continually reviewed People are supported by staff that have in the main the appropriate qualifications and skills and they are protected by robust recruitment procedures. EVIDENCE: We were informed that three members of staff are provided throughout the day. At nighttime people are supported by a waking and a sleepin member of staff. The manager also works some supernummary shifts. The duty rota sampled indicated that these levels are maintained The manager stated that seven out of twelve care staff employed has completed National Vocational Qualifications and four other people are waiting to commence the course. The training records sampled for two members of staff demonstrated that they are supported to attend training and development. The manager maintains a training schedule, which identifies what mandatory training staff have attended and when this is due to be updated. Since the last visit progress has been Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 21 made ensuring that any outstanding training including health and safety, safeguarding vulnerable adults from abuse, health and safety and medication awareness have been updated. A notice on the wall indicated that fire safety training was being conducted later in then week. It was observed that staff require infection control training, which the manager said she was in the process of arranging. One member of staffs file sated that had received training in epilepsy, staff and some staff have attended training in autism awareness. New staff receive induction and follow the Skills for Care common induction standards. This document was available to view on one new member of staffs personal file. A member of staff spoken with confirmed that they had received induction. Staff are provided with a copy of the General Social Care Code of conduct (GSCC) Staff recruitment is based on an equal opportunities policy the recruitment files were sampled for three members of staff, which contained the required information including a fully completed application form and two written references. Protection of vulnerable Adult first checks (POVA) and enhanced Criminal Record Bureau (CRB) Checks are conducted. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is an experienced manager in post. Further improvement is need ensuring that the home is run in the best interests of people living in the service. One matter needs attention ensuring the peoples health, safety and welfare is protected EVIDENCE: There is an experienced manager in post who holds the registered Managers Award. During this visit the manager was observed to have an open and inclusive approach. The manage has attended a range of training and development course including equality and diversity and is arranging to cascade this information to staff to increase their understanding Staff spoken with said they enjoyed working in the service and that they felt well supported and the manager was approachable. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 23 The service provides annual feedback surveys to people, which are formulated in an accessible format. Feedback surveys are also provided to relatives, which were sampled during this visit and contained a number of positive comments. Information supplied in the self-assessment states that the outcomes of the surveys are discussed at staff meetings and consultation meetings take place with people living in the service where their views are considered. The home also seeks evaluation from visitors to gain feedback. We were informed that the registered provider visits the home regularly, however the registered provider could not provide written evidence that monthly quality visits are conducted and that they were carried out in line with the regulation. These visits must be unannounced and include conducting interviews with people living in the service and staff, inspecting the premises and reviewing any complaints. These visits would have highlighted the shortfalls in the maintenance issues before they become a regulatory issue. Therefore it is required that a written report must be completed monthly and maintained in the home for inspection ensuring that that the home is being regularly audited and run in the best interests of people living there During a tour of the premises all substances hazardous to health were appropriately stored. The fire records were sampled which indicated that regular alarm checks and fire drills are conducted and regular water temperature checks are maintained. Information supplied in the selfassessment indicates that servicing and maintenance of equipment used in the home is up to date. It is required that risk assessment is carried out in respect of the uncovered radiators following advice from environmental health office ensuring the health, safety and welfare of people. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 3 X 1 X X 2 X Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 25 No 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 YA24 Regulation 23 (2)(b) (c) Requirement Timescale for action 10/09/08 2 YA39 2 YA42 The registered person must ensure that the home is maintained in a good state of repair. This is to include the maintenance issues identified in the downstairs shower room and in one persons bedroom. 26 The registered person must 10/08/08 ensure that written reports are maintained of monthly quality visits conducted in the home, which must be available for inspection. 13(4)(a)(c) The registered person must 10/08/08 consult with the environmental health office as to whether radiator covers are required due to the ageing process of people living in the home and to ensure that any risk assessment meets the health and safety executive legislation. Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 26 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 YA7 YA17 Good Practice Recommendations It is recommended that where people require assistance with their finances this should be documented in their individual care plan. The registered person should as good practice provide people with condiments with their meals Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Burntwood Lodge DS0000013582.V367361.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!