Inspection on 09/07/07 for Burntwood Lodge

This inspection was carried out on 9th July 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burntwood Lodge 08/07/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Burntwood Lodge Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA Lead Inspector Sandra Holland Unannounced Inspection 9th July 2007 09:30 Burntwood Lodge DS0000013582.V345974.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.V345974.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.V345974.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.V345974.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 7th August 2006 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 £800 to £1000 per week. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulatory Inspector, carried out the inspection over six hours. Ms Sally Skinner, Registered Manager, was present representing the service. All areas of the premises were seen and a number of records and documents were sampled, including medication administration record (MAR) charts, resident’s individual plans and staff files. Five residents, four members of staff and a visiting health care professional were met and spoken with. A small number of residents have communication difficulties, and their responses were assessed by observing their facial expressions, body language and interaction with staff. An annual quality assurance assessment (AQAA) was supplied to the home by CSCI, and this was completed and returned. Information from the AQAA will be referred to in this report. The AQAA states that the home has policies and procedures to promote equality and diversity and further training for staff is planned, to increase their knowledge and awareness of these issues. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents and staff for their hospitality, time and assistance. What the service does well: Staff members and residents were observed to have a relaxed, friendly relationship and there is a homely atmosphere in the home. The home offers a high level of personal support that is specific to the needs of each individual. All residents are encouraged to be as independent as possible and to maintain and develop their skills. The individual plans for residents are well written, regularly reviewed and viewed from the residents’ points of view. The residents are supported by the home to be a part of the local community and there is a good range of activities in place for them to take part in. The home has its own vehicle to enable residents to get to their activities. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 6 Residents spoken with are happy with the service provided, and say that the staff team are kind and the home is nice. All are happy with their bedrooms and the home in general and enjoy the activities on offer. The home supports and encourages residents to keep in contact with their friends and family. Residents are supported by a stable team of staff and it is clear that staff are committed to the needs of residents. Members of staff spoken with said that they are happy working at the home and some staff had worked there for a number of years. The home is managed in an open way and it is clear that all aspects of the home are led by the wishes and needs of those living there. What has improved since the last inspection? What they could do better: An immediate requirement was made at the time of the inspection, that the receipt of all medication into the home must be recorded and the records of medication administration must enable an audit trail to be followed. The amounts of money held for safekeeping on behalf of residents must accurately match the record held. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 7 Unwanted garden items stored on the rear patio must be disposed of. Records of the induction of staff must be maintained and must be kept in 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. The summary of this inspection report can be made available in other formats on request. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 8 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.V345974.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents would be assessed before they moved into the home. EVIDENCE: The manager advised that most of the residents have lived at the home since it opened. Only one resident has joined the home since then and no residents have moved into the home since the last inspection. A detailed admission process is included in the AQAA that was supplied to the CSCI. The process includes a thorough assessment of the needs of prospective residents and a number of visits to the home by any prospective resident, to ensure that the home can meet the needs of the resident. This also enables the prospective resident to see if the home suits them, enables a prospective resident to meet the existing residents to ensure they were compatible and to meet staff. The manager advised that the majority of residents are supported financially by a local authority and, where this is the case, an assessment would also be carried out under the care management process. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed individual plans have been drawn up to effectively guide staff to the needs of residents. Residents are supported to make their own choices and risks to residents have been assessed. EVIDENCE: Comprehensive individual plans have been drawn up to guide staff to the support and care needs of residents. As required following the last inspection, residents and their representatives are being asked to sign the individual plans, to show that they have been involved. It was positive to note that the individual plans have been written from the resident’s perspective, and indicate their identified needs, how these are to be met, what help is required and from whom. Needs that have been identified Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 11 included those relating to communication, personal care and hygiene, relationships, life skills, culture and religion, medication, activities and holidays. Information in the AQAA indicated that the community nurse for people with learning disabilities had approved the format of the individual plans. The individual plans clearly record residents’ specific likes and dislikes and the amount of detail included provides staff with the information required to effectively support residents. Staff stated that they have come to know the various ways that residents respond and understand what these mean. The communication methods used by residents have been recorded in their individual plans, to be available to all staff. Staff advised that residents are actively encouraged to make their own choices, even if they have limited methods of communication. Residents are offered a selection of items, such as clothing, and almost all are able to indicate their preference. Where a resident is not able to indicate their own choice, staff advised that they choose for the resident, taking into consideration known likes and dislikes. In relation to clothing, staff would also consider what was appropriate for the resident and the weather or temperature. Residents are vulnerable in a number of ways due to their disabilities, but any known or identified risks have been assessed in order to safeguard residents. Assessments of risks have been carried out, including those associated with mobility, managing money, developing pressure sores, accessing the community and any allergies. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a wide range of activities and to be part of their local community. A well-balanced diet is offered to residents and they are supported to enjoy their meals independently. EVIDENCE: A weekly activity plan has been drawn up for each resident and was included in their individual plan. It was positive to note the range of activities that residents take part in. These include music and art therapy sessions, going out shopping or for coffee, going out to places of interest, horse riding, bingo and attending a local day centre. One resident who used to attend a day centre has indicated that they no longer wish to do this and this choice has been recorded in their individual plan. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 13 A large television and a music centre are available in the lounge and most residents also have televisions and radios in their bedrooms. These enable residents to listen to their own choice of music and watch their favourite programmes or DVD’s. Staff advised that residents enjoy going out into the community, to go shopping, to eat out or to visit a pub and the home has its own wheelchair accessible vehicle to transport residents to their activities and appointments. Staff advised that none of the residents currently choose to attend church or are involved in other religious groups. It was clear from information and records seen, that residents are supported to maintain contact with their families and friends. Resident’s individual plans recorded their family contacts, and letters and documents recorded their involvement. A resident spoke of going to visit their family members and the manager advised that it is planned to incorporate this in a day out. Where they are able, residents are supported to assist with household activities and the extent of this is recorded in the resident’s individual plans. Daily records are maintained and include residents’ activities and involvement in the household. Residents also spoke of the household activities that had taken place recently, including the cleaning of the home’s vehicle. Residents were spoken with as they enjoyed their lunchtime meal. It was positive to observe that residents had been provided with aids to enable them to manage their meals independently, including adapted plates, cups and cutlery. Prescribed products to thicken drinks and fluids which make them easier to swallow were also available for those residents who required them. Information in the AQAA advised that changes had been made to the menu in consultation with a dietician. Staff were available to assist those residents who required it and were observed to help residents patiently and sensitively. Staff waited for residents to finish each mouthful before offering more, assisted at the resident’s speed and accepted the resident’s decision when they indicated that they had eaten enough. Staff were encouraged to sit with residents whilst assisting them with their meals, as this creates a more positive body language message to residents, and is less dominant than standing in front of residents. Burntwood Lodge DS0000013582.V345974.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): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in the way that they prefer and their healthcare and emotional needs are well met. The administration of medication needs to be managed more effectively to ensure that residents are safeguarded. EVIDENCE: Information supplied in the AQAA stated that a keyworker system is operated in the home, to ensure that residents are supported, wherever possible, by staff of their own choice, with due regard for ethnic, cultural and religious backgrounds. This also enables staff to promote consistent liaison between residents’ families, friends and others involved in their support. It was positive to observe that residents were able to name their keyworker and staff could name their key resident. The keyworker system helps to ensure continuity and consistency of support and residents receive support in the way they prefer from people who are well known to them. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 15 Detailed health action plans have been drawn up for each resident to record residents’ health care choices, their healthcare needs, contact with healthcare professionals and how healthcare needs have been met. It was positive to note that for a small number of residents with specific conditions, information regarding these had been obtained, and was included in the healthcare plans for staff to refer to. From the records and documents seen, it was clear that a number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), community nurses, hospital specialists, dentist, optician, dietician and speech and language therapist. It was noted that residents are supported to have regular healthcare checks to maintain their health and well being, as well as treatment being sought for any ill health that develops. A visiting healthcare professional was spoken with and gave positive feedback regarding care and support in the home. It was advised that prompt referrals are made to appropriate professionals if changes are noted in residents’ health, and any instructions regarding care or treatment are recorded and followed. The manager stated that medication is supplied to the home in “blister” packs as a monitored dosage system, by a local pharmacy. Each blister contains individual doses of separate medications and is administered by staff who have undertaken medication training. A medication training session took place in the home during the course of the inspection. It was noted that the receipt of medications received into the home had not been recorded, so it was not possible to know, or calculate, how much medication should be present, or whether residents had received their medication as prescribed. The manager advised that the receipt of medication is recorded on separate record sheets, but the record sheets for the most recently received monthly supply of medications could not be found. An immediate requirement was made at the time of the inspection that the receipt of medication into the home must be recorded and records must be maintained to enable an audit trail to be followed. Burntwood Lodge DS0000013582.V345974.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): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are aware of the ways in which some residents would their express unhappiness and are aware of their responsibilities in the protection of residents. No formal complaints have been received. EVIDENCE: The home has a detailed complaints policy and procedure and a summary of this was stated in the AQAA, although no complaints have been recorded since the last inspection. The complaints procedure is displayed in the home and made available in a pictorial format to be more accessible to residents. No information has been received by CSCI regarding any complaint made to the home. Staff stated that some residents would not be able to say if they had a complaint or were unhappy. Where this is the case, staff would recognise physical signs of the resident’s unhappiness, such as changes in mood or behaviours, or changes in facial expression and body language. Staff advised that they would then look to find the cause of the problem in order to resolve it for the resident. Staff stated that they had received training in abuse and were aware of the home’s policies and procedures on abuse and whistle-blowing. The home’s abuse policy was seen and it was noted that this had been recently reviewed, referred to local authority procedures and had been signed by staff to show they had read it. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 17 The manager stated that in the event of a suspicion or allegation of abuse, the home would follow the Surrey Multi-Agency Procedure for Safeguarding Adults (formerly the Protection Of Vulnerable Adults). An up-to-date copy of the procedure is kept in the home for staff to refer to if required. Staff advised that they would report any concerns regarding residents, or possible abuse of residents, to the manager or person in charge and would have no hesitation in doing so. Staff were aware that they could also report their concerns outside the home, to the provider for example, if required. Monies are securely held for safekeeping on behalf of residents and, to safeguard them, only senior and administrative staff have access to these. The manager stated that these are reconciled on a monthly basis and are also checked each month by the administrator, to ensure that they are managed appropriately. The manager stated that expenditure on behalf or residents is often paid for out of the home’s petty cash and is then reimbursed later from the residents’ monies. The monies held were checked against the records held and, for most of the residents, these accurately matched. For one resident, it was noted that the amount of money held was less than that stated in the record. A receipt for expenses was held, which exactly matched the amount of money that was “missing” from the resident’s monies. The manager stated that the money for these expenses may have been reclaimed twice and further checks and reconciliation would be carried out. A requirement has been made regarding Standard 23, that the amount of money held for residents must accurately match the record held. Burntwood Lodge DS0000013582.V345974.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is furnished and equipped to meet the needs of residents and was clean and appeared hygienic. EVIDENCE: The home is well presented, and decorated and furnished in a homely style to meet residents’ needs. All ground floor areas are accessible to wheelchairs, as a small number of residents use these. There is a level entrance at the front door and ramps enable residents to access the patio and garden. It was observed that the end of the ramp to the lawn needs attention to enable residents to access that area. A large patio has been equipped with tables, chairs and sun umbrellas, to enable residents to enjoy the outside space. A number of plant containers and hanging baskets decorate the patio and staff advised that these had been prepared with the help of residents. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 19 To meet a requirement made following the last inspection, the laundry has been moved to an outbuilding near the rear patio. The space off the kitchen, which was previously occupied by the laundry equipment, is now used as a storage area. It was also required, following the last inspection, that the garden fence must be repaired and this has been done. It was noted that items of unwanted garden equipment, including a broken barbeque and broken sun umbrella, were stored on the rear patio. These present a hazard to the safety of residents who can move about independently, and must be removed. A large bin, which is unsightly and no longer used, is also stored on the patio and should be removed. The door of an outside storage cupboard had fallen off and the manager stated that it was scheduled for repair. The manager advised that the home shares the services of a full-time handyman with its sister home nearby, and the home’s management committee meet regularly to discuss maintenance and to prioritise any works. Information in the AQAA stated that a number of improvements have been made in the home during the last year, including decoration of the lounge and renewal of the cooker and dishwasher, and provision of an additional washing machine and tumble dryer. A resident’s bedroom has also been decorated and a resident’s bedroom floor has been replaced and carpeted with carpet of the resident’s choice. Areas of the home that were seen were clean, freshly aired and appeared hygienic. Information in the AQAA stated that the cleanliness of the home is maintained by cleaning schedules, which are allocated to staff on a daily basis by the person in charge. Colour-coded cleaning equipment is provided to prevent cross infection from one area to another. Paper towels, liquid soap and personal protective equipment, including gloves and aprons, were available in the home and were seen in use by staff, to prevent infection and the spread of infection. The manager stated in the AQAA that she has undertaken infection control training and plans to share this with all staff. A requirement has been made regarding Standard 24, that unwanted items of garden equipment must be removed from the patio area. Burntwood Lodge DS0000013582.V345974.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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of appropriately recruited staff are employed to meet residents’ needs. EVIDENCE: From the records and documents seen, it was clear that a team of staff are employed to meet residents’ needs, a number of whom have worked at the home for two years or more. All are employed as care staff and the team share all the support tasks that need to be carried out, including shopping, cooking, laundry, housekeeping and activities. The manager advised that further staff are being recruited to ensure that there are sufficient staff to support residents and avoid the need to use agency staff, which can be unsettling for residents. It is hoped to recruit more staff who can drive because the manager stated that at present she is the only member of staff who can drive the home’s vehicle. This can cause restrictions on residents’ activities, although drivers from the sister home assist when necessary, the manager stated. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 21 A number of staff have achieved a National Vocational Qualification (NVQ) in Care to Level 2 or above, and information supplied in the AQAA indicated that 41 of staff have achieved this or are working towards it. The files of a number of staff were sampled and the required recruitment records and information had been obtained, including two references and Criminal Records Bureau (CRB) disclosures. As required following the last inspection, individual training and development files have been established for staff. These recorded that staff have undertaken training including moving and handling, abuse awareness, health and safety and medication awareness. A notice in the home indicated that first aid awareness training was arranged for later in the month and all staff were to attend. The manager agreed to forward to CSCI a record of all the training undertaken by each member of staff, as this was not available at inspection. The training record for all staff was received before this report was written and it was noted that a small number of staff need to receive training in fire safety, food hygiene and health and safety. The completed AQAA indicated that staff receive a thorough induction to enable them to understand their roles and a small number of recently recruited staff are still undergoing induction, the manager stated. The records of induction for these members of staff were not available at inspection. The manager stated that staff take these away from the home to work on them and had not returned them. A requirement has been made regarding Standard 35, that induction records must be maintained and be kept in the care home and staff must receive training appropriate to their role. Burntwood Lodge DS0000013582.V345974.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, 29 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a person who is fit to be in charge, but the management must be more robust to ensure residents’ health and welfare is promoted and protected. EVIDENCE: The manager advised that she has been employed at the home since November 2005, was registered as manager by CSCI in June 2006 and has completed NVQ Level 4 in Care and the NVQ Registered Manager’s Award. The manager is waiting to receive her certificate for the NVQ 4, she stated. Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 23 The manager stated that since her arrival she has worked hard to improve record keeping in the home and the updating of policies and procedures. The current shortage of staff however, and the manager being the only driver at present, is impacting on the manager’s role and has required delegation of tasks to others, it was stated in the completed AQAA. The weaknesses identified regarding medication and inaccuracies in the accounting of residents’ monies, indicate that the home must be managed more robustly and more regular checks must be carried out to ensure that these areas are appropriately managed. A requirement was made following the last inspection, that a system must be developed to ascertain the views of residents’ representatives in regard to the quality of the service provided. This has been done, and surveys were supplied to residents’ representatives last autumn. The majority of responses were positive and indicated that residents were well looked after and seemed to be happy. Others commented appreciatively that, “Staff work to a high standard under difficult circumstances” and of being “Grateful for the high level of care provided”. The manager stated that monthly residents’ meetings are held, to provide residents with the opportunity to air their views and discuss matters relating to the running of the home. Minutes (notes of what was discussed) of the meetings are kept, so that these can be provided to any residents who were not able to attend. Keyworkers also hold meetings four times a year with residents and their representatives to review the support provided, and this gives another opportunity to residents, or their family or friends, to raise any issues. Information was supplied in the AQAA to confirm that equipment and systems in the home are maintained and serviced appropriately, to ensure the health and safety of all who live and work there. The home’s Health and Safety at Work poster and insurance certificate are displayed as required. A requirement was made following the last inspection, that specialist beds must be serviced by appropriate and approved persons. This has been met and the manager was able to demonstrate this with the record of the service engineer’s visit. Burntwood Lodge DS0000013582.V345974.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 17 Schedule 4.9 Requirement Timescale for action 20/07/07 2 YA24 3 4 YA35 YA35 The amount of monies held for safekeeping on behalf of residents must accurately match the record held. 23(2)(0) The external grounds of the home must be safe for residents to use. Unwanted items of garden equipment must be disposed of. 17 A record of the induction of staff Schedule must be maintained and kept on 4.6 the premises of the home. 18(1)(c)(i) People employed to work at the home must receive training appropriate to the work they are to perform. 10/08/07 10/08/07 10/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burntwood Lodge DS0000013582.V345974.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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.V345974.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!