Inspection on 12/09/07 for Burrowbeck Grange Nursing Home

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Burrowbeck Grange Nursing Home 09/09/08

Burrowbeck Grange Nursing Home 15/08/06

Burrowbeck Grange Nursing Home 22/02/06

Burrowbeck Grange Nursing Home 03/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Burrowbeck Grange Nursing Home The Mallards North West Regional Office Scotforth Road Lancaster Lancashire LA1 4XN Lead Inspector Mrs Christine Marshall Unannounced Inspection 12th September 2007 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 Burrowbeck Grange Nursing Home DS0000065247.V340357.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 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. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burrowbeck Grange Nursing Home Address The Mallards North West Regional Office Scotforth Road Lancaster Lancashire LA1 4XN 01524 841876 01524 848699 jim.brown@optimacare.co.uk 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) Optima Care Limited vacant post Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (10) of places Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with nursing - code N, to service users of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, (maximum number of places: 10) Dementia over 65 years of age - Code DE (E) (maximum number of places: 23) The maximum number of service users who can be accommodated is: 23 Date of last inspection 15th August 2006 Brief Description of the Service: Burrowbeck Grange Care Home with Nursing is a detached property, in an elevated position, situated on the main A6 Lancaster Road. The home offers nursing care for 23 residents. There are 17 single bedrooms, one of which has en-suite facilities, and 3 double bedrooms; these are on ground and first floor levels. There is wheelchair access to the home and there is a passenger lift in place. The registered providers are Optima Care and the Responsible Individual is Mr Jim Brown. At the time of this visit, (12/09/07) the information given to the Commission showed that the fees for care at the home are from £497.00 to £650.00 per week, with added expenses for hairdressing and chiropody. Communal newspapers are provided by the home. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process of Burrowbeck Grange included a site visit to the home which was completed during the morning, and unannounced, which means that the manager, staff and residents did not know it was taking place until the inspector arrived. Shortly before this visit, a thematic inspection visit took place, which was a special observation of people with dementia. A report about this special themed inspection was written. An Annual Quality Assurance Assessment (AQAA) record was completed by the acting manager and forwarded to the Commission before this inspection visit: this offered good information about the home and its policies and was helpful in the planning of the visit. Again, on this visit, time was spent sitting and talking with people who use the service and observing the day-to-day routines of the home and care staff, as they provided support. A tour of the home was undertaken and included bedrooms, lounges and dining areas, toilets and bathrooms. This was to assess whether the home provided a comfortable, homely environment for the enjoyment of everyone, and to ensure the residents’ safety. Comment cards were sent to the home for residents and relatives to fill in. 7 resident comments were received by the Commission, 4 were happy with the care and 3 had some issues about communication and not being given enough information about the home, also about occasional malodour in a room and staffing approaches. 4 relatives comments were also received, 2 were happy with the service and 2 raised issues about not enough information prior to admission to the home and staffing provision and staff attitude. Discussions took place with the residents, the acting manager and members of the care staff. Comments from residents included – “I am alright here.” “They look after me.” “The food is alright.” “They (the staff) are very nice.” Administration records were also looked at. Everyone at the home was friendly, welcoming and co-operative throughout the visit. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A number of comment cards were received by the Commission from relatives raising issues about staffing, communication with the manager and staff and the environment’s cleanliness; these issues were focused on during the visit and the outcomes are included in this report. The home’s Statement of Purpose and Service Users Guide did not reflect the registration of the home and the service that it provides. This information is needed when prospective residents (or their representatives) are looking for a home to live in, so that they can get a clear picture of what life will be like at the home. The pre-admission assessments that were in place were not always fully completed; there were gaps in information that was needed to plan and provide individual care services for the people who were going to live there. Any assessments must reflect the actual care that is needed so the residents can enjoy a fulfilling, and good quality of life. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 7 Information in the plans did include a lot of aspects of care, but did not include full social history or hobbies and interests that would give a picture of the person that was being cared for; this collection of information is known as person centred care planning. The manager needs to ensure that all care plans fully reflect the care that is needed and is being given. The medication system was basically safe, however during the special observation inspection visit shortly before this inspection, (mentioned in the summary introduction to the report) it was identified that a resident with dementia had not been given their night sedation for three nights because the tablets were not in stock. The manager should ensure that all residents have the correct medication stocks and that they are given their drugs according to the GP’s prescription. On this occasion, the manager immediately attended to the missing medication. An activities programme was in place, however there were no special considerations for those residents with dementia. The manager should ensure that there is equality of access to appropriate social and diversional activities, so that all who live at the home are valued. There are two bathrooms in use at the home and neither are particularly suitable for the residents to use. Information about this is contained under Standards 19 to 26 of this report. Suitable assisted bathrooms should be provided for the comfort and hygiene of the residents. Some of the bedrooms some were furnished very nicely and personalised, however a number of rooms were malodorous and in need of tidying up. The manager should ensure that the domestic provision for the home ensures that all rooms are clean and free from smells. The home has an ongoing staff training programme, but the manager was unable to provide a matrix of training updates to show the progress of each member of staff and any up-dates or special training programmes such as dementia awareness. A matrix would identify staff achievements and indicate when reviews were needed. The Quality Monitoring system that was in place did not reflect the current registration categories, the residents’ opinions or the current auditing that is planned for the home. The manager should review this to make sure that the residents are given the opportunity to state their views on the care that they are receiving at the home. The policies and procedures that were in place did not elate to Burrowbeck Grange, but to Optima Care’s other care establishment. Policies and procedures specifically for Burrrowbeck Grange should be developed as a matter of priority. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 8 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. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 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 Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide, or gather enough information for and about prospective residents to ensure that their needs can be met. EVIDENCE: Three pre-admission assessments were looked at, which are records of prospective residents’ social, physical, medical and psychological strengths and needs. Although these assessments were in place, they were not all fully completed, which means that information that may be needed to produce and develop a plan of care, was not available. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 11 The home’s Statement of Purpose and Service Users Guide did not reflect the care provision and services for people with dementia. The home has recently changes its category of registration to include care of people with Dementia and the Commission for Social Care Inspection policy guidance states that – When applying for registration in the DE category, the Statement of Purpose should set out, in detail the special support facilities offered and demonstrate how, with reference to sources of good practice guidance, they will secure positive outcomes for people with dementia. This was not evident from the records that were produced on the day of inspection. We requested that the manager forward a reviewed Statement of Purpose and Service Users Guide to the Commission within ten days, however when they were received, again they did not reflect the dementia care that is provided at Burrowbeck Grange; in fact the wrong registration numbers (24) was in the document and the actual registration for the home is for 23. A requirement has been made in respect of this and the pre-admission assessments, at the end of this report. 2 Relatives comment cards that were received by the Commission before the inspection visit which raised issues about not being given full information about the home: At the start of the visit, there were no Statements of Purpose, Service Users Guides or a copy of the most recent report available in the home’s reception. The manager produced copies of the Statement of Purpose for the reception, however these inaccurate in respect of the registered number and categories of people who can live at the home, not updated and didn’t reflect the care that is provided at the home. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents health and social care needs not always met and records need attention. People are mostly treated with dignity and respect at this home. EVIDENCE: Care plans are records of the care that is given to each person who lives at the home. Three of these were looked at and found to be in need of review and updating. Although some of the plans were quite reflective of the care that was given, some plans had gaps in information such as religious and marital status, and no evidence of resident or relative involvement in the care plan. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 13 As stated under the heading “What they could do better” in this report, information in the plans did include a lot of aspects of care, but did not include full social history or hobbies and interests, that would give a picture of the person that was being cared for; this collection of information is known as person centred care planning. For the dementia resident, there was not always evidence of any special provision for their communication abilities, mental competences or person centred care consideration. This lack of information may result in equality of care for those who are unable to express themselves, or speak for themselves. A requirement in respect of this has been made at the end of this report. Two relatives’ comment cards that were sent to the Commission, raised issues about management and staff communication and adequate care planning at the home, which could lead to residents not being given the right care. There are a number of new members of staff at the home, who might be in need of time to build up relationships with the residents and their relatives. Advice was given in respect of the staff communication with relatives and representatives and the manager said that she was always available for relatives when she was one duty. However, a recommendation in respect of this has been made at the end of this report. Not all of the care plans contained a photograph of the resident (with their permission) for identification. The manager was attending to this for the purpose of identifying each resident at the home. The care plans did however contain evidence of access to health care such as GP, optician and chiropodist. The medication system appeared to be basically safe, however during the special observation inspection visit shortly before this inspection, (mentioned in the summary introduction to the report) it was identified that a resident with dementia had not been given their night sedation for three nights because the tablets were not in stock. This is unacceptable as daily records showed that this caused the resident to be anxious and distressed. The medication ordering system must be reviewed to make sure that residents always have their medicines and tablets according to their GP advice and prescription. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 14 On checking the Medication Administration Records (MAR) for the residents it was also found that a hand written drug instructions had been signed by one nurse and not countersigned as was advised by the Commission’s Pharmacy Inspector in line with the Royal Pharmaceutical Society guidelines. Also not all MARs had photographs of the resident for identification purposes. Again the manager was attending to this. A requirement and recommendation has been made in respect of this at the end of this report. On general observation, the residents were treated with dignity and respect, with the staff speaking calmly and courteously to all of the residents. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents could benefit more by being better supported, so as to promote the quality of their daily lives. EVIDENCE: It was found that although there was a varied programme of activities for the general residents at the home, such as bingo and carpet bowls, there was not an appropriate programme of activities suitable for the resident with dementia. The manager was asked to provide a programme for this and forward it to the Commission: This was not received and a requirement has been made in respect if this inequality of care at the end of this report. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 16 Although there were many instances of good practice during the inspection, on one occasion a resident was given a morning drink without being offered a choice of tea or coffee, and two biscuits were brought into the room placed on to the resident’s table without a plate or napkin. The resident did not make any comment about this. This indicated that there may be issues about the resident’s’ choice and equality of care. We advised the manager of this who said that she would supervise and monitor staff closely. A recommendation has been made at the end of this report. During the visit is was evident that the residents’ were able to have visits from relatives and friends at all times and comment cards that were forwarded to the Commission and the home’s open-door policy confirmed this. Staff also said that relatives and visitors were welcomed at all times. The midday meal looked nourishing and appetising and the mealtime was relaxed and unhurried. Most of the residents were unable to make comment of the food, but those who could said that it was good. Comment cards that were received before the inspection visit also confirmed that there were no complaints about the food. The cook on duty was aware of the residents’ preferences and dietary requirements, such as diabetic or salt-free meals. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are protected by policies and procedures and appropriately trained staff and able to voice their concerns. EVIDENCE: There are policies and procedures in place for concerns and complaints. There have been four complaints during the past twelve months and these have been dealt with under the home’s policies and procedures. All staff have had abuse awareness and Protection of Vulnerable Adults (POVA) training. During this visit the majority of staff showed that they were caring and considerate and two carers were able to explain the issues of abuse and the prevention of this. In view of the incident mentioned in respect of a carer not being seen to ask a resident what they prefer for morning drinks, and also using etiquette and providing plates or napkins when giving biscuits, the manager was advised about the residents right to raise concerns about their choice and preferences, Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 18 and the need to supervise and monitor all staff member’s attitude and approach when they were dealing with and caring for the residents. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are in the most part provided with a comfortable environment and bedrooms are personalised, which means that residents feel at home with their belongings around them. However, inadequate bathroom provisions and lapses in basic hygiene could compromise the residents’ wellbeing. EVIDENCE: A tour of the home was done and the outcome for this set of standards would have been good but for some bedrooms and bathroom provision. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 20 There is equality of care in that the home provides aids and adaptations in toilets such as grab rails and raised toilet seats and there are ramps and a passenger lift for those with mobility problems. A number of bedrooms were visited and some were refurbished and clean, hygienic and very personalised; however some rooms were untidy, had malodour and were in need of refurbishing. The maintenance man was very busy refurbishing the lounge area and the manager said that there was an unwritten refurbishment plan for the home over the next few months. The two bathrooms that were looked at were not really suitable: The ground floor bathroom was cluttered and not cleaned, with a waste bin with no lid on that could have been a source of cross infection. Two other waste bins were found to have no lids; again this could be a source of cross infection. The first floor bathroom had been repainted and cleaned, however this is a very high bath with a fixed hoist, which has to lift the resident very high to get into the bath. This would be quite intimidating for any resident who was being lifted and this has been commented on during other inspection visits. The home has had plans to refurbish and rebuild shower rooms and bathrooms at the home, but this has not come to fruition after over a year and a requirement has been made in respect of this at the end of the report. Generally the home provides comfortable furnishings and furniture and was quite clean, however the front conservatory was cluttered with boxes and stacked chairs making is unusable for the residents; this might encroach on the minimum space requirements for the residents at the home. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents care needs are met through adequate staff provisions who mostly are appropriately trained. EVIDENCE: Staff duty rosters showed that there were adequate staff on duty. There were sufficient domestic staff on the roster, however when it was pointed out that some rooms were in need cleaning, late on the morning of the inspection visit, the manager said that the domestic was due to come on duty shortly. It is recommended however, that the manager review the domestic duty hours so that the cleaning can be done earlier rather than later in the day. Should residents wish to go to their rooms in the afternoon, say with their relatives or representatives, then the bedrooms should be clean and tidy for their comfort. A recommendation has been made at the end of this report. Over 50 of the care staff have achieved their National Vocational Qualification (NVQ) at level 2, which is good. This means that the residents are Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 22 being cared for by staff who are adequately trained and competent to do their jobs. Some carers had already undertaken the dementia awareness course and there were plans for all staff to undertake dementia awareness training over the next six months. Two carers said that they had given mandatory training and also some training in dementia care. The manager is also planning to do a University course in dementia care. Staff recruitment files were sampled and found t o be mostly satisfactory. One did not have a photograph for identification and the manager said that she would attend to this immediately. The staff are all given mandatory training and plans are in place for all staff to have refresher courses within the next few months and the AQAA information also confirmed that this was the case. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are basically supported but the quality systems in place need to make sure that the residents are consulted. EVIDENCE: This set of standards would have been assessed as having a good outcome but for the lack of relevant policies and procedures that related to the home and Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 24 also the quality system that did not include residents and relatives’ views, or display the outcomes of any surveys for the stakeholders to see. The manager is very experienced and qualified in the management of care homes, and gave assurances that she was always available to speak to residents and relatives whenever she was on duty. The home’s Statement of Purpose and Service Users Guide that the manager produced was not current, and did not reflect the dementia care services that the home provide. This is an essential document that is used to provide information about the home and its services. On entering the home, the conservatory to the side of the reception was cluttered with medication boxes and chairs, making it unusable for the residents. This needs to be checked to make sure that this area is not part of the required 4.1 sq metres of communal space per resident that the home provides. Also, it may be an inequality of access to areas of the home that some residents might want to use. A recommendation has been made at the end of this report. Although there was a training day ongoing during the inspection visit, the manager was not able to produce a training matrix that would identify whether or not all of the staff had been given mandatory and dementia care training. The Quality Monitoring system that was in place was inherited from the previous owners and did not reflect the current registration categories, the residents’ opinions or the current auditing that is planned for the home; the manager brought a folder of new policies and procedures to be implemented at the home, but these were written for Optima Care’s other establishment which is quite different from Burrowbeck Grange. The administrator gave assurances that all financial records were accurate and up to date and samples of the Health and Safety service and maintenance checks showed that these were all current, making sure that the residents were safe. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 26 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 OP 3 Regulation 14 Requirement Pre admission assessments must be fully completed before admission to the home. If these are not in place, then the resident may have needs that the home cannot meet. An up to date statement of purpose and service users guide must be produced. If sufficient and accurate information is not provided, then prospective residents may not be given the right package of care to meet their needs. This is a requirement from the two previous inspection visits that has been given a final extended timescale. Timescale for action 31/10/07 2 OP4 4&5 31/10/07 3. OP7 17 31/10/07 Care records must be fully completed and include information on residents’ strengths as well as needs. They should be reviewed and up-dated regularly. This is a requirement from the previous inspection visit and has been given a final extended timescale. DS0000065247.V340357.R01.S.doc Version 5.2 Page 27 Burrowbeck Grange Nursing Home 4. OP9 13 Residents must be given their prescribed medications at all times. If residents do not have their prescribed drugs it could cause illness, anxiety and distress. A dedicated programme of activities suitable for the dementia resident must be developed. Lack of appropriate social and diversional activities may well compromise the residents’ quality of life. Adequate and suitably furbished bathroom facilities must be provided according to agreed plan, to facilitate the levels of need of the residents. If adequate bathing facilities are not provided, the residents’ may have inequality of access to satisfactory bathing facilities and their health and welfare will be at risk. This has been strongly recommended on all previous inspection reports and required on the previous inspection visit of 13/8/07. This has been given a final extended timescale and must be addressed. The laundry area must be reviewed and improved facilities put in place. If laundry facilities are not in an area that can be kept properly clean and supervised then cross infection and hygiene may be compromised. This has been an issue for over twelve months and has been given a final extended DS0000065247.V340357.R01.S.doc 31/10/07 5 OP12 12 31/10/07 6 OP21 16 01/12/07 7. OP26 16 01/12/07 Burrowbeck Grange Nursing Home Version 5.2 Page 28 timescale and must be addressed as a matter of priority. 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 Good Practice Recommendations All care plans should include a photograph of the resident (with their permission) for identification and to consolidate the person centred approach to care planning. All hand-written drug instructions should have two signatures. Hand written drug records that are not countersigned may contain errors and be unsafe for the residents. Photographs of each resident should be attached to the medication records for the identification of each person that is being given drugs. This would minimise any errors when dispensing medicines, especially when new or agency staff are on duty. The manager and staff should at all times have an open channel of communication with the residents and their relatives. Residents should always be offered choices as to their diet and daily care. If this is not maintained, then there may be inequalities of choice and care, and residents’ quality of life me be lowered. The manager should make sure that the minimum space requirement for the communal space at the home is maintained by checking that the conservatory is not included in this measurement. Residents should be able to access all facilities, including the conservatory provided by the home at all times. The home should be kept clean and hygienic throughout and all waste bins should have lids on to ensure proper infection control and the health and hygiene of the residents. There should be appropriate policies and procedures in place to ensure that quality of care is provided for the residents. If there are no policies, then staff and residents cannot relate to a standard of care that is acceptable to DS0000065247.V340357.R01.S.doc Version 5.2 Page 29 OP9 3 OP14 4 OP20 5 OP26 6 OP33 Burrowbeck Grange Nursing Home all. Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Burrowbeck Grange Nursing Home DS0000065247.V340357.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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