CARE HOMES FOR OLDER PEOPLE
Burrowbeck Grange Nursing Home The Mallards North West Regional Office Scotforth Road Lancaster Lancashire LA1 4XN Lead Inspector
Val Turley Unannounced Inspection 11th September 2008 09:15 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.V367551.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.V367551.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 Valerie Francis 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.V367551.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 12th September 2007 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 Syd Coombes. At the time of this visit, the information given to the Commission showed that the fees for care at the home range from £503.50 to £695.00 per week, with additional expenses for hairdressing, private chiropody and sundries. Communal newspapers are provided by the home. Burrowbeck Grange Nursing Home DS0000065247.V367551.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, quality outcomes.
This was an inspection that took place over a twelve-month period and culminated in a site visit to the home in September 2008 by one regulatory inspector. This visit was unannounced, which means that the manager, staff and residents did not know it was to take place until the inspector arrived. During the twelve months prior to this site visit two additional unannounced inspections had taken place to look specifically at the management of medication in the home. The inspection involved discussion with people living at the home where this was possible, discussion with staff, observation of staff supporting the residents and an examination of records, policies and procedures. Every year the registered persons are asked to provide us with written information about the quality of the service they provide and to make an assessment of the quality of their service. We use this information, in part, to focus our inspection activity. The manager completed this self-assessment (AQAA) and sent it to us before the site visit. Information was also provided through surveys recently completed and returned by 7 members of staff. They all included positive comments including ‘everyone is made to feel welcome’ and ‘this is their home’. During the course of the site visit residents praised the staff team, one said ‘they are very good and kind and always help me when I need it.’ As part of the inspection, the inspector used ‘case tracking’ as a means of assessing some of the National Minimum Standards. This process enabled the inspector to focus on three of the people living at the home. Records relating to those individuals were inspected and discussion took place with them where possible and with the staff team in relation to their support needs. What the service does well:
The home provides a comfortable, clean and homely environment for the residents who live there. The home has a good pre-admission procedure during which they assess the needs of the prospective resident to ensure that they are able to meet those needs. Care plans are detailed and give a good outline
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 6 of the individual needs of the residents; additionally the staff team have a good knowledge and insight into the needs of the residents. The health care needs of the residents are addressed appropriately and the medication in the home is managed well, helping to ensure that the residents remain well and comfortable. One of the residents said that the staff always call for the GP if they are unable to help her. The home has a varied programme of daily activities that range from group activities to 1-1 support from members of staff. Food is enjoyed with residents being given a choice of dishes. Individual dietary needs and preferences are taken into account. The daily routine in the home is relaxed with residents able to make choices and decisions as to how they can spend the day. Visitors are made to feel welcome and can visit at any reasonable time of the day. A visiting relative said she is never made to feel in the way. The home is well staffed and the staff team is well trained and feel well supported by the management. They were knowledgeable about the support needs of the residents and were sensitive in their approach. They were observed to ensure that the privacy and dignity of the residents was respected. The home uses few agency staff so that the residents are mostly supported by staff who are aware of their individual needs. The manager is experienced and qualified and has worked hard since taking up her post to make improvements at the home. The home had a number of quality assurance processes that they followed to help ensure that the home runs smoothly. The views of the residents were surveyed, care planning processes were audited and equipment and systems appropriately checked and maintained. Staff were encouraged to attend staff meetings and received regular supervision from a senior member of staff. What has improved since the last inspection?
A number of improvements have been made to the home since the last key inspection. An up to date statement of purpose and service user guide have been produced outlining the care and support residents can expect from the home. Pre-admission assessments are completed prior to a resident being admitted to ensure that the home is able to meet the needs of the resident. Care plans are fully completed and are reviewed and updated regularly to reflect the changing support needs of residents. Medication is much better managed, records are maintained and there is a more effective audit of medication in the home. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 7 More attention has been paid to the provision of activities in the home and advice has been sought from an occupational therapist in terms of how best to involve the residents in activities. The home has been redecorated and refurbished and provides a clean, homely and comfortable environment for both the residents who live there and the staff who work there, although the home recognise that some areas of the home are not ideal e.g. the laundry and the downstairs bathroom, these have been improved as far as is possible. Future plans to extend the home will overcome any problems associated with these areas. What they could do better:
There were a number of areas where the home could make improvements to the way it runs and as a result provide a better service for the residents who live there. The pre-admission assessment could be improved so that it includes more information regarding the interests and hobbies of the residents, enabling staff to be more pro-active in ensuring that a resident is able to follow their interests. Documentation should always be signed and dated to enable staff to monitor a residents needs more effectively. Care plans should be written in a more person centred way so that the strengths, choices and preferences of a resident are clearly expressed, giving staff a better picture of a residents support needs. Policies and procedures used in the home must be relevant to the residents and to the establishment. This would help staff to attend to resident’s needs more effectively, provide them with a greater measure of protection and also help them to run the home more efficiently. In particular the complaints policy and procedure and those policies and procedures relating to protection must give clear guidance as to the steps staff should follow when concerns are raised. The registered person must only employ staff when all the necessary checks and references have been undertaken and are found to be satisfactory as a thorough recruitment policy helps to protect the residents in the home. The self assessment from (AQAA) completed by the manager prior to the site visit should have been filled in more fully and must contain more detail of how the home intends to improve the quality of service it provides. Burrowbeck Grange Nursing Home DS0000065247.V367551.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.V367551.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.V367551.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): 3. Standard 6 was not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure it has enough information about a residents support needs and that they are able to meet these needs before they are admitted to the home. EVIDENCE: During our visit to the home we looked at several residents files and in particular at the file of someone who had recently been admitted to the home. From these it was clear that the home undertakes an assessment of the residents needs before they are admitted to the home. This enables them to decide if they are able to provide the support that the resident needs. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 11 Some improvements could be made to the way the information is recorded and in particular more emphasis should be place on the interests and hobbies of the resident – although it was noted that this information is included within the care plan. Care also needs to be taken to make sure that documents are signed and dated, this will help the staff note any progress that the resident makes or highlight greater support needs. There was evidence that relatives and residents had been involved in the drawing up of the care plans. One relative said she was very happy with the approach of the home and the way they had worked to help settle her mother in. Each of the residents had a plan of care that had been developed from the preadmission assessment. The plan outlined the care and support the resident needed. The home had an up to date service user guide that was available in each of the residents bedrooms. This outlined the services the home provides and what the resident could expect from the home. Burrowbeck Grange Nursing Home DS0000065247.V367551.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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and social care needs of the residents are met and residents are treated with dignity and respect. EVIDENCE: During the site visit the care plans of three residents were examined. One of these was examined in detail and the care of the individual was tracked to make sure that the resident was receiving the support as identified within the care plan. The plans contained some good information about the resident’s preferences and daily personal care needs. They also contained a number of risk assessments that identified those areas where the residents needed additional support and care. Both the care plans and the risk assessments had been
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 13 updated on a monthly basis to help ensure that the needs of the residents were adequately met. Where the care of the resident was tracked, it was clear that the resident was receiving the support as outlined in the plan. A member of staff was knowledgeable about the residents needs, had given consideration to them and was pleased at the progress she had made since being admitted to the home. The staff were observed to ensure that the privacy and dignity of the residents was respected and a visitor said that the staff certainly respected the privacy and dignity of her relative. The resident’s health needs had been identified throughout the care plan and there was evidence that they were being attended to. One of the residents said that the staff always called for the GP when she is unwell and the nurses are unable to help. A number of different health professionals are involved in the home providing care and support as and when necessary. It was recommended that the plans be written in a more person centred way and that they should concentrate more on the strengths, abilities and preferences of the residents rather than just their needs. The daily record should also be completed in more detail and give specific information as to the care provided on a daily basis to residents. Medication within the home seemed to be well managed. Two random inspections had been made to the home earlier in the year when some deficiencies had been highlighted in its management. These deficiencies had been addressed. Medication was dated on opening and a record of the receipt and return of medication was being kept. Controlled drugs were being well managed. Staff had received training in the administration of medication. Staff were observed to ring up both the pharmacy and the GP to sort out medication issues. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported to make choices and decisions to enable them to have a good quality of daily life. EVIDENCE: It was found that there was a varied programme of activities for the residents at the home, such as bingo and carpet bowls, gardening and invited entertainers. A file had been put together at the home by an occupational therapist and this included a range of possible activities. A member of staff said that although there is a timetable of activities it was not always possible to keep to this as it depended very much on the willingness and ability of the residents to join in. The member of staff said that they were always encouraged to use their initiative with activities and provide 1-1 support wherever possible. During the course of the site visit a member of staff was observed reading a newspaper to a resident. One of the residents confirmed that there were activities that she sometimes joined in.
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 15 The lunchtime period was observed. Residents said that they enjoyed the food and a visiting relative said that the cook had worked extremely hard to provide her mothers favourite meals when she was first admitted to the home, helping her to settle in. Staff were observed to offer sensitive support to the residents at lunchtime and they were aware of the dietary needs of the individual residents. The mealtime was unhurried. A relative confirmed that there were choices available each day. New menus were in the process of being prepared taking into account the needs and preferences of the residents. Visitors were observed to be made welcome to the home and one relative said she was never made to feel in the way even though she spent a lot of time there. The resident’s care plans contained elements that stressed the need to allow residents to make choices and decisions themselves. One of the residents said she stayed up late at night and could get up when she liked in the morning. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are not fully protected by relevant policies and procedures, however staff are trained in the protection of vulnerable adults and residents feel able to voice their concerns. EVIDENCE: Since the last inspection only one complaint had been logged and this had been responded to appropriately by the home. The manager said that they had learnt from this complaint and had put things in place to prevent it from happening again. Staff have had abuse awareness and Protection of Vulnerable Adults (POVA) training and those staff spoken to were aware of the action they should take if they became aware of any concerns or incidents of abuse. During the site visit the staff showed that they were caring and considerate and sensitive to the needs and preferences of the residents. Those residents who were spoken to were aware of who they would speak to if they had any concerns about the care they were receiving at the home.
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 17 Unfortunately the policies and procedures in relation to complaints and protection were not available on the day of the inspection. These were provided after the visit to the home but they were not appropriate for a residential care home, having been produced for a different type of service provided by Optima Care. The home must work to appropriate policies and procedures to help ensure that the residents are adequately protected. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 18 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are provided with a clean and comfortable environment which means that the residents can feel at home with their belongings around them. EVIDENCE: On the day of the inspection a tour of the home was undertaken to look at the environment as a whole to see if it was of an acceptable standard. A great deal of redecoration and refurbishment has taken place with new carpets, curtains and furniture having been provided. Everywhere was clean and tidy, there were no odours and the home was comfortable.
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 19 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 these and were comfortable, clean and hygienic and had been personalised by the residents. The maintenance man was present at the home and was attending to any necessary repairs. The bathrooms were bright, fresh and clean having been recently refurbished. They had been appropriately equipped to allow residents to use them more easily. Access to the facilities in the ground floor bathroom is limited but the shape and layout of the room, plus its position in the home, make this difficult to change. The home is fully aware of the limitations of this room and has researched ways of how it may be changed for the benefit of the residents. Unfortunately none of these are easily achieved. There are plans in place to extend the home and this would enable the home to adapt this bathroom successfully. In the meantime there are facilities elsewhere within the home for those residents who may find it difficult to access this one. The laundry had new equipment installed. Again the building was not ideal as it was situated outside, however improvements had been made to it since the last inspection. It is kept clean and tidy to reduce the risk of infection. A planned extension to the home will provide a new laundry. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 20 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): 27,28,29 and 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 by well-trained and well-supported staff, helping to make sure that they receive a good quality of care. EVIDENCE: There were sufficient staff on duty on the day of the site visit. The atmosphere was relaxed and staff appeared to be confident in their role. The staff spoken to said that they felt that there are usually enough staff on duty to meet the needs of the residents and that it is only when staff are absent at short notice that they feel under pressure. The home uses few agency staff so that the residents are mostly supported by staff who are aware of their individual needs. The home was clean and tidy, indicating that the home employed sufficient numbers of domestic staff to maintain these standards. 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.V367551.R01.S.doc Version 5.2 Page 21 being cared for by staff who are adequately trained and competent to do their jobs. Staff said they were given very good training opportunities and the training records confirmed this, with staff having attended a wide range of courses including mandatory training. The manager is also planning to start a University course in dementia care. We looked at some staff recruitment files. It was clear that the home knew what process should be followed and what checks needed to be made, before someone could start work at the home, but there were two instances where staff had started work before their references had been received. The manager must ensure that no one starts work at the home before these checks are undertaken so that the residents are protected as far as is possible. Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 22 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): 31,33,35 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager has made changes in trying to make sure that the home is run in the best interests of the residents, however further fundamental changes and planning must take place so that residents may receive an improved service. EVIDENCE: The manager is experienced and qualified in the management of care homes, and gave assurances that she was always available to speak to residents and
Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 23 relatives whenever she was on duty. This was confirmed by the staff on duty and by a visiting relative. The manager is about to commence a course in dementia studies and the deputy manager is working towards the registered managers award. Those members of staff spoken to said that they worked for a strong and reliable team and that they felt very well supported by the manager of the home. They said they felt able to speak to the manager about any concerns they may have or to make suggestions as to how things may be organised differently. Team meetings were held and staff received regular supervision from a senior member of staff. A survey of the resident’s views on the home had been undertaken earlier on in the year and the feedback from this was generally positive. The home was also working towards the ‘Investors in People’ award which is a quality assurance award accredited by an external organisation. Unfortunately the homes policies and procedures were not available on the day of the site visit, but those policies and procedures which were forwarded on to us following the site visit were written for another Optima Care’s establishment which is quite different from Burrowbeck Grange. They were not appropriate for a residential care home setting. And as such may result in residents not receiving relevant care and support. The self assessment from (AQAA) completed by the manager prior to the site visit was poorly completed and should have contained more detail of how the home intends to improve the quality of service it provides. The administrator gave assurances that all residents’ financial records were accurate and up to date and those checked were accurate. Samples of health and safety and service and maintenance checks showed that these were all current, making sure that the residents were safe. A number of audits were undertaken throughout the home helping it run for the benefit of the residents. Training in relevant aspects of health and safety is delivered to all staff and incidents and accidents are reported and managed appropriately. Burrowbeck Grange Nursing Home DS0000065247.V367551.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 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP16 Regulation 22(2) Requirement The complaints policy and procedure must be appropriate to the needs of the residents of the home to help ensure that their concerns are dealt with efficiently. Timescale for action 30/11/08 2 OP18 13(6) The policies and procedures 30/11/08 relating to the protection of the residents must be appropriate to their needs. Any concerns raised must be dealt with efficiently and in accordance with local procedures. The registered person must not 30/10/08 employ a person to work at the care home unless the necessary checks and references have been undertaken and are found to be satisfactory. A thorough recruitment process helps to protect the residents. There should be appropriate policies and procedures in place to ensure that a good quality of care is provided for the residents. Inappropriate policies
DS0000065247.V367551.R01.S.doc 3 OP29 19 4 OP33 12(1) 31/01/09 Burrowbeck Grange Nursing Home Version 5.2 Page 26 do not give staff the correct guidance and may lead to residents not receiving the right care and support. 5 OP33 24 The registered person must, when requested, provide a selfassessment that explains in detail how the home intends to improve the quality and delivery of the services provided in the care home. 31/10/08 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 OP3 OP3 Good Practice Recommendations Care should be take to ensure that all documents are signed and dated to enable a residents support needs to be monitored more effectively. More information regarding a residents hobbies and interests should be recorded as part of the pre-admission assessment. This would help staff provide relevant help and support to the resident enabling them to follow their interests. Care plans could be written in a more person centred way, placing more emphasis on the strengths and preferences of the residents. The daily record should be more detailed giving a clear account of the care and support each resident has received during the day. This would enable the staff to have a much clearer picture of a residents needs. 3 4 OP7 OP8 Burrowbeck Grange Nursing Home DS0000065247.V367551.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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
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