Inspection on 03/05/07 for Burstow Lodge

This inspection was carried out on 3rd May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burstow Lodge 07/06/06

Burstow Lodge 10/02/06

Burstow Lodge 12/07/05

Burstow Lodge 26/01/05

Burstow Lodge 26/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Burstow Lodge Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 3rd May 2007 10:10 Burstow Lodge DS0000006919.V339211.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 Burstow Lodge DS0000006919.V339211.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. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burstow Lodge Address Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ 020 8659 6874 020 8776 9833 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) Mills Family Limited Terence Michael Smith Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 13 Adults of either sex with a learning disability and or a mental illness Date of last inspection 7th June 2006 Brief Description of the Service: The home is a detached house located in a residential area of Penge. It has parking to the front of the building and an enclosed garden to the rear. Bedroom accommodation is located on all floors. There are two dining areas and kitchens, one of which is used specifically for rehabilitation sessions. There is a large bright lounge furnished in a domestic manner. The home is registered for thirteen places however the maximum number that the home takes is twelve, as one double bedroom is used as a single. Bedrooms were personalised, clean and tidy as were all areas in the home. The range of fees for this home are £750 - £1200 per week. The inspection report is available in the main hall for anyone to access. In the event that residents need assistance with the reading/understanding of the report, staff would assist. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced over the period of one day .During the course of the day the inspector met with residents individually and in groups. The Manager facilitated the inspection. The inspector met with three staff .The inspector selected two care plans to case track, met with the residents and after the inspection contacted next of kin, care managers and members of the multi disciplinary team for feedback on the service. This could not be addressed prior to the inspection, as the pre inspection questionnaire was not returned to CSCI. The Manager stated that he had not received a pre inspection questionnaire for completion. Residents in this home are subject to Care programme Approach (CPA) after care systems. This is a system of aftercare monitoring and reviews by the multi disciplinary team to support and enable residents to live in the community. During the site visit the inspector accessed records relating to staff recruitment, staff training, quality assurance audits, health and safety certification. In general, the feedback received from resident’s relatives and other professionals was positive in respect of the improvements in the service. Members of the multi disciplinary team confirmed this citing examples of active rehabilitation for residents, more structure in the home and improved leadership and guidance overall. What the service does well: The home provides education, support and rehabilitation to those residents living in the home. The main focus of this is to enable residents to live more independently, and it has been successful in moving residents on to more independent accommodation. The home works closely with members of the multi disciplinary team for the best interest of residents. Staff are safely recruited and there after provided with on going supervision training and support to work effectively. The home is well kept and domestic in style with such a client group this can be difficult to maintain. On call and emergency arrangements are in place which provides staff with support should untoward events or occurrences take place. Quality assurance measures are in place to audit and improve the service. Opportunities are provide to enable staff and residents to give feedback on the services. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments are undertaken to establish the needs of the residents although current supporting information provided through the CPA, and the multi disciplinary teams was lacking. Comprehensive assessment documentation should be obtained in order to furnish staff in the home with sufficient information to address resident’s needs and to establish that resident needs can be met within the home. EVIDENCE: The inspector selected two care plans for case tracking and viewed the documentation relating to the assessment process. The last resident admitted was on 4/4/07. This resident had been issued with Terms and Conditions through the Mills Family, which included reference to the trial period, the fee, and the room to be occupied. The residents had signed this document. The contract issued through the funding authority had not been received by the home. The resident’s property list was incomplete. Burstow Lodge assessment sheet was completed, dated 1/3/07.The Manager had undertaken the assessment which is the usual process. The document format a tick list with information added as appropriate. In Burstow Lodge, where there are residents with complex health issues, both physical and Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 9 mental in nature, comprehensive information must be obtained prior to admission. The inspector was unable to locate any information received from the multi disciplinary team. The updated Care Programme Approach (CPA) Assessment, care plan or risk assessment were not available. The last one on file was dated 28/2/06. There was no Community Care Assessment or single care management assessment-health and social services, on file either. The Manager confirmed that neither of these documents had been received although requested. In the document dated 28/2/06 reference to a history of violence was recorded. It was stated that this was not a current issue, although staff needed to be aware of it. There was a reference to a pre admission visit which took place 5/3/07.There was no information in this entry giving an overview of the visit. Another document dated 19/4/07 was completed this was headed “ Burstow Lodge assessment sheet “, which is completed once the resident is admitted. The contact information in respect of this resident was completed. The assessment information of another resident was inspected; they had been in some time almost three years. It too contained terms and conditions from the Mills Family and the Local Authority contract. The registration certificate is in the process of being changed to reflect bed numbers of 12 previously it was for 13 residents. The double bedroom in the home had not been used as such for some time, and provides single accommodation only. The certificate is currently with the CSCI for amendment. The Statement of Purpose was available in the hall and Service User Guides were in individual bedrooms. Please see requirement 1. Burstow Lodge DS0000006919.V339211.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and enabled to maximise their daily living skills through the staff team and support from multi disciplinary professionals. They have choices in their lives and are supported to be as independent as possible. Documentation and care plans supported these finding although CPA reviews should be followed up. EVIDENCE: Residents in this home are undergoing rehabilitation in order that they may within a three year period, develop enough skills to allow more independent living. The main thrust of the support is integration in to the local community, accessing services including those for health and leisure as well as to using public transport. Daily living skills such as budgeting, cooking, shopping and attendance to laundry are promoted by staff. The care plan of the most recently admitted resident was inspected. The care plan was dated 10/4/07 six days after admission. In all cases an initial care plan needs to be in place within 48 hours to address the main areas of support required and identified risks. This can be developed and expanded upon as more information is obtained The care plan outlined mental health issues , Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 11 activities of daily living and financial support required by the resident .The interventions section provided staff with good information whereby they could address the identified problem. The resident did confirm that they had seen the care plan although the document was without the residents signature .The staff signature was also omitted as was the review date, although there is a statement on all care plan documentation relating to frequency of reviews. The supporting risk assessment documentation is laid out in two parts , one is a general risk assessment where all aspects of daily living are assessed. The second part is the actual risk assessments to address those areas identified as high risk. The individual missing persons risk assessment was incomplete without the residents description, height , build etc, although a passport photo was attached to the documentation . Some of the documentation was without full staff signature, and first names only recorded. A second care plan was inspected. It too, was without current CPA information, the last record relating to this was dated 12/1/05, it did however contain good information. The inspector followed this up with CPA coordinator for this service .He explained that there had a lack of reviews conducted due to staff absences and vacancies. This resident’s care plan covered mental health issues activities of daily living and financial affairs. The resident’s signature and the staff member’s signature were in place. Reviews had been undertaken including those for the risk assessments. Within the care plan documentation there is a separate sheet for entries in respect of multidisciplinary visits or attendance to out patients or the GP surgery. In those care plans inspected these were completed. Records of regular weight checks were in place as was a record of activities. As residents in this service are under CPA aftercare systems, it is important that the care plans and risk assessments in the home reflect the content of the CPA care plan and identified risks, in order to promote a consistent approach, hence, the need to ensure the current documentation is received by the home. Individual key worker sessions take place and serve as an opportunity to discuss the progress made on areas identified through the care planning system. Burstow Lodge DS0000006919.V339211.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to access local services including health and leisure. Visiting arrangements are flexible to enable residents to maintain relationships with friends and family. Staff in conjunction with the multi disciplinary team maximise opportunities for personal development and integration in to the community to achieve the goal of more independent living. EVIDENCE: During the course of the inspection residents were coming in and going out to different activities in the community .One resident met the inspector as she approached the home on his way to MIND. He enjoyed MIND and had several friends in the centre. He stated that within the home there were more weekend activities organised which he participated in. He felt that the Manager was approachable and encouraged residents to be more active and involved with activities and participation in the community. Most residents use public transport to get around. Free bus passes encourage this. Residents are encouraged to access health facilities in the community and as well as educational and College courses .One resident explained to the Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 13 inspector that he was attending College doing a number of subjects including cooking . All residents have a key to their bedroom door although not to the front door. This was raised as an issue for one resident who did not want to have staff waiting up for home on his return. This was related to the staff team. The residents who were included as part of the case tracking confirmed the activities, which were included in their care plans. Residents told the inspector, about meals which they had prepared and cooked, and for some this had given them a sense of achievement. One resident is working with staff and the Occupational Therapist (OT) on a calorie controlled menu, to achieve weight loss. This resident is seen regularly by the OT, who provides support and advice to the resident and staff. Individual menus are prepared for residents ,and staff work with residents to shop prepare and cook their individual meals .Once a week all residents sit down to eat together . On Sunday the majority of the residents attend the MIND centre and have a Sunday roast. Residents stated they enjoyed this. There is a Monday club, which goes on till 10 pm organised through MIND. Feedback from multi disciplinary professionals was positive referring to the fact that residents were more motivated engaged more with service s and the emphasis on rehabilitation significantly increased. Burstow Lodge DS0000006919.V339211.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): Quality in this outcome area is adequate .This judgement has been made using available evidence including a visit to this service. Residents are enabled to access heath care through local community services as part of ongoing rehabilitation .Staff promote self medication again equipping them with skills for independent living . EVIDENCE: In this home all residents are, with prompting and supervision able to address their own personal care. All residents must be mobile as there are no mobility aids or equipment, including a lift. Residents in this home are encouraged and supported to access all services in the community. This means that residents attend GP appointments, out patients, dentist and other health facilities usually unaccompanied. This is to encourage independence and promote living in the community. This can however cause a breakdown in communication particularly if the residents or health professionals do not inform the home of their visit. The home may not be aware of important decisions reached during that consultation .Another area raised specifically related to resident’s appointments, which were sometimes aborted because of non attendance by the resident, due to a lack or Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 15 breakdown in communication, between staff or residents ,or residents themselves sabotaging appointments . There were records relating to health appointments that residents had attended. The home records accidents in a data protection compliant accident book. There have been two since January 2007 and non have required reporting under RIDDOR. There is always a trained first aider on duty to manage an accident . The medications were inspected. Each medication chart had the residents photograph in place. A list of their current medications was attached which also indicated any side effects that may occur. This is good practice. The allergies that residents may suffer, were on a sheet in the front of the charts. On some occasions the medications had not been signed as received into the home, although the MAR (Medication Administration Record) sheet, has space to record this. All medication received into the home, returned to the pharmacy or destroyed must be recorded .There was discussion about this with a staff member who pointed out that it was a pre packed system. Errors can still occur and checking provides further safeguards to residents. Particularly in the pre packed systems medications can become dislodged and filter into another part of the pack. The home operates the Boots monitored does system. Amendments to charts need to have two staff signatures except where a GP has authorised this. Those medications which are administered, as required, need to have full instructions included particularly the maximum dose, reason for administration, and where applicable duration. The medication cupboard itself was tidy with no overstocking evident. Those residents who go on weekend leave have their medications pre prepared in to individual blister packs .The medications are handed to a responsible individual either the resident themselves or a family member, and signed out by staff as given. Within the home there are two residents who self medicate. Specific risk assessments are in place to address the safety and competence of the individual. These risk assessments were checked and both were about a year old. It is recommended that these are reviewed as necessary or have an annual review. Staff were aware of where to access the reference books for queries on medication and also cited the pharmacist as an advisor. Staff confirmed that only those who had received training to administer medications did so. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 16 The inspector asked about Controlled drugs and was advised non were in use at present although Temezepam had been in use recently. The home is without a CD cupboard and when CD’s are used they are stored in the medication cupboard in a lockable tin. The inspector referred this practice to the CSCI pharmacy inspector for comment. Once the advise has been received this will be relayed to the home. Please see requirement 2. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides information on how to complain and advises of external avenues should there be a need to action it through those bodies. Staff receive training in adult protection matters, although demonstrated a limited knowledge of how to action such an event. The absence of interagency guidelines in the home means that the correct course of action may not always be taken. EVIDENCE: The complaints procedure was on display with contact details of the CSCI and time frames to address complaints. This information is also contained in the Service User Guide. The CSCI has received no complaints regarding this service since the last key inspection. The home holds a complaints record, which had one entry. This record needs to be amended, to include details of whether the complainant is satisfied with the outcome of the investigation, and where applicable the investigation route for audit purposes. All relevant documentation obtained during such an investigation must be securely retained. The home has policies relating to adult protection, although they did not have a copy of the interagency guidelines for dealing with this matter. The interagency guidelines sets out roles and responsibilities in the event of actual or suspected abuse taking place. The procedures are in place to safeguard evidence and prevent this from being tarnished or amended /altered to enable an open investigation to take place. This needs to be obtained and staff made familiar with it’s content .Staff sign to say that they have read the policies . Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 18 Four staff have attended adult protection training in the last year .The newest staff member has been booked on the next available course. The staff who met with the inspector had a variable knowledge of how to action suspected abuse ranging from those who knew very little, and required further training to those who had a good concept of it and how to report it appropriately. In the main staff related that they would refer it through the management in the home and indicated only a limited knowledge on external bodies. Please see requirement 3. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides comfortable safe accommodation for those who live in it. It provides sufficient equipment to enable residents to enhance their daily living skills during their rehabilitation . EVIDENCE: The home was clean and tidy throughout. The communal areas are maintained in a homely manner .New sofas are on order for the lounge area. The dining table and chairs which had been purchased approximately two years ago, were still in good condition which is an achievement with such on going wear and tear. Only a small selection of bedrooms could be inspected as residents were out and they were locked. Those which were viewed were personalised. Heath and safety measures were in place including, window restrictors ,covered radiators and records relating to hot water temperatures. Some records indicated hot water above the recommended 43 degrees. There was discussion regarding this .The Manager stating he had been advised that 43degrees could be exceeded. Information was forwarded on this point. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 20 There are no aids in this facility all residents are mobile, this is clearly set out in the admission criteria. There is a separate domestic kitchen which is used or rehabilitation sessions such as preparing and cooking meals There is a separate laundry area where residents are supported to do there own washing. Leisure equipment, TV ,a music centre and computer are all provide in the activities room in the home. The exterior of the building was tidy. The garden is laid with lawn and garden furniture available to use. The greenhouse glass panel has been made safe, although not replaced. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff employed are subject to robust recruitment procedures to maintain residents safety. The service provides sufficient staff to meet resident’s needs. Training is provided to equip staff with sufficient knowledge and skills to meet the needs of residents. EVIDENCE: At the time of the inspection there were three staff on duty including the Manager. There was one domestic also on duty. Two sleep in staff cover the night duty period. The staff compliment totals nine which includes the Manager. Of the nine staff five have current updated first aid training, three are due to attend. Every shift is covered by a staff member who is first aid trained this information is displayed in the hall. In respect of NVQ training, three have level 2, and two have level 3. The inspector met with the two care staff and the newly appointed domestic. One staff member had been in post for fifteen years. She worked full time on day duty. She had completed her NVQ level 3 and was in the process of doing NVQ level 4. She confirmed that she had undertaken training in medication administration provided through Croydon College . Other training included Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 22 mental health updates, supervision, as well as statutory topics including manual handling ,health and safety. She stated that she was due to attend an update in first aid September 2007. Supervision was conducted with the home Manager and this she found a useful opportunity to discuss residents , her training needs as well as issues relating to the home .She confirmed that in her opinion there were sufficient staff to meet the needs of residents . She felt that training opportunities were provided with time off facilitated .Her training record confirmed that training which she had related to the inspector as well as other courses attended. The inspector met with the domestic. She had been in post one month. She was employed for twelve and a half hours a week. She confirmed that she had completed an application form, attended an interview and received CRB clearance . Her induction was limited to a tour and fire procedures and thereafter she started work as a domestic on that day. She did confirm that she was booked to attend first aid training. This employee was observed to have a good rapport with residents and the Manager confirmed this to be so. She described some good techniques when engaging with residents such as listening, being attentive and avoiding any confrontation. She had a basic knowledge of infection control principals; she was unaware of adult protection issues, accident reporting or other areas pertinent to her work. This employee will need further training on issues such as COSHH, adult abuse and other topics, which impact on her working life. She confirmed that so far she was enjoying the work. The third staff member was a shift leader who had worked at the home for two years. She was due to complete her NVQ level 2 on the day of the inspection. She felt hat a lot of training had been provided particularly in the last 12 months. Some of the topics which she had attended were HIV, basic food hygiene, medications (through Croydon College – a 14 week course), health and safety and mental health awareness .She was due for an update in manual handling .She confirmed that supervision took place. Two staff files were selected for inspection. The first contained information relating to recruitment procedures including application forms, checks made on identity, references and a medical questionnaire. There was a current CRB on file. Once appointed the staff member had been issued with terms and conditions, a confidentiality statement and an orientation programme. A second staff personnel file contained similar information and confirmed robust recruitment procedures were in place prior to employment and thereafter induction. This staff member was appointed to do two sleep in duties a week .The inspector did not meet with this staff member. Since the last key inspection 4 staff have left all have been replaced. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 23 Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and safety checks are in place to afford protection to residents. Quality assurance measures seek out residents and relatives views to inform the service and guide future developments for the benefit of residents. EVIDENCE: The Manager has completed the CSCI process to become the Registered Manager. He has had experience in the private sector and has worked in the past with learning disability residents. He has been in post almost one year and has made improvements in a number of areas. There was a health and safety statement on site dated 2006. The home has a designated heath and safety officer who, is due to attend specific training on this topic shortly. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 25 Regulation 26 visits are conducted unannounced monthly and a report on the findings left in the home. These were informative and covered the areas required under the Regulation. Staff meetings are held usually monthly; the minutes of these were available and again well presented. Staff stated that these meetings, as well as individual supervision were beneficial in their working lives. The relatives and residents survey was conducted September 2006 .The Manager audits the responses and then displays the results in a graph form. From the information obtained positive feedback was received. Any areas that raised concern or received negative feedback would be addressed through himself and the company. Resident’s meeting’s minutes were seen; the last one dated March 2006. Residents are encouraged to attend and participate, as this is an opportunity to raise any issues regarding life in the home. Alternatively the Manager operates an open door system where residents’, staff or relatives can contact him at any time. He is on call through his mobile phone when he is not on duty. There are monthly health and safety audits covering items such as water temperatures maintenance issues and fridge temperatures. The service certifies for heath and safety matters were well filed and easy to access. A number of certificates were checked including the electrical inspection, gas safety and portable appliance certificate. All were valid. The procedures and checks relating to fire are retained in a separate book. There was evidence of weekly fire alarm testing in different zones, monthly checks made on fire doors and escape routes. Fire drills had been conducted during 2006 and in January 2007 with staff and residents. These had signatures in place to confirm attendance. In addition staff had fire instruction through a video session. The home retains no money for residents except where residents request this to prevent them overspending. In these cases there are petty cash vouchers issued, residents’ signatures are obtained and where appropriate receipts are retained. A balance sheet gives details of transactions and the running total. All residents have appointees or their own bank accounts. The employers’ liability insurance cover up to five million was on display in the hall. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 26 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 2 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 3 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 3 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 2 x 3 X 3 X X 3 x Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 27 yes 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. YA2 Standard Regulation 14 Requirement The Registered Manager must ensure that a comprehensive assessment is conducted and all relevant updated information is received prior to any admission taking place. Previous time frame for action 30/03/06. This is now outstanding. The Registered Manager must ensure that all records relating to medications are fully completed including those for medications received into the home, and instructions for “ as required” medications. The Manager must ensure all staff have a working knowledge and an awareness of abuse, they are aware of how to action it and report this appropriately. Timescale for action 30/06/07 2 YA20 13 30/06/07 3. YA23 13 30/09/07 Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 28 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. YA4 YA20 Refer to Standard Good Practice Recommendations The Manager should ensure that information on trail visits is available to inform the admission procedure The Manager should ensure the complaints log is comprehensively completed. Burstow Lodge DS0000006919.V339211.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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