Inspection on 07/06/06 for Burstow Lodge

This inspection was carried out on 7th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burstow Lodge 03/05/07

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 Key Unannounced Inspection 7th June 2006 10:00 Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 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.V293421.R01.S.doc Version 5.1 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.V293421.R01.S.doc Version 5.1 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 Mrs Elizabeth Maoneyi Nicholas 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.V293421.R01.S.doc Version 5.1 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 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.V293421.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by two inspectors. The preinspection information had not been received prior to the inspection and therefore any comment/information that residents, relatives or multidisciplinary team members wished to share was unavailable on the inspection day. At the time of the visit there were two staff on duty, one was covering for a senior member who was off site as the inspectors arrived. Once the senior care staff arrived back in the home, she facilitated the inspection. She was only able to provide the inspectors with limited documentation and was unable to access several items. A further announced visit was undertaken 17 June by the inspector and Regulation Manager. It was at this visit that further documents were inspected and comments, which had been received, related to the newly appointed manager. On the day of the inspection residents were in and out of the home undertaking activities. There were no visitors in the home that day. The inspection findings are related to the information received, staff discussions, residents’ feedback and a tour of the premises. Several of the requirements have been repeated on previous inspections, these must be addressed within the time frames stated. What the service does well: What has improved since the last inspection? The record keeping in respect of medications had improved with more detail provided on which audit trails could be undertaken. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 6 Some of the care plans provided good information in respect of residents and the interventions that staff should take to address issues, although information and record keeping was to a variable standard. 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. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 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.V293421.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality rating in this section is poor. This is based on all the information received including the site visit. Evidence of assessments conducted by the home and other relevant documentation was limited. Information on trial visits and the evidence of these was not available. The information available was of a variable standard for the case notes inspected. EVIDENCE: The assessment information, of two residents who were case tracked was inspected. In the first file it was difficult to establish if there had been an assessment conducted by the home prior to the residents arrival. Evidence of trial visits and information provided before admission was also difficult to locate. There was one document, which related to an assessment of activities of daily living and mental health issues. This was possibly the admission assessment, however this had review dates on it as though it were in current use. Another form of identical information was also in the file. This was confusing. The inspector queried whether this was the care plan format although another document for issues relating to care planning was in place. This resident was on the enhanced level of the Care Programme Approach (CPA) as were all of the eleven residents in the home. Within the file it was difficult to locate the information received under the CPA or that received through care managers. In general the assessment information was scant and it would be difficult to base an initial care plan on this. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 9 In the second care plan there was information relating to the CPA and the supporting care plan. There was a summary from the Occupational Health department. Again there was no information received from the care manager or from the other agencies involved. Assessment by a member of Burstow Lodge was also not available. Confirmation that after the assessment the home had the ability to meet the resident’s needs is available in a standard format. Terms and Conditions were in place. The Statement of Purpose was available in the hall - this will need to be amended to reflect the staff and management changes. The Service Users Guide was off site waiting up-dating; this has been seen in every residents’ bedroom on previous inspections. Please see requirement 1. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. The quality rating in this section is poor. This is based on all the information received including the site visit. Care plans and risk assessments are in some cases not reflective of the needs of residents. Risk assessments are limited in content and the measures recorded would not reduce the identified areas of risk. EVIDENCE: The inspectors viewed two care plans each. In general they contained photographs of the residents and information relating to individual missing persons procedures. The care plans contained information relating to mental heath, activities of daily living and other areas of support required. The interventions section contained good detail and the goals were realistic. The care plan reviews were in date and generally reviewed at three monthly intervals. The risk assessments for one resident was provided in a standard format identifying issues in a high, medium or low category. This was limited in interventions and particularly concerning as aggressive behaviour was identified within it. The interventions need to provide information on how to reduce the risk or where possible eliminate it. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 11 The supporting daily events entries were limited in reflecting the actual problems in the care plan and general in their content. Key worker individual sessions were in place, the last one dated 24/04/06. The CPA information was not current or available. There was one document dated 13 June 2005, and it was questionable if this had actually been a CPA review as there were no details of the attendees, review of needs; it was simply an overview statement. The records relating to health appointments, i.e. GP, dental, chiropody, optician, were available although there were no entries since December 2005. The second care plan was of similar content and completion. This resident had a high risk with fire however there was no specific fire risk assessment in place. The last entry in respect of their rehabilitation cooking skills programme was January 2006 and prior to this August 2005. Two further residents’ care plans were inspected by the other inspector. These contained basic information with assessments, care plans and risks identified for both. Whilst these covered a number of areas including mental and physical health problems, they were limited in specific information. For example, where a resident had a false eye, and others such as eating issues, dietary needs and skin problems, there was little information on these areas, as they had all been included in one section. Nor was there information regarding the management of monies. The inspector suggests that each area of need is identified separately allowing for more information to be provided such as the support required, by whom and when. Risks had been assessed in a number of areas, however, there was a lack of information as to how these risks would be minimised. Again the home had highlighted that this resident had aggressive outbursts and limited interventions noted. In another case there were assessments for swimming and cycling, which had last been reviewed in February 2004. Another assessment showed a risk in relation to cooking and vulnerability, however, there was no further assessment or action indicated as to how these risks would be minimised. In the case of one of the plans viewed there had been regular CPA reviews taking place with copies of the CPA care plans provided to the home. In the second file viewed the review had been due May 06 but this had not yet taken place. Discussions with the keyworker of one resident showed an understanding of the resident’s needs and the specific risks in relation to their behaviour. This information should be reflected in the care plans and risk assessment information. Please see requirements 2 and 3. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,16,17 The quality rating in this section is adequate. This is based on all information including the site visit. Activities of daily living are encouraged and staff support residents with these. Records relating to activities were limited and from these records it was difficult to assess the level of improvement in identified areas EVIDENCE: Residents were seen to spend time in the home as they wished; some were going out, others in the garden and one watching TV. The inspector did note that there was little in the way of staff with residents undertaking rehabilitation skills. One staff member had gone out to buy toiletries for a resident, and had called another staff member to cover. The resident themselves did not go out and the inspectors wondered why this was such an emergency to leave the home inappropriately staffed. The inspector also noted that monitoring of residents was lax. Whilst freedom of movement is encouraged, staff need to be aware of whereabouts of residents, timesframes for their return, etc. Activities are based on daily living skills to enable the resident to live a more independent life. All residents should have an assessment of need made and have suitable rehabilitation programme developed with this information. In one Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 13 care plan there was some information relating to financial assistance developing friendships and interpersonal skills but little to indicate what progress had been made in these areas. The home employs an activities coordinator three days a week. She works with residents to meet their objectives. From the information the inspectors received it appeared that staff do not get involved with these sessions and that they consider that the activities person works independently. All staff must work cooperatively and in a consistent manner for the best interests of residents. One of the tasks undertaken by the activity co-ordinator is to assist residents in planning the weekly menus. The home keeps a list of residents likes and dislikes and when the residents have chosen the menu for the week the coordinator informs staff what food needs to be purchased to ensure the choices can be met. Residents are supported to prepare their meals and participate in the cooking club to improve their skills. All of the residents go to MIND for Sunday lunch. The two residents case tracked indicated some of their activities including use of local support groups and external activities. The key worker to one resident indicated that one of the residents does a number of rehabilitation activities but was unable to advise on how he had progressed in respect of them. The inspectors were advised that, at all times, there must be two staff in the home. This they were advised impedes residents’ activities, as they are not permitted to leave the house with one staff member. The Nursing Director for the company stated that this was not the case. However this should be made clear to staff working within Burstow Lodge. The company may want to develop a lone working policy and supporting risk assessments to cover this aspect. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The quality rating in this section is adequate. This is based on all information including the site visit. Health care is provided through local community services which, for this type of resident, is appropriate. Documentaion relating to health care, both that provided by staff in house and external professionals, was available although needs more consistency in actual recordings. EVIDENCE: Residents access all health provision in the local community. Specialist support is addressed by the community mental health teams who provide CPN’s, Consultant Psychiatrist and other health professionals. Care plans and supporting records showed that residents’ healthcare needs are being met by accessing appropriate health professionals. On the day of the inspection one resident was attending an appointment and the diary showed a number of residents attending appointments for blood tests etc. Some of this information was not contained within the daily record documentation but an entry made in the diary. There was also some evidence of residents accessing chiropody and dental appointments and a record of individual weights each month in the two files viewed. The home had some good records in respect of specialist support and reviewing by consultants within the mental health teams although information received from CPA reviews was in some cases not current. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 15 Medication is stored in the ground floor office cupboard attached to a cupboard secured to a wall. This is an unusual arrangement/location although secure and adequate. Currently there are four residents who are self medicating. In respect of self-medication there was a standard assessment form completed, although no formal risk assessment. Again it appeared that this assessment record was used in a number of ways, not only as an assessment but also as a review document, as contained within it were dates referencing reviews i.e. 24/06. A separate document should be developed for each aspect of selfmedication. Within the case notes there was a care plan in place to address self-mediation. The content of this was fairly comprehensive. The medication charts themselves were generally well completed. The charts had resident’s photographs in place, information relating to the quantity received, and reasons for those medications, which were refused or not administered. Some of the instructions in respect of “as required” medications need to have the maximum dose included. Medications are received weekly although there is only space on the MAR chart for one entry monthly. There needs to be some system so clear records of received /disposed medications are in place. The procedure for medications given to residents who go out for weekend/ social leave needs to be reviewed. The current system is that the medications are removed from there original packaging and dispensed into a small dosette box, then handed to the resident. This is in effect dispensing which can only be addressed by the pharmacist. Advice from the dispensing pharmacist should be sought and actioned. Please see requirement 4. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality rating in this section is adequate. This is based on all information including the site visit. Information on which to make a complaint is available including external bodies. More detail is required in the actual complaints log retained in the home. EVIDENCE: The home has a complaints procedure, which meets with the regulations. The home has also produced a complaints book to ensure recording of complaints. The log enables recording of the date, name of complainant and action taken. However, this is basic information, which needs improving with details of how the home investigated the complaint and information as to whether the complaint has been resolved. Residents themselves referred to a number of avenues, through which they would raise concerns including keyworkers, care managers and CPN’s. Two staff personnel files were inspected and training in respect of adult abuse awareness was not evident. One staff member advised the inspectors that it had been proposed that she watch a video on adult abuse, however, this has not been entirely successful with the video not working in the case of the adult abuse. Staff had a basic knowledge of adult protection and some of the avenues for reporting it. Please see requirement 5. Please see recommendation 1. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. The quality rating in this section is good. This is based on all information including the site visit. The home is well maintained and efforts to promote a homely comfortable environment are evident. EVIDENCE: The home was maintained to a good standard. Communal areas are pleasantly furnished and well maintained. There is a large dining lounge area with a kitchen adjacent to it. The kitchen has been recently refurbished and is well presented. There is a separate quiet area and rehabilitation kitchen/ dining area. All areas were clean, tidy and hazard free. Those bedrooms seen were well kept, all had lockable doors, secure storage areas and were personalised, which with this type of resident this can be difficult. The home is maintained as a non-smoking environment, which can sometimes be hard to enforce, although in this home it is managed. The garden was tidy and provided with a table and chairs. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. The quality rating in this section is adequate. This is based on all information including the site visit. Staff are provided in sufficient numbers although more flexibility is needed to meet residents’ needs. Induction, mandatory and specific training are inadequate. EVIDENCE: The inspectors arrived in the home to find two support workers and one domestic. There was also a child on the premises. Further investigation showed this child to belong to one of the staff members who had been called in to cover the senior due to an emergency. However this is unacceptable practice, especially as the inspectors later discovered there was no emergency. Whilst the staff roster showed adequate staffing levels with two staff working during the day and two at night there should be more flexibility to provide staff with the time and opportunity to undertake activities outside of the home. The current regime states that there must always be two staff on duty in the home. This does not allow for staff to become involved in external activities with residents. Involvement in the community is important and there is little evidence of staff being able to assist residents to join in community-based activities such as shopping, eating out, cinema etc. Of the eight staff working in the home including bank workers, one is a RMN; one is a GP from the EEC; one a second year student and two have NVQ 2 or Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 19 above. One other support worker has registered to undertake NVQ 3 with two having no NVQ or equivalent. Discussions with one member of staff who has been employed for seven months shows some training provided. However this has been limited, the inspector was told that they had not undertaken induction or foundation training. Some of the training involved watching of videos e.g. fire and adult abuse. However, this has not been entirely successful with the video not working in the case of the adult abuse. She has attended recent mental health training at Beckenham hospital and is also undertaking health and safety training. The training she stated had been limited, and had left the residents and staff member in a vulnerable position over the last few months. Training must be provided in a timely fashion by competent individuals to equip staff with the skills they need to undertake the work that they perform. Two staff personnel files were inspected .The recruitment procedures for both were inspected. One file contained comprehensive information relating to references CRB checks, identity etc. The second had a number of items although the work permit had expired and evidence of CRB was not available. One staff member’s file indicated a selection of training this year including mental health awareness medications and fire safety. The second file referenced two topics in 2005 and others prior to this, 2004. No records were in place for recent training including mandatory topic updates. Staff must be provided with induction, core training including mandatory topics and specific training to meet residents’ needs. Please see requirement 6 and 7. Please see recommendation 2. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The quality rating in this section is adequate. This is based on all information including the site visits. Although the equipment and environment are maintained with ongoing servicing, staff have a limited knowledge of health and safety topics. Training in respect of health and safety was insufficient and mandatory topics needed updates. EVIDENCE: The company have just appointed a new manager, who was not on duty for the first day of the inspection. The home had been without a Manager for a few weeks and in the interim period the Director of Nursing had covered the home, however this was a temporary arrangement without full time cover provided. The inspectors viewed a selection of health and safety certificates. The health and safety statement policy was dated June 2006.The employers liability was just out of date but in hand. This was available on the second visit Certificates covering electrical, gas and legionella were all current. The fire extinguishers had been serviced April 06. Weekly fire alarm testing, fire door check and escapes were all recorded. Fire training had been Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 21 conducted 12/6/04 with four staff and eight residents and prior to this April 06 with three staff and nine residents. Whilst the records show a number of drills to have been completed there was information lacking such as time of drill and few had staff signatures in place. The home also keeps a record of hot water temperatures. However, discussions with staff showed they had very little understanding of what temperatures should be to ensure the safety of residents. The hot water temperature in the kitchen was several degrees below the accepted 60 degrees to reduce risk of infection when washing crockery etc. The fridge temperature also read 10 degrees, which had been highlighted as too high by the Environment Health Officer during October 2005. No action has been taken to address this during the last seven months. On the second visit the inspector saw evidence of residents and staff meetings. Individual one to one sessions are also held. Regulation 26 visits are conducted unannounced and at weekends on occasions. Please see requirement 8. Please see recommendation 3. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 22 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 1 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 2 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 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 X LIFESTYLES Standard No Score 11 2 12 X 13 2 14 X 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 1 X Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 23 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 Standard YA2 Regulation 14 Requirement The Manager must ensure that all residents are assessed prior to admission and all relevant information received prior to this. Information in respect of trial visit/periods must be retained. Previous time frame for action 30/03/06. This is now outstanding The Manager must ensure that care plans and daily records are comprehensive in content and reflective of needs. Previous time frame for action 30/9/05. This is now outstanding The Manager must ensure that risk assessments are robust enough in content to reduce the identified risk. Previous time frame for action 30/03/06.This is now outstanding The Manager must ensure all instructions for medication are documented. The system for on leave medications must be reviewed. Timescale for action 30/07/06 2. YA6 15 30/07/06 3 YA9 13 30/07/06 4 YA20 13 30/07/06 Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 24 5 YA23 19 6 YA34 19 7 YA35 18 The Manager must ensure that 30/07/06 staff are fully trained in adult abuse, whistleblowing and complaints. Previous timeframe for action 13/09/05. This is now outstanding The Manager must ensure all 30/07/06 staff are subject to robust recruitment checks including on going monitoring of work permits and all other relevant employment records. The Manager must ensure all 30/07/06 staff have appropriate training, which is current, related to the work they do and includes all statutory topics. Previous time frame for action 30/09/05. This is now outstanding. The Manager must ensure that all records relating to health and safety are current and fully completed. All staff must be trained in all aspects of health and safety and action taken to ensure that the environment is safely maintained. 30/07/06 8 YA42 23 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 YA20 YA32 Good Practice Recommendations The Manager should ensure the complaints log is comprehensively completed. The Manager should ensure that adequate levels of staff are NVQ 2 trained. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 25 3. YA42 The Manager should ensure that all training is signed for including that for fire. Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 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 Burstow Lodge DS0000006919.V293421.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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