Inspection on 17/04/07 for Burton Closes Hall Nursing Home

This inspection was carried out on 17th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burton Closes Hall Nursing Home 23/05/06

Burton Closes Hall Nursing Home 16/01/06

Burton Closes Hall Nursing Home 02/08/05

Burton Closes Hall Nursing Home 08/02/05

Burton Closes Hall Nursing Home 26/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Burton Closes Hall Nursing Home Haddon Road Bakewell Derbyshire DE45 1BG Lead Inspector Susan Richards Key Unannounced Inspection 17th April 2007 09:30 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 Burton Closes Hall Nursing Home DS0000002048.V334997.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. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burton Closes Hall Nursing Home Address Haddon Road Bakewell Derbyshire DE45 1BG 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) 01629 814076 01629 814078 burtoncloseshall@hotmail.co.uk Hill Care Limited Lynn Armstrong Care Home 58 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (51), of places Physical disability (7) Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The named resident (category YA/PD) may continue to be accommodated in Room 5 in the Hall Unit as previously agreed provided the total number of residents in that unit does not exceed 25. This agreement is not transferable to any other resident than the person named. Up to 25 older persons (OP) with nursing in the Hall Unit. Up to 7 younger adults with physical disability (PD) in the Orangery Unit. Up to 26 older persons (OP) and elderly, dementia (DE(E) personal care only in the House Unit. 23rd May 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Burton Closes Hall Nursing Home provides nursing and personal care and support for up to 47 older persons and 5 younger adults with physical disabilities. The home is of substantial character and is organised within three separate units in accordance with the category and needs of service users. Each unit has communal lounge and dining space, together with adequate bathing and toilet facilities. With the exception of four shared rooms, the care complex provides all single room accommodation, the majority of which have en suite toilets and wash hand basins or showers. Each unit also has a kitchenette area in which drinks and snacks can be prepared. There are centralised kitchen and laundry facilities. A range of equipment is provided to assist service users with mobility, both individual and communal. A shaft lift is provided in the home and there is ramped access to an outdoor courtyard, with seating areas. There are also extensive gardens, including a central courtyard, with seating, which are well maintained. Service users receive care and support from a team of Registered Nurses, care and hotel services staff. The deployment of nurses and care staff is in accordance with the category of the three service user groups accommodated. Fees charged (as at 17/04/07 range from £300.00 - £1,000.00 per week and are set in accordance with individually assessed needs and service provision. For residents who receive assistance with payment via their local authority, fees are determined within this range in accordance with individual purchasing contracts set by Derbyshire County Council. The above fees do not include personal toiletries and hairdressing, newspapers, private chiropody and transport. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 5 Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection there were forty seven service users accommodated (twenty one older persons and six younger physically disabled adults receiving nursing care and twenty service users receiving personal care). This key inspection report has been collated on the basis of information held or provided about the home as follows: Current and up to date information the Commission holds about the home. Information provided by way of a pre-inspection questionnaire completed by the manager. A total of thirty-three survey questionnaire returns from service users or their representatives. Information detailed in the previous key inspection report for this service in May 2006. Information collected during the site visit for this inspection. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of five service users representing a cross section of the registered care categories within the home. Discussions were held with those service users as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: Service users are well supported and informed throughout their admission and their personal, social and health care needs are effectively assessed and met. Service users are treated with dignity and respect and staff strive to deliver person centred care based on individual’s wishes and lifestyle preferences. Service users are provided with a wholesome and appealing diet, which is in accordance with their risk assessed needs and overall to their satisfaction. Individual’s rights to complain are effectively promoted and upheld and they are protected from abuse. Service users live in a clean, safe and comfortable environment, which is well maintained, furnished and equipped and which suits their needs. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 7 Service users needs are well met and they are supported and protected by competent staff, who are effectively recruited, inducted, deployed and trained. The home is well managed and run in the best interests of service users and their best interests, health, safety and welfare is effectively promoted and protected. What has improved since the last inspection? What they could do better: Develop the type and formats of information provided about the service to intended service users. Ensure that for those service users with dementia. That their care plans always specify in detail the action which needs to be taken by care staff in respect of their health, personal and social care. Consider reviewing the teatime dessert menu with a view to providing more variety throughout the week. Establish a method to formally seek the views of other stakeholders (such as district nurses, GP, care managers, etc) as to how the home is achieving its goals for service users. Publish the results of service user surveys and make them available to current and prospective service users and their representatives. Seek to further develop and establish innovative mechanisms for consulting with service users, such as residents meetings, newsletters, establishment of representative committees. Burton Closes Hall Nursing Home DS0000002048.V334997.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. Burton Closes Hall Nursing Home DS0000002048.V334997.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 Burton Closes Hall Nursing Home DS0000002048.V334997.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): NMS 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using evidence available, including a site visit to the home. Service users are well supported and informed throughout their admission and their needs are effectively assessed and met. EVIDENCE: Discussions were held with some service users, including three of the five case tracked about the arrangements for their admissions to the home and information provided by the home regarding its care and service provision. All described satisfactory arrangements and support with regard to the admission process, which were established directly with them or via their nearest relative on their behalf and were provided with sufficient information about the home. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 11 Written information about the home, its care and service provision is provided within the home’s brochure/guide, which together with individual written contracts of residence, are provided in standard type format. The home’s statement of purpose has been revised since the last inspection in accordance with changes in its care and service provision with regard to dementia care. From a total of thirty-three service user questionnaires returned, all said that they were provided with enough information before moving in. Two referred to visiting the home before admission and reading the last inspection report. Service users case tracked who were admitted via local authority funding arrangements had copies of the single assessment and care plan as provided by care management arrangements for the purpose of their placement in the home. Service users who were privately funded had pre-admission assessment recorded, which were undertaken by the registered manager, who strives to meet individuals in their own environment prior to any visit or admission to the home. These also included relevant information from other professionals. All those case tracked had written contracts of residence between them and the home, which clearly detailed the terms and conditions of their residence, including fees charged, including a breakdown of those fees. The recorded needs assessment information was examined for each service users case tracked and discussed with them. Needs assessment information was comprehensive, person centred with daily living plans and longer-term outcomes identified in accordance with their needs as assessed with them. In the questionnaire returns referred to above, the majority responded that they always received the care and support needed, with two stating that they usually did. Comments received from service users, either directly or by way of the questionnaires, included, “Staff always give my mother and the family the kindest support and help.” “Staff is excellent and very aware of my needs.” “Staff always assist me in the way that I wish and are very professional in their approaches.” The home does not provide for intermediate care and there were no service users accommodated at the time of the site visit with diverse cultural or religious needs. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 12 Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 13 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): NMS 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health care needs are well met in accordance with safe and recognised practise in consultation with them or their representatives and they are treated with dignity and respect. EVIDENCE: The written care plans of service users case tracked were examined and their care discussed with them. Overall care plans examined were formulated in accordance with individual’s risk assessed needs and were person centred concerning individuals’ preferred daily living and lifestyle routines, including that relating to social care and activities. Care plans had been developed considerably with regard to the latter since the previous inspection of this service and service users, who were able, were consulted about their care plans and some had signed their agreement with Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 14 these, or their representatives on their behalf. However, care plans were not as well maintained for two of the service users case tracked, who had dementia and whose required care interventions were not always clearly recorded. Discussions held with two staff concerned with their care delivery indicated they were conversant with their care needs and required care interventions. Discussions were also held with the manager about those care plans. Overall, care plans were reflective of recognised guidance concerned with the care of older persons. There was a written record of individual’s agreement to care plans. Of persons surveyed via questionnaire, all said that staff listened and acted on what they said and that staff was usually available when they needed them, although one commented that some staff was not as responsive as others, although the majority were very attentive. Discussions with service users indicated the same in that they did not have to wait for long periods of time for staff to assist them. The majority surveyed said that their medical needs were met. Similar positive comments were received regarding care provision as follows: ‘We have been delighted with the care that mum has been given at Burton Closes. She is treated kindly and affectionately at all times and has settled happily because of this.’ Service users spoken with said that care was well organised and that staff always had time for them and did not rush them. One service user said that staff are highly competent and always act in a professional manner. All said that staff was respectful towards them. The home operates a named nurse/key worker system for each service users. Discussions were held with six individual staff about the care of those service users case tracked whose care they were involve with. All were fully conversant with the care to be delivered to those individual’s. Aids and equipment were observed as being provided within service users personal and communal accommodation in accordance with their written plans, including aids to communication. Specialist advice and access to outside health care professionals, including that relating to routine health screening was also well accounted for and in accordance with assessed needs and personal wishes. One service user case tracked attended a local day hospital in order to receive assessment and care via outside health care professionals as part of their rehabilitation, including physiotherapy. The arrangements for the management and administration of service users medicines were examined and discussed with staff and service users and were Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 15 largely satisfactory. The manager had reviewed procedures and revised arrangements in one unit of the home and had arranged for additional medicines training for some staff there. There is a satisfactory approach to determine and agree with the service user (or their relative where this is not possible) the arrangements for either the service user to retain and manage their own medication or for the home to retain control of this on their behalf. Medicines records examined for those service users case tracked were properly maintained and service users said they were satisfied with the arrangements. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 16 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The establishment of a more consistent approach in promoting service users social, cultural, religious and recreational interests, has increased opportunities in accordance with their preferred lifestyle routines and interests. Service users receive a wholesome and appealing diet, in accordance with their risk assessed needs, which overall is to their satisfaction. EVIDENCE: At the previous key inspection of this service in May 2006, a recommendation was made to improve and develop arrangements for service users access to appropriate social and occupational care and activities, both in and outside the home, ensuring that it is in accordance with their individual lifestyle preferences, choices and abilities. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 17 A review of those arrangements had been undertaken and the activities coordinators hours re-arranged with the aim providing more flexibility to better meet service users needs. There has been considerable progress to date in determining service users individual lifestyle preferences and choices with them with regard to the arrangements for their social, recreation and leisure. With the exception of two persons with dementia who were case tracked, this information was well recorded within individual’s needs assessment and care planning information. Discussions were held with the manager regarding the two persons referred. Service users spoken with expressed that there were considerable improvements in this area and that activities now more regularly organised, both group and individual. One the day of the site visit to the home, a group of service users went out via community transport to a local garden centre. Service users spoke about some of the activities, which they chose to regularly take part in. These included, outings into the local community, (group and individual), church and communion attendance, in house entertainment, dancing, seasonal activities including the recent Easter crafts, watching TV programmes of their choice, music and singing, story telling, movement to music, clothes shows, videos, library books/reading, including large print, reminiscence, hair and nails sessions and garden/bird watching activities. Examples of activities accessed in the wider community, include, shopping, cinema, bowling, holidays and swimming. A dog visited the home, which service users said they particularly enjoyed, together with singing and entertainment from local school children. One service user case tracked regularly attended a luncheon club at a local village where she previously lived. She said this was wonderful as this gave her regular contact with the village and old friends, including the local church. Arrangements were also in hand to provide staff-support to enable her to visit the studio of a local artist who she admired and for her to attend the funeral of a close relative. Another service user case tracked regularly attended local day services. The activities co-ordinator had recently set up a bird watching club and bird feeders were provided at various locations around the home, with direct visibility from the bedroom windows of some service users who had expressed an interest to have these. Seventeen service users surveyed by questionnaire said that activities were always arranged. Ten said that they usually were and five said they sometimes were. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 18 Information regarding access to advocacy, by way of displayed leaflets was provided in the main entrance hallway for service users and their representatives. Nineteen questionnaires returned by service users or their representatives said that they always enjoyed the food provided, eight said they usually did and four only sometimes. The Inspector was not able to identify those surveyed to follow up these views individually, although menus were examined, which for the most part detailed and balanced and varied diet, with the exception of the tea time dessert menu, which was the same each day. However, service users spoken with said they enjoyed the food provided, which was very good and that an alternative was always offered and individual choices accommodated. Dietary supplements were provided for some service users case tracked, which was in accordance with their recorded risk assessed needs. Food is also prepared and presented with individual assistance in accordance with individual requirements and capabilities. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 19 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): NMS 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users rights to complain are effectively promoted and upheld and they are protected from abuse. EVIDENCE: Of the thirty-three survey questionnaire returns, the majority of service users (or their representatives) said that they knew how to make a complaint. Four said they did not know, although did not provide and further written clarification. The Inspector is not aware of the identity of those four and therefore was unable to determine a reason for this. Service users spoken with during the site visit said they felt confident to complain, knew how they would do this and felt comfortable to do so. Staff spoken with was clear as to their roles and responsibilities in respect of receiving and handling a complaint. There is a written complaints procedure in place for the home, which is openly displayed in an accessible and visible area of the home. Information regarding how to complain is also provided within the home’s guide provided for service users. Service users had copies of these in their own rooms. This information is provided in standard type format. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 20 There is an established and satisfactory system for recording complaints. None have been made since the previous inspection of this service in May 2006. There are clear written policies and procedural guidance in place in the home with regard to recognising abuse and dealing with and responding to any suspicion or witnessing of the abuse of any service user. Staff demonstrated that they were conversant with their roles and responsibilities with regard to these during discussions with them and training records examined for four staff detailed relevant training arrangements in this area as a core-training subject for staff. There has been one investigation under local joint agency safeguarding adults (adult protection) procedures. This was due to the sudden death of a service user following a fall. The home acted timely and effectively and reported this incident via those procedures. The subsequent investigation found that there was no evidence of the abuse or otherwise of the service user and procedures were closed. Service users spoken with and able to do so, said they felt safe and comfortable in the home. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 21 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): NMS 19, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, safe and comfortable environment, which is well maintained, furnished and equipped and which suits their needs. EVIDENCE: Since purchasing the home some four years ago, the registered provider has invested considerably in a programme of upgrade, repair and renewal of the environment. An ongoing programme of routine repair and renewal is now well established. A general tour of the home was undertaken and the private and communal areas of service users case tracked inspected. All areas seen were safe, clean and hygienic, comfortable, warm, well ventilated and well lit. Furnishings and Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 22 décor are to a good standard and service users expressed considerable satisfaction with their surroundings including their own rooms. Service users own rooms are well personalised and equipped. Beds and bedding are to a good standard with suitable specialist mattresses in accordance with their riskassessed needs. Of the thirty-three questionnaire surveys returned 31 said the home was always fresh and clean and 2 said it usually was. All bedrooms have an accessible en suite facility, many providing bath or showers and some with toilet and sink facility. Although space is restricted in the House unit with regard to the ground floor corridors/access to lounge areas, discussions with staff and observations indicated that this is reasonably well managed in terms of any risks to service users given the very narrow corridors. There are separate laundry facilities, which are satisfactory. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 23 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): NMS 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are well met and they are supported and protected by competent staff who are effectively recruited, inducted, deployed and trained. EVIDENCE: Satisfactory details of staff employed, their recruitment, training, deployment and turnover were provided within the pre-inspection questionnaire completed by the registered manager. At our site visit the personal files of four of the most recent staff files were examined, these contained satisfactory records and information with regard to the above. Discussions were also held with staff about the arrangements for their recruitment, induction, training and deployment, which accorded with written records and information provided. Formal equal opportunities monitoring is incorporated within the home’s recruitment process. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 24 A total of 60 of care staff have achieved at least NVQ level 2 with plans for more recent staff starters to commence. Included in this percentage are four staff with NVQ level 3, with one currently undertaking this level and one to commence. All staff has undertaken equality and diversity training over the last year and dementia training has been provided to staff in the ‘house’ unit. Details of future training planned, included a rolling programme for core health and safety training areas, diabetes, medicines and dementia for staff as relevant to their training needs. Staff meetings are regularly held and minutes recorded and staff receive regular supervision sessions, which they said were helpful. Staff spoken with felt that overall they were well supported with good arrangements for access to training, although it was expressed by a number of staff that there were marked differences in the personal effort and workload contribution from some staff, resulting in them not always feeling best supported. However, all who expressed this had felt comfortable to discuss those views with the manager who was aware. Service users spoken with and surveyed expressed confidence in staff abilities, availability and approaches with them. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 25 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, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the leadership and management of the home and their best interests, health, safety and welfare is being effectively promoted and protected. EVIDENCE: The registered manager is a registered general nurse with relevant experience in management. She was employed at the home in December 2005 and since there have been substantial improvements in the management and administration of the home. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 26 At the last key inspection of this service a requirement was made to establish the formal system for the ongoing monitoring and review of the quality of care and services provided by the home. Good progress has been made in this area and the manager receives consistent support via external management arrangements. Formal satisfaction surveys are now periodically undertaken with service users and/or their representatives by way of circulated questionnaires concerned with the quality of services the home seeks to provide as detailed in its statement of purposes. The last survey was conducted in August 2006. This was discussed with the manager. Out of 45 surveys, 29 returns were received. A significant matter arising from this survey was the expressed view that the service needed to develop its arrangements for service users to engage in and access social and recreational activities, both in and outside the home. Significant progress has been achieved in this area as detailed under the Daily Life and Social Activities section of this report. The results of service user surveys are not published or made directly available to service users and their representatives and there is no formal mechanism for seeking the views of stakeholders in the community, such as GPs, chiropodists as to how the home is achieving its goals for service users. There is a suggestions box located in the main entrance and a formal system is now established for the auditing of care and services provided by the home via quarterly audits and including clinical care audits. Service users and staff spoke with significant professional regard for the manager and expressed confidence in her open management style and positive approach. Action has been progressed within agreed timescales to implement requirements identified in the previous inspection report. Staff confirmed they received supervision on a ongoing and individual basis. A number of records, which the home is required to keep were inspected during the site visit. These included service user assessment, care planning and associated care records, medicines records, staff records, accident records, food records and staff duty rotas. These were secure and properly maintained. The arrangements to ensure safe working practises were discussed with staff and training records examined, which were satisfactory. There were no untoward hazards observed to service users safety during the inspection of the premises, which were clean and well maintained. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 27 Details of the maintenance of equipment were provided by way of the preinspection questionnaire completed by the manager. These were satisfactory and up to date. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 28 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 3 3 3 3 3 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 3 17 X 18 3 3 X X X X 4 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP1 Good Practice Recommendations Consideration should be given to further developing the type and format of information provided about the service to intended service users (for example large print and audio tape formats, newsletters). Service users (with dementia) care plans should always set out in detail the action which needs to be taken by care staff in respect of their health, personal and social care. Consideration should be given to reviewing the teatime dessert menu with a view to providing more variety throughout the week. The views of other stakeholders in the community (eg district nurses, GPS, care manager etc) should be formally sought as to how the home is achieving its goals for service users. DS0000002048.V334997.R01.S.doc Version 5.2 Page 30 2. OP7 3. 4. OP15 OP33 Burton Closes Hall Nursing Home 5. 6. OP33 OP33 The results of service user surveys should be published and made available to current and prospective service users and their representatives. Wherever possible, the home should seek to further develop and establish innovative mechanisms for consulting with service users, such as resident meetings, newsletters, establishment of representative committees. Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burton Closes Hall Nursing Home DS0000002048.V334997.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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