Inspection on 23/05/06 for Burton Closes Hall Nursing Home

This inspection was carried out on 23rd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burton Closes Hall Nursing Home 17/04/07

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Burton Closes Hall Nursing Home Haddon Road Bakewell Derbyshire DE4 1BG Lead Inspector Susan Richards Unannounced Inspection 23rd May 2006 09:30 X10029.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.V289874.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 Older People and 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. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burton Closes Hall Nursing Home Address Haddon Road Bakewell Derbyshire DE4 1BG 01629 814076 01629 814078 carechcc.plus.com 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) Hill Care Limited Vacant Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (5) of places Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 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. Accommodation 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, which are generally 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 31/04/06) range from £298.20 - £750.00 per week and are set in accordance with individually assessed needs and service provision. For residents who receive assistance with payment, fees are determined within this range in accordance with individual purchasing contracts set by Derbyshire County Council. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focuses on outcomes for residents, with case tracking used as part of the methodology. Case tracking involves the random selection of a number of residents, whose care and support provision is examined and discussed with them and their representatives, including staff. Discussions were held, care and associated records examined and their private and communal accommodation inspected. Discussions were also held with other residents in the home about their care. Management arrangements were examined, together with the arrangements for the recruitment, induction, training and supervision of staff, including the arrangements for the staffing of the home on a daily basis. What the service does well: What has improved since the last inspection? Management and communication systems in the home have improved considerably, resulting in a cohesive and systematic approach, towards increasing standards of care and service delivery for the benefit of residents accommodated. The number of requirements made following inspections, totalled 30 in August 2005, reducing to 14 by mid January 2006 to a total of three at this inspection. Areas of improvement include – Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 6 The provision of a planned programme for the upgrading, repair and renewal of the fabric of the home, with timescales set and work being undertaken in accordance with these and health and safety priorities. Staffing levels have been reviewed and increased in accordance with residents needs. There is a systematic planned approach to staff training, development and supervision. What they could do better: Review and seek to develop the existing arrangements for residents to engage in occupational, recreational and leisure activities of their choice, both in and outside the home. This should be done in accordance with individual’s lifestyle preferences, choices and capacities with a view to promoting best practise. Develop individual lifestyle care plans, which clearly reflect residents preferred routines and which are inclusive of their social care needs. Review future plans and arrangements for the support of residents during mealtimes (nursing unit for older persons), particularly breakfasts in order to enable the registered nurse on duty, increased flexibility to work with care staff to promote their increased supervision and learning and development. Ensure the timely completion of the plan for the upgrading and renewal of the home, which is now on track by the end of August 2006. Establish and maintain a formal quality assurance and monitoring system in order to proactively measure and develop the quality of services offered by the home and its success in meeting the service aims and objective/statement of purpose. Please contact the provider for advice of actions taken in response to this Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 (OP) and comparable (YA) standards as specified above. Staff communicated effectively with residents and delivered their care and support in accordance with their individually assessed needs and written terms and conditions, which were generally well met. However, needs assessment information did not fully promote their preferred daily living routines and lifestyle preferences, in respect of their social, occupational and recreational needs. The quality outcome in this area is adequate. This judgement has been made using all available evidence, including a visit to the home. EVIDENCE: Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 10 Case tracking was undertaken for a number of residents across the three units of the home and its registered categories. Each resident had individual written terms and conditions/contracts in place, which had been provided to them (or their relative/representative as appropriate to their needs). These provided all required information relating to the care and services afforded to them, including their fees and the arrangements for their payment. Discussions were held with residents’ case tracked about their care needs and how these were met (with the exception of one resident who the Inspector was unable to converse with due to the nature of the residents illness and frailty). Observations were also made during the inspection regarding the organisation and delivery of care to residents and also how staff communicated with them. The recorded needs assessments for each resident were examined. These were comprehensive, although did not always detail well all aspects of their preferred daily living routines and lifestyle preferences, including social needs. Discussions with residents indicated that there needs were largely well met, although reflected these omissions in respect of social care and activities and preferred routines, which it was felt could be improved. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 (OP) and comparable (YA) standards as specified above. Residents were treated with dignity and respect and their independence promoted in accordance with their risk assessed needs. Their specified personal support and health care needs were being met and proper records kept in relation to these. However, their care plans did not effectively detail care interventions and support in respect of their social stimulation and occupational/social care needs. The quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 12 Discussions were held with residents about their care plans and the arrangements for their care and support. Care plans were also examined for those residents case tracked, which were signed by them or their representative. Care plans were formulated within a framework of risk management and in accordance with their individual needs assessment information. Care plans did not always include strategies and interventions for the stimulation and occupation of residents, including aspects of their social care needs and most residents spoken with felt that that these were areas of their care delivery which could be better improved. Discussions were also held with staff about the planning and delivery of care to residents’ case tracked and arrangements to ensure their nursing and health care needs were being met. Discussions were also held with residents about arrangements for them to see their own doctor and also outside health care professionals, including that relating to routine health care screening, which were satisfactory. Individual’s health care records examined were properly kept and detailed inputs from outside health care professionals. Arrangements for the management and administration of residents’ medicines were examined and were satisfactory. Residents said they were consulted on an ongoing basis about their personal and health care needs and support requirements and said that staff were respectful towards them and promoted their dignity and privacy. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 (OP) and comparable (YA) standards as specified above. Residents were supported and enabled to some extent in terms their social and occupational care needs, although these needs were not always being met in accordance with individual’s personal and lifestyle preferences, choices and abilities. However, residents were provided with enjoyable, wholesome and nutritious meals, in accordance with the preferences, choices and individual needs. The quality outcome in this area is adequate. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 14 Discussions were held with residents and their representatives about their social, cultural, religious and recreational interests and needs and the arrangements in the home for these to be met. Care records were examined in relation to these aspects by way of their recorded individual needs assessment information and care planning documentation. Discussions were also held with staff about the same. Residents and staff felt that approaches to the organisation and provision of social and occupational activities could be improved in respect of developing the organisation and provision of social care and activities both within and outside the home in accordance with individual’s personal lifestyle preferences and choices Specific examples were given in relation to these. Visiting to the home is open and visitors said they were made welcome. There were arrangements in place for those residents who were less independent and unable to self-advocate to ensure that relatives and representatives were kept informed and contacts maintained. Residents said that they were consulted on an ongoing basis regarding their daily care and support, including some aspects of their personal routines. Staff was observed to effectively consult with residents during the inspection, for example at mealtimes. Lunches were observed being served in the Orangery, accommodating young adults with severe physical disabilities. Residents were provided with a nutritious meal and drinks and were appropriately assisted in accordance with their individual needs. All residents spoken with said that the standard of food provided in the home was excellent and enjoyable, with choice and alternatives provided and their likes and dislikes accounted for. They also said that drinks were offered routinely and also as they requested. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 (OP) and 22 & 23(YA) Residents knew how to complain and there were suitable systems and arrangements in place to promote their protection from abuse, but although residents felt they would be listened to, not all were confident to raise any concerns they may have, unless they perceived them to be of a serious nature. The quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: Written information was provided by the manager by way of the pre-inspection questionnaire about complaints received by the home over the previous 12 months. There had been one complaint made since the previous inspection for this service, relating to the use of a portable ramp located at the main entrance for the home. This has been in place for many years and there have been no other known complaints or concerns raised in relation to this. There were no known concerns raised by the health and safety officer regarding its use at their last visit to the home. However, the manager and provider advised that they were assessing possible alternatives to this. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 16 The complaints procedure for the home is openly displayed and information about how to complain is also provided in the service user guide – copies of which were observed around the home. Residents spoken with said they knew that they knew who to complain to. However, feedback was variable in respect of individual’s personal confidence to raise any concerns they may have. All felt they would only complain about what they considered to be ‘serious matters.’ (See the Management section of this report, regarding arrangements for consultation with residents). The arrangements to enable staff to understand key working principles and practises in relation to safeguarding adults were examined and discussed with the manager and staff. Staff was conversant with their responsibilities in respect of these and recognised procedural guidance. There has been one complaint made (October 2005) which was investigated by the home and in accordance with joint agency procedures for safeguarding adults (adult protection). Appropriate action has been taken by the home in relation to the outcome of those investigations. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 (OP) and comparable standards (YA) specified. Good progress has been made to date with the provider’s written programme of upgrading, repair and renewal of the home and in accordance with timescales identified by him and with requirements made in the previous inspection report for this service, although this is to be completed. Quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 18 A site visit was made to the home on 11 May 2006 in respect of a variation to registration application currently being processed by the Commission to increase the number of beds and provide an added category of service provision. At this visit a tour of the building was undertaken for the purposes of assessing environmental provision. Comments made in this section in respect of the environment are confined to the home’s existing registration. The provider has been notified separately in writing of the outcome of the visit in relation to their variation to registration application. All areas of the home were clean and hygienic, comfortable, warm, well lit and odour free. A number of areas of redecoration, upgrading and renewal are required. However, these have been identified by the registered provider and are included in a written planned programme of upgrading and renewal of the home, which is well underway with timescales for completion determined by the provider and which are inclusive of some outstanding requirements made at the previous inspection for this service in January 2006. Residents spoken with were satisfied with the own rooms and both residents and staff were pleased with progress so far in relation to the planned programme of upgrading and renewal of the home. Discussions were held with the manager in relation to the need to review dining furniture in the nursing unit of the Hall where older persons are accommodated and also in the residential unit (house) where older persons are accommodated. The manager advised that this was to be included in the upgrading programme. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 (OP) and comparable (YA) as specified above. Residents are in safe hands and well supported and protected by staff who are effectively recruited and appropriately trained. However, a further review of skill mix would benefit quality of care outcomes for residents in terms of ensuring greater flexibility for the registered nurse on duty on the nursing (older persons) unit to actively promote the continuous supervision and development of care staff and also to increase provision for social care and activities for residents throughout the home. Quality outcome in this area is good. This judgement has been made using available evidence, including a site visit to the home. EVIDENCE: Information provided by the manager in the pre-inspection questionnaire regarding staff employed, of their recruitment, induction, training and supervision, together with staff duty rotas were examined. Discussions were Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 20 held with the manager and staff about these and the personal files of four staff examined. Discussions were also held with residents about their care needs and staffing arrangements in the home. The same was also discussed with the manager who had started to review staffing provision, with some positive changes having been made to ensure the safety of residents in the home. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 and comparable (YA) as specified above. There have been substantial improvements in the management and communication systems in the home and appropriate action has been taken by the provider to ensure the health, safety and wellbeing of residents and staff within agreed timescales. However, the introduction of a formal system of quality assurance and monitoring based on actively seeking residents views and measuring the success of the home in achieving its stated aims and Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 22 objectives/statement of purpose would better promote a more proactive approach to the planning, monitoring and development of the home. Quality outcome in this area is good. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: The manager at the home has been in post since early December 2005. She has not yet submitted an application to the Commission for registration as manager of Burton Closes under the Care Standards Act 2000. She is a registered general nurse and has been employed as a registered manager previously. Discussions were held with the manager about strategies for communication, leadership and direction in the home and for the promotion of equal opportunities in the organisation. Discussions were also held with staff about their support and supervision (see also the Staffing section of this report) and systems of organisation and communication in the home. Discussions were held with residents about how they were consulted in terms of their views about the home and its service provision. (See also the Complaints section of this report). Monthly reports were provided by a representative of the registered provider of their monthly visits to the home and the outcomes of those visits, which included details of some discussions/observations in relation to residents and staff about the home. However, there is no formal quality assurance and quality monitoring system in operation, which is based on actively and formally seeking the views of residents and their representatives with the aim of measuring the success of the home and its aims and objectives/statement of purpose. However, the manager advised of a satisfaction survey, by way of a written questionnaire, which was to be circulated to residents and their relatives over the coming weeks. The format of this was examined. A number of records were examined, which are required to be kept in the home (referred to under the various sections of this report). These were properly kept and safely stored. Information regarding the promotion of safe working practises by way of staff training was provided on the pre-inspection questionnaire completed by the manager. Records sampled during the inspection, together with discussions with staff were reflective of the information provided in the questionnaire and were satisfactory. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 23 Since previous inspection in January 2006, key areas regarding the arrangements for the ongoing maintenance of equipment in the home have been addressed and appropriate action has been taken in respect of requirements identified in the report of that inspection in relation to these. The system for the reporting and recording of accidents and untoward incidents in the home was discussed with the manager and staff and records were examined for those residents case tracked. These were satisfactory. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 2 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 3 21 3 22 3 23 3 24 3 25 2 26 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 4 33 2 34 X 35 3 36 2 37 3 38 2 Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP23 Regulation 15 23 Requirement Timescale for action 31/08/06 3. OP33 24 (YA 9 applicable). Residents social care needs must be set out in an individual plan of care. (YA 24 applicable). The plan for 31/08/06 upgrading, repair and renewal of the home, must be fully completed. (YA 39 applicable). A formal 31/08/06 system must be established and maintained for reviewing at appropriate intervals and improving the quality of care provided at the care home, including the quality of nursing provision - by way of a formal quality assurance and monitoring system, which includes regular consultation with residents and their representatives. Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 26 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 OP3 Good Practice Recommendations (YA 2 applicable). Residents’ needs assessment information should fully promote their preferred daily living routines and lifestyle preferences, in respect of their social, occupational and recreational needs. (YA 11, 12 & 14 applicable). Access to appropriate social and occupational care and activities for residents, both in and outside the home, should be further developed to ensure that it is in accordance with their individual lifestyle preferences, choices and abilities. (YA 20 applicable). (As the weather becomes warmer later in the year) The acting manager should monitor the temperatures of the medicines storage room in the hall and ensure temperatures appropriate for the requirements of medicines storage. (YA 33 applicable). A further review of staff skill mix should be undertaken with a view to providing increased flexibility for the registered nurse on duty on the nursing (older persons) unit to actively promote the continuous supervision and development of care staff and increase the provision for social care and activities for residents throughout the home. 1. OP12 2. OP9 3. OP27 Burton Closes Hall Nursing Home DS0000002048.V289874.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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