Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/09/05 for St Michael`s View

Also see our care home review for St Michael`s View for more information

This inspection was carried out on 15th September 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home carries out a monthly detailed medication audit, which is of high standard and includes action plan for the trained staff to work on. The home adopts a proactive role in providing social and recreational activities for the service users. The role of the activities organiser had been commented on by relatives, service users and staff as very positive and service user focused. On the first day of the inspection, a Greek evening meal was being organised for the service users. Coffee mornings are regular features in the home. There are good arrangements on the Cleadon unit for getting service users up in the mornings. Service users are not rushed into getting ready for breakfast and a number are encouraged to have a lie-in if they wish. The atmosphere in the early hours of the morning was calm and organised. The home continues to support overseas nurses and carers to improve on the English skills. Those staff spoke with stated that they feel supported in this regard and that the process has enhanced their self-confidence.

What has improved since the last inspection?

The foyer of the Cleadon unit has been furnished and made more homely for service users to sit. This includes the provision of extra chairs and a bookshelf with selection of books for those who wish to read.

What the care home could do better:

On arrival for the early morning inspection, it was noticed that a number of service users have their room doors opened and had their TVs on with high sound volume on. Some of the service users were actually asleep in their chairs and did not appear to be watching the TV. The noise from TVs and buzzers made the unit appear chaotic and unorganised at that time of the morning. This should be reviewed to ensure a calm and organised environment for the service users. There were a number of doors wedged open with either tables or chairs. This is a fire risk and must be reviewed to promote good practice. Other health and safety measure must be adhered to all time to avoid possible accidents to staff and service users. Suitable arrangements must be made to ensure the effective supervision of the service users on the Cleadon unit. This would ensure that personal appearance of the service users could be observed and where appropriate, action taken by staff to promote the dignity of the person concerned. In organising staff rotas the person responsible must take into account the skills mix and the dependency levels of the service users.

CARE HOMES FOR OLDER PEOPLE Bamburgh Court Nursing Home St. Michaels Avenue North South Shields Tyne And Wear NE33 3BP Lead Inspector Sam Doku Unannounced Inspection 20:30 8 to 15 September 2005 th th 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 Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 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. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bamburgh Court Nursing Home Address St. Michaels Avenue North South Shields Tyne And Wear NE33 3BP 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) 0191 455 1215 0191 455 1238 Ashbourne Homes Limited Care Home 64 Category(ies) of Dementia (32), Dementia - over 65 years of age registration, with number (32), Old age, not falling within any other of places category (33), Physical disability (2), Physical disability over 65 years of age (16) Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The additional 1 OP service user category relates to one service user and is specific to the duration of the placement. 19th May 2005 Date of last inspection Brief Description of the Service: Bamburgh Court Care Centre is owned by the Ashbourne Homes Limited, which was first registered in November 1994 and now accommodates 32 older people of mix gender for general nursing care and another 32 persons with mental ill health, 16 of who may also have a physical disability. The home does not provide intermediate care services. It is situated amid a residential area and convenient for the town centre of South Shields. It is close to local train and bus transport. The seaside, shopping outlets, local theatres and social amenities are close by. The local shops and a post office are within easy walking distance of the care home. Bamburgh Court is a modern single storey care home, custom designed and built to provide facilities and services in 2 distinct separate units. There are in total 4 lounges, 2 dining areas and bedrooms with en-suite facilities. There are 2 internal courtyards both with easy wheel-chair access. The home is decorated and furnished to a good standard, and in keeping with the age, character and style of the building. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents the findings from three unannounced visits to Bamburgh Court on 3rd, 8th and 15th September following concerns raised by a service user regarding lack of staff leading to delays in activities such as serving of breakfast and getting people out of bed. The inspection included early morning, weekend and a late night visits. The inspection process involved talking to service users, visitors, sitting in the lounge and observing staff interaction with the service users, discussions with the unit managers and care staff, tour of the house, inspection of the drugs administration system, examination of health and safety practices and service users’ personal file including care plans. What the service does well: The home carries out a monthly detailed medication audit, which is of high standard and includes action plan for the trained staff to work on. The home adopts a proactive role in providing social and recreational activities for the service users. The role of the activities organiser had been commented on by relatives, service users and staff as very positive and service user focused. On the first day of the inspection, a Greek evening meal was being organised for the service users. Coffee mornings are regular features in the home. There are good arrangements on the Cleadon unit for getting service users up in the mornings. Service users are not rushed into getting ready for breakfast and a number are encouraged to have a lie-in if they wish. The atmosphere in the early hours of the morning was calm and organised. The home continues to support overseas nurses and carers to improve on the English skills. Those staff spoke with stated that they feel supported in this regard and that the process has enhanced their self-confidence. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 7 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 Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5. The home has a policy stating that assessments are completed prior to admission. This has been adhered to and ensured that the needs of potential service users are met. Pre-admission information is available to prospective service users and their relatives to enable them to make an informed choice about the home. EVIDENCE: The home has a corporate written policy on admissions which serves as guidelines for staff to follow. The service user records contained copies of preadmission assessments by social workers/nurse assessors and also assessments that had been carried by the nursing staff from the home. This ensured that that the staff obtained the most recent and accurate information about the prospective service users and also assured them and their families that proper steps had been taken to ensure that the needs of the person can be met. It also enabled the staff to satisfy themselves that they had the necessary skills and resources to meet a prospective user’s needs. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 9 A number of service users on the Marsden Unit and visitors to both units confirmed that they were visited by a social worker and also by staff from the home as part of the pre-admission arrangements. They all said they found the exercise useful as it gave them the opportunity to meet with the staff and ask appropriate questions. All those spoken with said they were offered the opportunity to visit the home before admissions was agreed. The Service User Guide provides a summary of the admission procedure including the opportunity for people to visit the home prior to admission. However, in the case of the Cleadon Unit, because of the mental frailty of the service users, the unit manager stated that it has not always been appropriate for prospective service users to personally visit the home before their admission. Such visits are often made by relatives to assure themselves of the facilities available to care for their loved ones. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The service users healthcare needs are met and suitable arrangements are in place to promote this. Some aspects of care practices, particularly on the Cleadon unit compromised the dignity of the service users. EVIDENCE: Care plans, daily report records and GP/professional visits records confirmed that the service users healthcare needs are being met. The records showed evidence of visits by GPs, consultant psychiatrists, chiropodists, opticians, dentists, community psychiatric nurse and other healthcare professionals. In discussions with service users and some relatives, they all confirmed that their healthcare needs are met within the home and feel that the staff take active role in promoting this. The files also contain details of care plans relating to personal and social care needs. These files set out the identified needs and practical instructions of how such needs should be met. However, in practice not all of these personal and social care plans had been rigidly followed. A number of practices observed during the inspection visits which confirmed this. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 11 On the Cleadon unit it was observed that on three occasions service users were inappropriately dressed. One had torn pyjama top on, and another had his trousers back to front and two shirts and a cardigan on at the same time. It took a considerable time before the staff noticed this and took corrective action. The other service user was wearing pyjama top and bottom, which did not match. This compromised the dignity of the service users involved. On the Cleadon unit, staff had formulated a Continence Promotion Observation Chart to be followed by all staff. It was observed on two separate occasions a service user urinating in a chair in the reception area. In discussions with the staff and the unit manager, it was evident that the observation programme was not being fully implemented because staff did not have the time to do so. This negates the efforts to deal effectively with the problem of odour control on the unit. It also compromised the dignity of eh service user involved. Observations over long periods of time on the Cleadon lounge confirmed that there was no obvious staff presence around and some of the service users were presenting challenging behaviour and were in danger of falling or hurting themselves or others. Four visiting relatives confirmed that this is a common practice, which they believe is due to insufficient number of staff on the unit. Some of the visitors provided a number of examples where there was little or no supervision of the service users in that lounge. On speaking with staff, some stated that they did not always have the time to be in the lounge to observe the service users as they are frequently engaged in seeing to the needs of those heavily dependant service users. On the Marsden unit two relatives who were spoken with said they feel the staff are very caring and they were happy that the care needs of their relatives were being met. A number of service users also stated that they are very happy with the care they receive. Service users said they feel their care needs are met and a number pointed to the activities of the Activities Coordinator as something to look forward to. One service user spoke about the trip to watch the tall ships. However, some service users expressed concerns about the lack of adequate staffing which meant sometimes they had to wait for considerable time before being attended by the staff. Two service users said it is not unusual for the buzzer to go for five minutes or more without response from staff. They said they found this irritating and that it creates unnecessary stress for them and their families. One relative stated her dissatisfaction with the management of her father’s care on the Cleadon unit. The service user in question has had his spectacles broken by another service user. The same service user had a new hearing aid provided and this was missing in less than twenty-four hours. On the second visit for the inspection, again the hearing aid could not be found thus creating a sense of frustration for the service user and the relative. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The home operates in a way that encourages the service users to exercise choice and autonomy over matters relating to daily activities and health. However, the recent shortage of staff and the high dependency levels of service users on both units have had negative effect on the way the home normally runs. EVIDENCE: The files that were examined contained details of service users’ social interests. In discussion with staff it was evident that they promote an atmosphere where the service users could continue with their previous lifestyle as much as possible. The activities coordinator plays a key role in this respect. A service user spoke about the recent arrangements for the Tall Ship race and others spoke about recreational activities such as painting, music sessions, bingo and other forms of entertainment. There are good arrangements in place for one of the service users to visit the local church on a weekly basis. Some service users and relatives commented on the problems relating to language difficulties with some staff members. However, the management is aware of this issue and there are suitable arrangements in place to address it. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 13 Staff stated that they would take account of service users past lifestyles and base their care routines to suit the individuals. They also stated that they would consult with relatives to gain more information about the service users likes and dislikes. Staff are provide the opportunity for service users’ to be consulted about activities thus enabling them to influence and make independent decisions about what social activities they would like. During the inspection visits, a number of relatives were visiting and those spoken with stated that they are able to visit at anytime convenient to them. The manager stated that the daily routines are organised flexibly to take account of individual likes and dislikes. A four-week rotational menu is in operation in the home. The service users who were spoken with commented positively on the quality and quantity of the meals provided. Examination of past menus indicated that the home provides wholesome and nutritious meals for the service users thus promoting good health. However, in recent past, the organisation of breakfast on the Marsden unit was not considered satisfactory by some of service users. Two service users commented that because of the shortage of staff on the unit, breakfast had not been on time and sometimes they do not get their breakfast till after 10.00 a.m. Staff also confirmed that this was the case for some service users as they were involved in seeing to the care needs of other very heavily dependent service users. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. There is a satisfactory complaints procedure in place, within which complaints are taken seriously and acted upon. This procedure also helps with the protection of service users from abuse. EVIDENCE: There are written policies and procedural guidelines on abuse and staff are aware of how to instigate the ‘Whistle Blowing’ policy should this become necessary. The Service User Guide and Statement of Purpose have summaries of the complaints procedure. Copies of these were available to service users and their relatives, providing the opportunity for them to complain if they wish. A number of staff have received training in the Protection of Vulnerable Adults procedures and also of the homes whistle blowing policy. Some staff were spoken with specifically about adult protection. They were all aware of the various forms of elder abuse and how these could be prevented. The company had provided all staff with training relating to adult protection. Such training and awareness amongst staff has been aimed at reducing the likelihood of abuse to service users. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Generally, the home provides accommodation of a good standard. It is a safe, clean and comfortable environment, for the service users. EVIDENCE: The Cleadon Unit has problems with odour control. This is obvious on entry to the foyer of the unit. One relative complained about this and indicated that this affected him adversely whenever he visited the unit. A number of strategies have been put in place to deal with this problem. Other ways of resolving the problem are being explored by the company. Otherwise the rest of the home is clean and maintained to good standard. The secluded internal garden provides a safe and comfortable area for the service users to use. It was noted that all toilets had liquid soap dispensers. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. The manager stated that the staff have had Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 16 training in health and safety, infection control and food hygiene. These arrangements had been put in place to avoid the spread of infection and to promote the safety and wellbeing of the service users. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30. The deployment and number of staff in the home on occasions did not meet the needs of the service users. The recent staff numbers have not fully taken into account the high dependency levels and the challenging behaviour displayed by some of the service uses. EVIDENCE: The staff rotas show that there is an adequate number of staff on both units to meet the needs of the service users. However, in practice this is inadequate to meet the needs of the service users. On the Cleadon unit, staff indicated that they have little or no time to supervise service user properly. They described situations where the needs of the dependent service users were such that most of their time is spent caring for those people. The night staff on the Cleadon unit also described similar situations at night and said that often they are not able to provide the level of supervision required to ensure the safety and wellbeing of some of the service users who have challenging behaviour. To safeguard the safety and wellbeing of the service users, senior management have increased the staffing on the Cleadon unit to three at night. Subsequent visits confirmed that some of the night shift problems identified have now been resolved with the increase in the staffing levels. On the second day of the inspection visit, it was noticed that the composition of the staff/skills mix on the Cleadon unit could not be considered as satisfactory. Of the four care staff on the day shift, one had just started work as a carer and was on her second day of duty; one was an agency staff and Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 18 that morning was his first day on duty, the other had just returned from five months sick leave and this being his second day. In effect, only the nurse in charge and the senior carer have been on the unit long enough to have detailed knowledge of the care needs of the service users. This arrangement was unsatisfactory and did not offer the opportunity for service users to receive consistent approaches to their care needs. The staffing levels on night duty on the Marsden unit are generally sufficient to meet the needs of the service users. The day staff who were interviewed on the first day of the inspection indicated that the problems with late breakfast and their inability to answer buzzers was due to the high dependency levels of the service without a corresponding increase in the number of staff during the day. However, later visits to the home indicated that the situation had greatly improved with the appointment of new care staff. Staff now feel that they are able to meet the needs of the service users. Service users also confirmed that there had been an improvement to breakfast arrangement and response time to buzzers. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38. The home is fairly well managed but the absence of a manager in recent weeks has posed some difficulties for the home. The service users’ health and safety is promoted by the staff. However, there are some areas of potential risk to service users’ care and safety which need to be addressed. EVIDENCE: During the course of the three-day inspection visits, the general manager of the home resigned her position. Arrangements were made by the senior management to provide management support for the two unit managers. Over the period of the inspection, there were a total of four managers from other homes within Ashbourne Care Ltd, who were providing management support in the absence of the immediate line manager for the home. In discussions with staff and the two unit managers, it appeared this arrangement Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 20 created extra pressure on the day to day management of the home as staff felt they were having to be answerable to four different people. Staff did not feel that this was satisfactory as they were answering to different people on a daily basis. The care situations described in previous sections of this report regarding lack of staff and the effects on the quality of the service demonstrated that in considering the staffing levels for the home, the registered person need to take into account the dependency levels and also of the number of people who present challenging behaviours. This would be evidence of the service being run in the best interest of the service users. Staff expressed concerns about the lack of physical presence of the unit manager on the Cleadon unit as most of her time has been taken up with administrative work in the office. Staff therefore felt unsupported and left to carry on with a difficult situation. Staff felt this had a negative effect on the quality of care on the unit. On the first day of the inspection it was noticed that a heavy door had been left against the corridor wall which posed a hazard to service users and staff. The inspector intervened in this case and asked for the door to be removed to a safer place out of the way of service users to avoid any accident in the home. On both units, it was noted that a number of bedroom doors were wedged open with chairs or tables. This practice must be reviewed and suitable strategies for put in place to ensure the safety of the service users in the event of fire in the home. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 22 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 OP26 OP27 Regulation 23(4)(d) 18(1)(a) Requirement Home must continue to explore ways of dealing with bad odour on the Cleadon unit. In compiling the staff rotas, the manager must take into consideration the skill mix of the staff on any given shift. The practice of keeping bedroom doors wedged open must cease as this poses fire risk in the home. Appropriate action must be taken by the responsible person to ensure that staff adhere to health and safety issues. Suitable arrangements must be made to ensure that the service users on the Cleadon unit are properly supervised. Timescale for action 15/12/05 03/09/05 3 OP38 23(4)(a) 03/09/05 4 OP38 13(4)(c ) 03/09/05 5 OP38 12(1)(a) 15/09/05 Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 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 OP14 OP27 Good Practice Recommendations The noise levels from TV sets should be reviewed to ensure cal and organised environment for the service users in the mornings. Staffing levels should take into account the dependency levels of the service to ensure their care needs are fully met. Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Bamburgh Court Nursing Home DS0000000270.V250884.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!