Care Home: Burleys Wood

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What has improved since the last inspection? This is a new service and this has been the home`s first inspection. What the care home could do better: No requirements or recommendations were made. Key inspection report CARE HOMES FOR OLDER PEOPLE Burleys Wood Brunswick Close Furnace Drive Furnace Green Crawley West Sussex RH10 6JE Lead Inspector Ed McLeod Unannounced Inspection 19th May 2009 09:30 DS0000073130.V374953.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burleys Wood Address Brunswick Close Furnace Drive Furnace Green Crawley West Sussex RH10 6JE 01293 554660 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) Shaw Healthcare Ltd Mrs Monica Penfold Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 60. Date of last inspection Not applicable Brief Description of the Service: Burleys Wood is a new and purpose-built sixty-bedded building which was registered as a care home on the 26th November 2008. The care home is located in a residential area in Crawley, close to local shops and bus transport services. The service is managed by Shaw Healthcare Limited who have appointed Mr Peter J. J. Nixey as the responsible individual for the service. The manager registered for the service is Mrs Monica Penfold. Fees in the home range from 420 to 675.07 pounds per week. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Burleys Wood is a new service, and the inspection visit was arranged to assess the services compliance with the key national minimum standards for care homes for older people. We prepared for this visit by obtaining the homes annual CQC quality assessment audit (the AQAA) which told us how they have been running the service and the improvements to the service they have made or are planning to make. We also took into account information received from them, for example in the form of notifications, and any views on the service received from other sources. The visit was carried out by one inspector who was on the premises for five and a half hours. During the visit we spoke with six people living in the home, five members of staff, and the manager. We also sampled care assessments, records and plans for three people living in the home. We observed interactions between staff and people living in the home, including during the serving of lunch. We sampled three sets of staff training, supervision and recruitment records to help assess how staffing arrangements were protecting and meeting the needs of people living in the home. Other records we sampled included complaints and health and safety records. What the service does well: Good arrangements are in place to assess the persons needs before they are admitted to the care home. The home is ensuring that peoples care and health care needs are being met. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 6 The varied provision of activities is supporting people to make the best of their abilities and maintain their interests. People live in a homely and attractive environment which has good facilities and is decorated and furnished to a good standard. People find the staff kind and considerate, and enjoy the meals in the home. The home is managed well and good arrangements are in place to ensure the home environment is safe for the people who live there. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 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 Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 1, 3, 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident the home can support them. This is because there is an accurate assessment of their needs that they or people close to them have been involved in. This tells the home all about them and the support they need. EVIDENCE: In the homes annual CSCI quality assessment audit (the AQAA) the home tell us that large print formats of both the Service User Guide and the Statement Of Purpose (which provide information on the service) are available in the reception area and in the personalised welcome book which new residents receive. Prospective service users and their relatives are offered the opportunity to visit and assess the quality, facilities and suitability of the home. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 9 We are told in the AQAA that after a pre-assessment visit a letter is sent to the person confirming if the home are able to meet their needs. People are then offered a trial period of 28 days. We looked at the report of the provider visit to the home in April 2009, which tells us they found that all new admissions had a comprehensive pre admission assessment in place which had been undertaken by two competent staff. Service user/relative agreement was very evident on all. During our visit we sampled the pre-admission assessments for three people living in the home. We found that the persons needs and wishes were being clearly recorded and that information gathered during the pre-admission assessment was contributing to the persons care plan. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP7, 8, 9, 10, 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If people cannot manage their medicine the care home supports them with it in a safe way. Peoples right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 11 EVIDENCE: During our visit we sampled the care records for three people living in the home. We found that the writing of care plans was drawing on the information and needs assessed in the pre-admission assessment and other assessments, including assessments of risk which had been carried out and were being updated. We found that action to be taken highlighted in care plans was being effective in meeting the persons needs. For example, for one person who was underweight and reluctant to eat, care records showed that there had been an increase in weight and staff were recording the support being offered and the meals and drinks being taken by the person. records showed that supplement drinks were being provided for the person. A member of staff talked to us about ways in which staff have supported the person with their eating and drinking. For example, as the person likes to drink through a straw and drinks better this way staff ensure that the person has a straw for drinks. We found that peoples likes and dislikes were being recorded, for example the food and drinks they preferred. The care plan we looked at for one person with communication difficulties recorded that they preferred to drink hot chocolate at breakfast time, and when we observed them during breakfast they had hot chocolate to drink. One person we spoke to told us that they had got up later that morning than they usually do, and this was through their own choice. Another person we spoke to told us that the staff were very good and kind and considerate and do anything for you. During our visit we read a card received by the manager from some relatives which described how the resident had been very low in mood and conversed little before admission but was now much more talkative. The relative writes that you and staff clearly did a lot to encourage and sustain her. We found that people were accessing the medical services they were in need of. For example, one person we talked to told us that their ankles had become swollen. Later in the day we overheard the manager being advised by staff Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 12 The care plan had highlighted the need for the person to receive supplement drinks, and daily that the persons GP had been contacted and that medication for the swelling had been prescribed. Care records also evidenced that appropriate health care services were being accessed. For example, over a three month period one person had received several visits from a district nurse to assist with their pressure area care and other health issues. The persons care records also indicated that when health issues had been identified the care home was making contact with the GP concerning the issue in a timely fashion. We sampled some recent medicine administration records for three people living in the home, and found that records were being completed consistently. We discussed medicine arrangements with a team leader who told us that only staff who have received training in the safe administration of medicines are allowed to administer medicines, and that after training the member of staff shadows other staff during medication rounds for a while. The team leader also advised us that staff regularly have their competencies in the administration of medicines assessed. We looked at the arrangements for the storage and administration of medicines, including the arrangements for storing and recording controlled medicines. The report of the provider visit to the home in February 2009 notes that improvements to the safety of medicine administration has included the introduction of stock sheets to monitor the amount of medication being held for the person, and administration sheets being double checked by team leaders from other units. It was our observation that during our visit people were being treated with respect and dignity at all times. A letter the home received from a relative tells us that the staff are so caring, patient and courteous and most of all your residents are treated with dignity. Correspondence seen during our visit indicates that the home is sensitive to the needs of people receiving end of life care and their families, or when someone living in the home has lost a loved one. For example, the service received a written compliment from family members after the service offered the use of a room in the home for a funeral tea following the death of a residents husband. There was also evidence of how the home was supporting the person during their time of mourning. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks at a time and place to suit them. EVIDENCE: Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 14 The manager tells us in the AQAA that there are two activity co-ordinators employed who work between them 55 hours a week, including two evenings when they provide activities between 5 p.m. and 9 p.m. The manager tells us in the AQAA that the evening events are very popular. A record is made of the activities each person has been involved in, and one care record we looked at indicated the person had been visited by relatives, had her nails painted, and spent time with staff reading a newspaper. A member of staff we spoke to told us that people on one unit like playing dominos, making cards, going to the shops, and reading the paper, and that staff spend time reading the paper with them. We were told by staff that the Friday before our visit staff took some people to the shops and on the Thursday before our visit there was a trip out to the garden centre to buy things for the gardening club. One person we spoke to told us they had enjoyed a recent musical show of old songs. On the afternoon of our visit a volunteer was leading people in singing old songs. During our visit we observed a lot of interaction between staff and residents – for example one member of staff was telling people that her chickens had laid 6 eggs the previous day and this prompted some lively conversation. The activities board on Larch unit advised us that activities arranged for the week included a gardening club, cream tea, pat-a-dog, a mystery trip, arts and crafts, a birthday tea and a film show. During our visit the activities co-ordinator was in present at different times on each floor leading a singalong and encouraging people to play percussion, and many people were participating. A member of staff we talked to told us that the singalongs were always very popular. One person we spoke to told us that staff support her keeping in contact with her sister by facilitating her phone calls to her sister. We asked the manager how people maintain their links with the local community. The manager told us that occasional church services are put on by local churches, including recently a memorial service at the home which was attended by family and some of the congregation of the local church. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 15 The manager also told us that one church has a coffee morning club which staff support some people to attend, that a local childrens choir has performed at the home and a junior marching band is planning to come in once a month. During our visit we observed that arts and crafts materials are readily available for anyone who wishes to use them, and that sunflowers planted by the gardening club were sprouting and being put out in the garden. During our visit we observed that people who wished to have a cooked breakfast were receiving this at various times of the morning. Staff told us that people have their breakfast at the time they choose, and can choose to have breakfast in the dining room or in their bedroom. We observed lunch being served in three of the units in the home. We found that if people needed assistance they were receiving this, and the atmosphere was relaxed and unhurried. People we talked to told us they had enjoyed the meal. We visited the kitchen and found that arrangements were in place to ensure that people needing a specialist diet, such as diabetic and soft food diets, were receiving meals which met their needs. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns about their care they or other people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. EVIDENCE: The AQAA tells us that there is a comment, concerns and complaints procedure in place throughout the home – and that prospective residents and their relatives or advocates are told about it during the pre-assessment visit. We are told in the AQAA that the complaints procedure is included in the service user guide which tells people about the home and what it provides, and is also given to people with their welcome booklet. The AQAA also advises that there is a reminder at reception asking people not to leave without speaking to a senior member if they feel uncomfortable about anything, Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 17 or have not managed to get an answer from someone on the visit regarding concerns they may have. During our visit we found that no complaints had been recorded. We looked at a number of written comments received from peoples relatives which were all complimentary, and some of which we have referred to in other parts of this report. One person living in the home who we spoke to named a member of staff who they said they would approach if they had any concerns or complaints. Staff training records we looked at indicated that arrangements are in place for staff to receive training in safeguarding vulnerable adults. The manager advised us during our visit that there had been one safeguarding referral concerning the managers decision to order new stocks of medication for one person who had come to the home for a respite visit. The manager advised that the investigation of the issue had found medication records to be well documented, and that the action taken was precautionary and appropriate. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP19, 20, 24, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People stay in a well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. Their rooms feel like their own, it is comfortable and they feel safe when they use it. EVIDENCE: Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 19 The premises are a new, purpose built home arranged to care for people in units of up to ten people in single bedrooms with en-suite facilities and toilets and bathrooms, a sitting area, dining area and kitchenette included in each unit. We found that the care home has been decorated and furnished to a good standard and is comfortable, homely, and has good natural light. We found that the external areas of the home including the gardens are being well maintained, and people we spoke to told us they use the garden in good weather. We found that the premises are being well maintained and that staff are recording when a maintenance issue arises. We sampled the maintenance record book and found that the maintenance staff record and date the action taken. It was evidenced that maintenance issues are being addressed without undue delay. Communal areas in the home include a room designated as a cinema, and corridor areas with seating and decoration. This includes a wall painting of a beach done by two members of staff which the manager tells us is a talking point, and is a popular place for people to sit. One person we spoke to told us they like their bedroom, and that they had brought in some of their own things for her bedroom. Another person told us their bedroom had everything they needed but that t hey didnt spend much time there as they preferred to be in the sitting room. During our visit we read a letter from a relative complimenting the service on its beautiful rooms, its spaciousness, equipment and layout. The AQAA tells us that pictures are used to identify toilets and bathrooms so that they can be clearly identified. The maintenance staff advised us that the hot water temperatures are controlled through thermostatic valves which can be adjusted when needed, and hot water temperature checks records we sampled indicated that regular checks are taking place. During our visit we found that arrangements were in place for the hygienic handling of laundry, and that arrangements were in place for good food hygiene in the kitchen. All areas of the home which we visited were clean and free from odours. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 20 Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training. EVIDENCE: It was our observation during our visit that there were enough staff being provided to meet the needs of people living in the home. For example, during lunch there were enough staff available to assist people who needed support or encouragement. One person we spoke to told us that staff work hard, and are around when you need them. A member of staff we spoke to told us that there were enough staff on each shift to meet peoples needs. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 22 We asked the manager if there were particular staffing arrangements for one person living in the home who was needing a lot of staff input to meet their complex care needs. The manager advised us that additional care support was being provided for the person by the deputy manager and another senior member of staff. We are told in the AQAA that all staff must have had required references and checks before commencing work in the home. We sampled the recruitment records for three staff employed in the home and found that required references and checks had been received before staff began work in the home. We are told in the AQAA that new staff work shifts shadowing other staff until they feel confident about working shifts and the manager or deputy manager agree this. The manager told us during our visit that before the home opened training and team building with staff took place, including guiding inexperienced staff on things such as knocking on doors, care of spectacles and teeth, infection control, and using equipment such as hoists, stand aids, and slide sheets. We looked at the training records for three members of staff and found that arrangements were in place for staff to receive appropriate training. One member of staff we spoke to told us that it had been agreed at their supervision session with their line manager that they undertake training in the administration of medicines and that this had now been arranged. We spoke to one member of staff who told us that a three day training course in dementia has improved their understanding of the condition, and that it had given them ideas about how to deal with situations. The AQAA tells us that seven staff in the home are trained as trainers in moving and handling, and the manager tells us that at all times in the home a moving and handling trainer is available to be called on by staff. The AQAA tells us that staff are offered in-house training in care at National Vocational Qualification (NVQ) levels 2 and 3. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): OP 31, 32, 33, 35, 36, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 24 EVIDENCE: The AQAA tells us that the manager Mrs Penfold has continued to update her skills and training. The record of the monthly provider visit carried out in March 2009 tells us they found that the manager monitors regularly and encourages all staff to use their skills and truly feel a part of the home and its residents. Our discussions with the manager indicated that that she is committed to providing person-centred care in the home, and the care provision observed on the day of our visit indicated that the staff team are also seeking to ensure people are receiving the care the need in the way they wish it to be provided. We found that there was a good atmosphere in the home. Quality assurance policies and procedures are in place to ensure that the service seeks the opinions of people living in the home and others on the care being provided. During our visit we looked at the arrangements in place for when amounts of money are being held for people living in the home. We found that a system for recording and checking transactions was in place, and staff told us that (where relatives are involved in supporting the person with their finances) when relatives visit they are given the opportunity to inspect the records held. The AQAA has advised us of the most recent equipment services and tests carried out in the home. The record of the monthly provider visit tells us that on the day of their 26th March 2009 visit a fire drill took place which staff responded well to. We discussed with the manager Mrs Penfold the arrangements for staff supervision. We looked at the records for staff supervision for three people living in the home. Discussion with a carer indicated that their sit-down supervision with a team leader was taking place, and was helping to identify their training needs. For example, the Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 25 need for training in the administration of medicines had been agreed at their most recent supervision and this has now been arranged for the coming month. We talked with the person responsible for maintenance in the home, and looked at records for fire drills, daily and weekly checks, and hot water temperature checks all of which were being undertaken regularly with clear records kept. Staff training records we looked at indicated that staff are receiving training in health and safety topics such as infection control and manual handling. Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/a 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. Refer to Standard Good Practice Recommendations Burleys Wood DS0000073130.V374953.R01.S.doc Version 5.2 Page 28 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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