Care Home: Burnham Lodge Nursing Home

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• St Vincents
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• The Maypole Nursing Centre
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What the care home does well Before agreeing admission the home carefully considers the needs assessment for each person and its capacity to meet their diverse needs. Prospective people to use the service and their families are encouraged to visit the home and spend sometime.Burnham Lodge Nursing HomeDS0000019186.V376940.R01.S.docVersion 5.2The home ensures that people’s personal and health care needs are met in a manner that protects and promotes their privacy and dignity. Family members spoken to as well as people using the service and staff were confident that the home was providing an excellent standard of care. The home ensures that people using the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. People who responded to the Commission`s survey said that `there were always activities organised in the home.` The home is clean, safe, comfortable, and fitted with the appropriate aids and adaptation to promote independence. There is an ongoing refurbishment programme to the existing building and grounds. People said that `the home provides a safe and caring environment tailored to their individual needs and wishes.` The home ensures that staff are provided with the appropriate training to meet people using the service diverse needs. People said that `the staff were very friendly, caring, approachable and respectful.` The home is managed by a stable and experienced management team and there are systems in place to ensure that the home is run in the best interests of people using the service to promote their safety. What has improved since the last inspection? The home has reviewed its nutritional risk assessment documentation tool to ensure that people are protected from the risk of malnutrition. The home has employed a second activity person to ensure that there are adequate activities provided to meet people’s diverse needs and satisfy their social cultural religious and recreational interests. The home continues to make improvements to the environment such as, installing a new call bell system, bathroom and wet room. Arm chairs and new garden furniture have been purchased and a new heating system has been installed. This is to ensure that the environment is safe and comfortable for people to live. What the care home could do better: The manager and staff continue to offer a high standard of care to people living in the home and are aware of the areas that need improving. However, consideration must be made to ensure that concerns raised by people using the service and the actions taken in response to them are recorded. This would demonstrate that the management of the home is open and transparent.Burnham Lodge Nursing HomeDS0000019186.V376940.R01.S.doc Version 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Burnham Lodge Nursing Home Parliament Lane Burnham Buckinghamshire SL1 8NU Lead Inspector Joan Browne Key Unannounced Inspection 28th July 2009 09:00 DS0000019186.V376940.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. Burnham Lodge Nursing Home DS0000019186.V376940.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 Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnham Lodge Nursing Home Address Parliament Lane Burnham Buckinghamshire SL1 8NU 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) 01628 667345 01628 602761 brian.bronock@zen.co.uk Burnham Lodge Ltd Mrs Jaquie Margaret Taylor Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Burnham Lodge Nursing Home DS0000019186.V376940.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 with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 52. Date of last inspection 14th August 2007 Brief Description of the Service: Burnham Lodge is a care home providing nursing and personal care for people who are elderly and physically frail. There are qualified nurses, supported by a team of carers, on duty at all times. The home is situated on three floors. There are pleasant communal areas. Access to all floors is by a passenger and stair lift. The home is a large country house set in tranquil surroundings, backing on to woodlands at the edge of Burnham Beeches. There are extensive gardens, which are well maintained. Public transport and other amenities are not easily accessible. Burnham Lodge Nursing Home DS0000019186.V376940.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 3 stars. This means that people who use this service experience excellent quality outcomes. This unannounced key inspection was carried out on the 28 July 2009 and covered all of the key National Minimum Standards for older people. The inspection lasted for approximately seven hours; commencing at 11:30 am and concluding at 18:30 pm. Prior to the inspection, a detailed self assessment questionnaire known as the annual quality assurance assessment (AQAA) was sent to the manager for completion and surveys were sent to a selection of people living at the home, relatives, staff and visiting professionals. The AQAA was returned by the due date and contained detailed information demonstrating how the home had listened to people using the service and their relatives and recognising the areas that it still needs to improve in and how it was planning to do this. Six people using the service, three relatives, seven staff members and two health and social care professionals completed surveys and their replies have helped to form judgements about the service. The deputy manager, people using the service, staff and three relatives visiting the service on the day of the inspection were also involved in the inspection process and their responses and views of the home have been incorporated into the report. Further information was gained by observing staffs practice, examination of care plan documentation, staff’s records, health and safety records and a tour of the premises. Feedback was given to the deputy manager on the inspection findings. There were no requirements and recommendations made on this visit. We (the Commission) would like to thank all the people who use the service and staff who made the visit so productive and pleasant on the day. What the service does well: Before agreeing admission the home carefully considers the needs assessment for each person and its capacity to meet their diverse needs. Prospective people to use the service and their families are encouraged to visit the home and spend sometime. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 6 The home ensures that people’s personal and health care needs are met in a manner that protects and promotes their privacy and dignity. Family members spoken to as well as people using the service and staff were confident that the home was providing an excellent standard of care. The home ensures that people using the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. People who responded to the Commissions survey said that there were always activities organised in the home. The home is clean, safe, comfortable, and fitted with the appropriate aids and adaptation to promote independence. There is an ongoing refurbishment programme to the existing building and grounds. People said that the home provides a safe and caring environment tailored to their individual needs and wishes. The home ensures that staff are provided with the appropriate training to meet people using the service diverse needs. People said that the staff were very friendly, caring, approachable and respectful. The home is managed by a stable and experienced management team and there are systems in place to ensure that the home is run in the best interests of people using the service to promote their safety. What has improved since the last inspection? What they could do better: The manager and staff continue to offer a high standard of care to people living in the home and are aware of the areas that need improving. However, consideration must be made to ensure that concerns raised by people using the service and the actions taken in response to them are recorded. This would demonstrate that the management of the home is open and transparent. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 7 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. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 8 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 Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 9 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): 3 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. The needs of prospective people are assessed prior to them moving into the home. This is to ensure that the home would be confident that it can meet individuals’ diverse needs. EVIDENCE: The files of three people recently admitted to the home were examined. Evidence seen verified that the manager and the deputy manager had undertaken pre-admission assessments. The deputy manager informed that for individuals admitted through care management the home ensures that a copy of the care plan and the assessment is obtained from the placing authority before an assessment is undertaken. Wherever possible, prospective people to use the service and their relatives are encouraged to visit the home Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 10 and spend some time before making a decision. Individuals are given one month’s trial period to see if they are happy with the placement and the home is confident that all assessed needs can be met. People who responded to the Commission’s survey and those spoken to during the inspection confirmed that that they had received enough information about the home to help them decide if it was the right home to move in to. The home does not provide intermediate care. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 &10 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and healthcare needs are met in a sensitive manner to ensure that their privacy and dignity are promoted. EVIDENCE: The randomly selected care plans examined were clear detailing how identified needs should be met. Risk assessments outlined how identified potential and actual risks would be managed. The daily report sheets along with discussions with people using the service and staff demonstrated that individuals’ diverse needs were being met. All staff undertaking the development and monthly review of the care plans signed and dated them. There were no persons in the home on the day of the inspection with tissue damage. The risk of individuals acquiring pressure sores due to immobility is Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 12 assessed and the appropriate equipment is provided. We were told that the home’ training facilitator arranges training on health care topics , which relate to the health care needs of people using the service. The Primary Care Trust (PCT) supports the home with continence aid and equipment if required. People were registered with a general practitioner (GP) who visits the home weekly or as and when required. The GP responded to the Commission’s survey and said that ‘the home provides excellent nursing care. The staff are always ready to help people in the best ways possible and nothing is too much trouble.’ People who responded to the Commission’s survey said that they ‘always’ received the care that they need and that the staff listened and acted upon what they say. The AQAA informed that the home’s staff involves the multi-disciplinary team in the management of people’s health care needs and seek advice to improve the quality of care when necessary. People spoken to were confident that staff assisted them with all aspects of their personal care in a sensitive manner in private and at a time and pace to suit them. The AQAA reflected that the home has a robust procedure for the receipt, storage and handling of medication which the manager monitors. The home’s pharmacist also carries out audits on a regular basis. The medication and administration record (MAR) sheets were checked and no unexplained gaps were noted. There were photographs of individuals in the medication record folder to minimise the risk of errors occurring during medication administration. There was no one living in the home on the day of the inspection assessed as capable to self-administer their medication. However, the home has policies and procedures for self medication should this become necessary. The controlled medication for two people using the service was checked and the balance of tablets in stock corresponded with the controlled drug register. The home has a system in place to ensure that the controlled medication is checked regularly. However, the practice in place needs to be consistent to ensure that two staff members participate in this task. The home does not have pre-printed MAR sheets. The AQAA informed that despite attempts to obtain pre-printed MAR sheets from the chemist the home has been unable to achieve this because of the change of management with the medication supplier and some lack of interest. The home has been pro-active by ensuring that two staff members check all handwritten medication charts which are also countersigned by the GP. We observed that staff wore name badges to enable visitors and people using the service with memory impairment to be sure of whom they were speaking to. Individuals were observed being treated in a friendly but respectful manner by staff. People spoken to rated the personal care they receive as excellent. They unanimously said, “We are treated with respect.” They also said that the staff team was “friendly.” People’s attire was clean and tidy with attention to detail. It was evident that staff were supporting individuals to look after their appearance. We observed the activity person providing nail care to some individuals. Three visitors were spoken to during the inspection and they were confident that staff ensured that people’s privacy and dignity Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 13 were upheld. We were told that individuals who were sharing a room had made a conscious agreement to do so. Staff confirmed that medical examinations and treatments were provided in people’s own rooms. Staff confirmed that care and comfort are given to people who are dying in a sensitive manner. The AQAA informed that the home has links with the Ian Rennie and Macmillan nurses who provide support and advice to staff to improve the end of life care for individuals. When required the Liverpool Care Pathway care plan is implemented. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 & 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that there is a range of activities available to meet people’s diverse needs and people are encouraged and supported to follow their own interests and to remain in contact with families and friends. Meals provided were of a high standard and served in pleasing surroundings. EVIDENCE: The home’s daily routine was flexible and varied. People spoken to confirmed that they were able to choose how they wished to spend their day. The AQAA informed that the home employs two activity persons and they both have an excellent rapport with people using the service. They both work three days a week, which means that activities are provided six days a week enabling individuals to enjoy a full and stimulating lifestyle with a variety of options to choose from. Those individuals who are nursed in bed or are unable to participate in group activities have one to one activities. A copy of the monthly activity programme is made available to all individuals and a copy Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 15 was displayed in the home to remind them of what was taking place. The AQAA informed that annual events such as the Christmas party, the summer garden party, bonfire night, carol concert have a high attendance of family and friends. An outside entertainer is booked monthly. Theme days such as ladies day at Ascot are celebrated and pictures of the activity events were on display in the home. Birthdays are celebrated and the chef would bake a cake and personalise it. Individuals who responded to the Commission’s survey said that the home ‘always’ arrange activities that they can take part in. Monthly church services are held and people are supported to promote their spiritual needs if they wish to. The home does not have any restrictions on visiting. People are able to choose whom they wish to see and can receive visitors in private in their rooms or in communal areas. Relatives are able to visit at any time and made to feel welcome. A relative was spoken to during the inspection and confirmed that they are made to feel welcome and often partake in lunch, which was very tasty. Telephones were installed in all bedrooms and people are able to make outgoing calls free of charge. Access to the internet is also available. The AQAA informed that people were encouraged to bring in personal items and small items of furniture to personalise their bedrooms if they wish to. The home supports people to be independent and to exercise choice and control over their lives. Those individuals who wish to, are encouraged to look after their finances for as long as they are able to and have the capacity to do so. The standard of food was very high and the menus were varied and tailored to meet individuals’ needs. The chef was very aware of individuals’ likes and dislikes and would provide special diets if required. The home has two lunch sittings to facilitate social interaction. Meals served looked attractive to stimulate appetite. Staff were observed offering assistance to individuals discretely and sensitively. They were patient and helpful, allowing individuals the time they needed to finish their meals comfortably. We observed fresh fruits in the dining room and lounge areas, which means that people were free to help themselves to a piece of fruit if they wished. People who responded to the Commission’s survey and those spoken to on the day of the inspection said that they ‘always’ liked the meals provided. All said that meals were the highlight of the day. The following additional comments were noted: “The chef would provide an alternative if I did not like what was on the menu.” “I cannot fault the chef. He tries to please everybody.” Burnham Lodge Nursing Home DS0000019186.V376940.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): 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. The home has a complaints and safeguarding policy in place this is to ensure that people would be confident that their complaints would be investigated and they would be protected from any potential risk of harm or abuse. EVIDENCE: The home has a complaints policy and procedure which was displayed in the front area of the home. The AQAA informed that it is reviewed regularly and can be provided in large print if required. In discussion with the deputy manager we were told no records of people’s minor concerns were logged. The home must review this practice to ensure that a record is kept of minor concerns and the actions taken in response to them. This would demonstrate that the management of the home is open and transparent. All the people who responded to the Commissions survey said that they knew who to speak to informally if they were not happy and how to make a complaint. A recommendation was made at the previous key inspection for the home to obtain a copy of the Buckinghamshire County Council safeguarding policy and procedure and the home has complied with the recommendation. Staff spoken to confirmed that they had undertaken updated training in the safeguarding of vulnerable adults. Those spoken to were aware of the action to take if they suspected or witnessed an incident of abuse. People spoken to during the Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 17 inspection said that they felt safe living in the home and the staff respected their privacy and dignity. People are encouraged to look after their finances for as long as they have the capacity to do so. The home ensures that lockable storage facilities are provided in bedrooms for money and valuables to be stored safely. Burnham Lodge Nursing Home DS0000019186.V376940.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): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people to live in a safe well-maintained and comfortable environment which encourages independence and protects their privacy and dignity. EVIDENCE: The home was well maintained and there is an ongoing refurbishment programme taking place to improve the existing building and gardens. Bedrooms seen were personalised with small pieces of furniture, family pictures and mementoes to reflect individuals’ characters. Bathrooms and toilets have been fitted with the appropriate aids and equipment to promote independence and uphold people’s dignity. The call bell system has been upgraded and mobile call pendants are available for those individuals who wish to sit in the garden. New armchairs and garden furniture have been purchased Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 19 to enhance the environment. Bedroom doors have been fitted with sliding door signs to display ‘knock and enter’ or ‘engaged’ to promote people’s privacy. The gardens are extensive and well-maintained and a new patio has been built. People spoken to said that they enjoyed sitting in the patio area. The home was clean, safe, pleasant, hygienic, tidy and free from offensive odours. Random review of staff training records demonstrated that they had undertaken training in infection control. Hand gels were available for visitors and staff to use to reduce the risk of cross infection. The standard in the laundry was satisfactory. Clothes are labelled, washed and ironed to a high standard. People who responded to the Commission’s survey and those spoken to on the day of the inspection said that the home was always fresh and clean. Additional comments noted were as follows: “The home has a homely feel.” “The gardens are well cared for and a joy to sit in.” “The home provides a safe and caring environment tailored to individuals’ wishes and needs.” A new call bell system was recently installed with safety features for example, it can only be turned off from the point of call. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 20 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): 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. Staff in the home are trained and skilled to fulfil the aims of the home and meet the changing needs of people using the service. Recruitment procedures are thorough which means that only staff that are suitable to work with vulnerable people are appointed. EVIDENCE: The rota demonstrated that the number and grade of staff on duty to provide care to people was adequate to meet their assessed needs. Nearly all the care staff have acquired the national vocational qualification (NVQ) in direct care at level 2. Three staff had acquired the level 3 qualification. There is a stable staff team and staff spoken to said that they enjoyed working at the home and felt valued. Team spirit and morale were high. The following comments were noted from staff members: “Since I have been nursing this is the happiest I have been.” “The home is very well run. The staff try their utmost to cater for all the residents’ needs.” “All staff work well together and Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 21 make a good team.” People using the service said that the staff were friendly, caring, pleasant and approachable. The recruitment files of three recently recruited staff members were examined. It was found that they contained the required documents to verify that appropriate checks had been undertaken. Individuals’ identity had been checked, two references, PoVA first check and enhanced criminal record bureau clearances obtained. Mandatory training for all staff was up to date. The home is part of the Milton Keynes and Buckinghamshire cluster group. The deputy manager is responsible for arranging training within the cluster group. The home’s nursing sister assists in facilitating all in-house training and she is also the manual handling trainer. A respondent to the Commission’s survey said that ‘the staff were trained and always ready to help people using the service in the best ways possible.’ Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 & 38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the experience to run the home which means that the home is well managed and there are systems in place to continuously improve the service delivery and provide an increased quality of life for people using the service to promote their safety. EVIDENCE: The manager is a qualified registered nurse and has ten years management experience in the care home setting and holds the registered manager’s award (RMA) certificate. The deputy manager is also a registered nurse and has undertaken an accredited leadership and management training course. The management team attend human resource seminars to keep up their skills and Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 23 knowledge with current legislation. The lines of accountability within the home are clear. In discussion with the deputy manager it was evident that both the registered manager and herself were knowledgeable about the care needs of the people using the service and the training needs of the staff team to meet these identified needs. Each staff member spoken to on the day of the inspection was aware of their role and responsibilities. Regular meetings are held with people using the service as well as staff meetings. The following comments were noted from staff who responded to the Commission’s survey: “the management team is excellent and work in a hands on manner as well as performing their many administrative duties.” “The home is managed by a very good matron, assistant matron and two sisters who have created a friendly working team. They are proactive and supportive and this gives off a confidence which has passed through to the rest of the employees.” There is a quality assurance programme in place. The views of people who use the service, relatives, staff and other stakeholders are listened to, and valued. User satisfaction questionnaires are sent out and the results are collated and action taken in response to findings. The AQAA contained excellent information that was fully supported by appropriate evidence. The management team shows a high level of selfawareness and recognises the areas that the home still needs to improve in and how it intends to do this. The home does not manage people’s money on their behalf. Small amounts are left by family members for some individuals which are not pooled to cover incidentals such as hairdressing, news papers, chiropody and toiletries. Written records of all transactions are maintained. The home has health and safety policies and procedures in place. Training records indicated that staff have had training in safe working practices which should ensure that they understand and consistently follow the home’s procedures to promote and protect people using the service safety. The AQAA informed that maintenance of equipment in the home and safety checks were up to date. The kitchen area was clean, tidy and well organised. Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 3 X 3 X X 4 Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burnham Lodge Nursing Home DS0000019186.V376940.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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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