Care Home: Burstow Lodge

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Townley Road, 2-3
• Chatsworth Care - Tudor Lodge

What the care home does well The home enables and facilitates mental health residents to develop sufficient skills to move on to more independent accommodation in a supportive environment. The service has always ensured that the environment is maintained to a high standard which is commendable given the type of resident. A domestic has been employed to maintain the environment which is beneficial in a home of this type. The home has retained a fairly stable staff team which provides residents with consistency. Recruitment checks are conducted through the Head Office and ensures that staff are thoroughly checked prior to employment. What has improved since the last inspection? Assessment information and pre admission procedures had improved and records retained to evidence this. The staff`s knowledge of adult protection and whistle blowing had improved which provides residents with greater safety. As part of the on going refurbishment the bathroom and rehabilitation kitchen have been refurbished. The staff team appeared to be working more cohesively together and consistently with residents. What the care home could do better: Care plans need to specifically detail the actual problem and general terms should be avoided. Interventions need to be specific and detailed to address the problem with reviews detailing progress made. This is particularly in important as mental health issues can be complex and must be addressed with the correct interventions in a consistent way. The risk assessment in relation to self medication procedures should be reviewed to include the pharmacists advice incorporated into this report. The Regulation 26 visits need to be conducted by an appropriate person external to the home. CARE HOME ADULTS 18-65 Burstow Lodge Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 7th July 2008 09:45 Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 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 Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burstow Lodge Address Burstow Lodge 17/19 Howard Road Penge London SE20 8HQ 020 8659 6874 020 8776 9833 burstow@tiscali.co.uk 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) Mills family Limited Terence Michael Smith Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 13 Adults of either sex with a learning disability and or a mental illness Date of last inspection 3rd May 2007 Brief Description of the Service: The home is a detached house located in a residential area of Penge. It has parking to the front of the building and an enclosed garden to the rear. Bedroom accommodation is located on all floors. There are two dining areas and kitchens, one of which is used specifically for rehabilitation sessions. There is a large bright lounge furnished in a domestic manner. The home is registered for thirteen places however the maximum number that the home takes is twelve, as one double bedroom is used as a single. Bedrooms were personalised, clean and tidy as were all areas in the home. The range of fees for this home are £750 - £1050 per week. The inspection report is available in the main hall for anyone to access. In the event that residents need assistance with the reading/understanding of the report, staff would assist. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was conducted over a one-day period. The Manager facilitated the inspection. Periods of observation were undertaken in the communal areas. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. Four comment cards were provided and returned during the inspection. During the visit the we met with two relatives, several residents and observed staff interaction and engagement with residents. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The home enables and facilitates mental health residents to develop sufficient skills to move on to more independent accommodation in a supportive environment. The service has always ensured that the environment is maintained to a high standard which is commendable given the type of resident. A domestic has been employed to maintain the environment which is beneficial in a home of this type. The home has retained a fairly stable staff team which provides residents with consistency. Recruitment checks are conducted through the Head Office and ensures that staff are thoroughly checked prior to employment. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information and opportunities to sample the service prior to any decision on placement being made. Information supplied to the home about the resident ensures staff have a good knowledge of the residents needs prior to admission to enable them to determine whether they could meet the resident’s needs in the service. EVIDENCE: The home operates on twelve beds as an existing double is used as single occupancy. At the time of the inspection there were two vacancies one of which had only recently occurred. All residents in this home are on Care Programme Approach (CPA) which is a system of after care for mental health residents monitored by the multi disciplinary team. Under this aftercare procedure specific documents are produced including care plans risk assessments and regular review meetings are held. In those file selected for case tracking had the CPA assessments had been received. These contained good information on the needs of the resident. Other information included the assessment provided through the funding authority and a hospital discharge summary. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 9 The Manager stated that residents were invited to the home for trial visits and that he retained the notes relating to that visit. Visits include those undertaken during the day time and an overnight stay. The number of visits can vary between individual residents as some require a greater lead in period. There were assessments conducted by the Manager of the home. The preassessment forms were completed prior to admission into the home. Information on life skills, activities of daily living and risk assessments were included. Individual missing persons risk assessments are conducted Following the assessment the home sends out and acceptance letter and offer of placement. Residents are issued with terms and conditions which includes the fee, details of insurance cover, trial periods and room to be occupied. Those seen were signed by the resident, a representative from Burstow and the Care Coordinator The Service User Guide is issued to every resident and retained in bedrooms. The Statement of Purpose was available. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are fully supported and assisted to be as independent as possible in their daily lives. The care plans have some limitations which need to be expended upon to fully reflect the level of support and assistance required within their given mental health conditions. EVIDENCE: There was evidence throughout the site visit that residents were offered choice and enabled to make their own decisions. It was apparent that very few restrictions were placed upon residents except those relating to rehabilitation programmes. The care notes for residents are contained in separate boxes with each section of the file clearly labelled for ease of access to information. These are safely stored. Care plans were selected for inspection. They contained areas relating to physical and mental health as well as financial support. The care plan format is a standard type used within the home. The care plan contained the Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 11 signature of the resident and staff as confirmation that both were involved in its development. In one file the care plan for dietary intake should have included reference to weight loss although there was evidence of referral to the dietician which had been actioned. The review was simply a date with no actual content of what the review had included or what had been achieved in respect of the identified problem. The Manager stated that this was because care plans worked with CPA procedures and reviews of care plans would be undertaken at CPA reviews and the care plan amended accordingly. In one file the CPA review stated that the resident has obsessive behaviour with regards to certain household chores, however these two specific problems were not included in the care plan. The individual missing person’s description had omission under height, weight and distinguishing features although completed once pointed out to the Manager. A second care plan included issues around mental state physical health and financial. Some general terms were used such as “ Mental state “ the care plan problem should be specific to detail what the actual issue is, as mental health problems vary considerably and would have very different interventions required to address the problem . The daily events were to a good standard and representative of issues as set out in the care plan. Residents in this home can go out unaccompanied and are supported and encouraged to use public transport and be involved with the local community. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,ad 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled and supported to develop the skills to facilitate more independent living within a supportive structured environment. Participation in the local community including accessing work and social activities are supported by staff in the home. EVIDENCE: Residents have choices in their day including rising and retiring times, mealtimes, choices of food and a range of varied activities. The home is as flexible as possible within given restraints of activity timetables. Residents have an individual activities programme which is designed around maximising their daily living skills. It was evident throughout the site visit that residents were occupied with various activities including those in the community. Most residents attend the local MIND centre in Beckenham travelling there by public transport. One Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 13 resident said that outside of the time they attends the centre they likes browsing in the charity shops. Residents confirmed that they receive visitors in the home at various times and that they go home for visits including overnight leave. Two visitors were in the home during the inspection although did not want to talk to the us. One resident was preparing to go to Spain with their family; this is something which they do yearly and really enjoys. Residents also confirmed that they were engaged in rehabilitation activities including meal preparation, doing their own washing, shopping and cleaning with varying levels of support . There is a separate rehabilitation kitchen where residents can do cooking sessions. Washing machines and tumble driers are available so residents can do tier own washing. Other residents are currently in the process of deciding what holiday arrangements they want either a weeks holiday or days out. One night in the week ex residents and those in the home all get together to watch a movie and have a take away. The take away food is of their choice and they are given money to buy this. This evening has proved to be very popular. It is also a good support mechanism for those residents who are now living more independent lives, and should they need re-admission to the home the links are well established. One resident works two days a week in a café. They told us that they enjoyed the work serving customers and taking the money. To enable residents to find gainful employment is commendable. One resident requested to have a kettle in their bedroom to make a drink as well as a front door key. Residents are not issues with front door keys as there are staff on throughout the 24 hour period and issues around security. All residents have a bedroom door key. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health needs are fully met by staff in the home and those services provided through the local community, which resident’s access as part of their rehabilitation and integration in to the community. EVIDENCE: Residents in this home are encouraged to access services through the local community provision including the General Practitioner. This is appropriate as residents will have to access service once they move from Burstow Lodge. Those records relating to such visits were brief simply stating the date of the visit and the reason. In the files inspected medical correspondence was available including hospital out patient letters and referrals to specialist services. Correspondence relating to CPA reviews was retained on file. The staff team includes male and female staff hence issues around gender care can be incorporated into residents care. Resident’s weights are monitored monthly and recorded. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 15 Regulation 37 reports are retained and forwarded to the CSCI the last one was December 07. The medications were inspected. Currently there are two residents who are self medicating. These residents are subject to risk assessments in relation to their suitability and compliance. This is a standard risk assessment and has been in use in the home for many years. This may need to be reviewed in light of the advice received from the pharmacist relating to self medication procedures as detailed below. In addition those residents who self medication have spot checks conducted where the amount of medication is checked to establish if this confirms that they are taking it appropriately. Lockable cabinets for safe storage are provided in every bedroom. One issue which was referred to the pharmacist for advice was the following : Staff were popping the medication from the blister pack into a dosette box for two residents, who were trying to start self medicating. The dossette box was retained in the drug cupboard and then medications were issued under staff supervision on a daily basis to the resident. This was in preparation for the resident to be fully self medicating . We were concerned that this may constitute secondary dispensing and referred it to the inspecting pharmacist for advice which was received as follows : This technically is secondary dispensing but as it is to support self medication then it is acceptable. It would only be acceptable, if the person can only manage a 24 hour supply at a time, and if they have assessed the risks associated with the secondary dispensing. This must be part of the self medication risk assessment, and put suitable checks in place to minimise the risks and keep appropriate records. Once people can manage a week’s supply, then they should be having medications supplied from pharmacy in a suitable container. During the site visit there were no controlled drugs in use or eye drops. The homely remedies list was signed by the GP January 08. The information included the medications which can be given as homely remedies the reason and the maximum amount. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Residents can raise complaints without fear of reprisal. Staff had a working knowledge of adult protection and whistle blowing procedures, which affords further protection to residents. EVIDENCE: The complaints procedure was on display. Complaints information is included in the Service User Guide which is issued to every resident. Residents who met with us stated that they would make concerns or complaints known through staff in the home or through their Care Coordinators whom they meet regularly. In the compliant information file there were no entries since September 2007. The CSCI have received no complaints regarding this service. There have been no adult protection issues since the last key inspection. It is essential that all complaints are logged and where appropriate investigations undertaken with the outcome noted. All information relating to complaints must be retained. The staff who were interviewed during the site visit were questioned on adult protection procedures and dealing with abuse. All confirmed that they had received training on the topic either through their NVQ or a specific training session on it. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 17 The staff demonstrated a satisfactory knowledge in relation to abuse and more importantly the reporting of such matters. They related the internal reporting procedures and external bodies which included the CSCI. Staff need to be updated in the current guidance and the single point of contact for referral of adult protection procedures. Staff were familiar with whistle blowing and understood its importance and this may impact on residents and staff working in the home. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a good standard of accommodation which is well maintained and has the facilities to meet their needs. EVIDENCE: All residents have single bedrooms with wash hand basins. Bedrooms seen were individual and personalised generally clean and tidy. Residents are responsible for maintaining their own bedrooms with staff support. Bedrooms are furnished and personal items including radios, TV’s etc can be purchase by the residents for their own bedrooms. There are plans to replace or recover sofas in the sitting area, although these are still in reasonably good condition. There has been upgrading of the rehabilitation kitchen and a first floor bathroom . The rehabilitation kitchen is well equipped to enable residents to undertake cookery sessions and store their own food purchases. Sufficient crockery and cooking utensils were available. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 19 There is a small activity/quiet room as well as the large dining sitting area. This provides an alternative area should visitors wish to see their relatives/friends in private although not in their bedroom. Health and safety measures are in place including window restrictors, radiator covers and hot water valves. The garden was provided with garden furniture. The shed had been removed and was to be replaced with a new one. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are supplied in sufficient numbers skill and gender mix to meet resident’s needs. Staff are subject to robust recruitment procedures to ensure that they are safe and suitable to work with residents in the home. Mandatory training and specific client related mental health topics, provides staff with the skills and knowledge to undertake the work. EVIDENCE: The home operates on two staff per shift with the Manager supernumerary. Night duty has two staff sleeping in. Nine staff are employed, this includes the Manager. The home has a domestic employed for two and a half hours a day and the hours are increased if they are required. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 21 Staff personnel files were inspected as part of the suit visit. The personnel files contained an application form, including the work history, two references, confirmation of identity, POVA and CRB clearance. There was the job description offer letter and terms and conditions which set out the employee’s entitlements and rights. Physical health is checked through self declaration health screening. Such robust recruitment ensures that the staff employed are safe and suitable to work in the home. Induction is conducted with all staff and they are issued with a staff handbook. Supervision is conducted monthly where objectives are discussed and set, the employee is issued with a copy of the notes of this meeting. Appraisal information was also on file. Three staff have NVQ level 3 and one of the Team Leader has completed RMA. Two staff, including the Manager, are NVQ assessors. Staff on duty were interviewed as part of the site visit. They all confirmed that they received good training including up dates on the mandatory topics as well as those relating to mental health awareness. They felt the received good support from the Manager and management personnel of the company. We spoke to staff who had completed NVQ training and as part of this had chosen the mental health option as one of the components of the course. Other related topics staff had received training on, included the Mental Capacity Act. When staff were asked about specific terms used in mental health such as Care Programme Approach (CPA), they had a good understanding. This means that staff have sufficient training on mental health issues to support residents and monitor their health. Mandatory updates in training are monitored by the Manager who produces a list of who requires updates on these. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced individual who is supported by the company’s management team. Health and safety measures provide a safe home for residents to live in . Quality assurance mechanisms provides opportunities for residents, relatives and staff to input into the further development of the service . EVIDENCE: The home is managed by a trained nurse who has experience of this type of resident and working in a community setting. He is well supported by the management arrangements provided through the company. An open ethos prevails where staff, residents or relatives can approach the Manager for any queries they may have. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 23 All staff have completed first aid training, which provides safety to residents knowing staff can competently assess injuries, and where needed refer them to hospital. Within the staff team employees have responsibilities for areas, one staff is a fire warden the other is the health and safety representative. The home has a number of training videos which are used in conjunction with other types of training. The videos include health and safety and infection control Regulation 26 reports were available and reflected monthly visits although the time of the visit was omitted. It was noted that staff in the home were undertaking these visits and completing the report. When the Manager was asked about this practice, he confirmed that this was the case at the direction of senior management. The reason for this was the staff undertaking such visits were all trained to level NVQ 4 and quite able to do so. Regulation 26 states the following Regulation 26 ( c) “ an employee of the organisation or the partnership who is not directly concerned with the conduct of the care home”. The staff conducting these visits obviously are directly involved with the home and therefore should not be undertaking the Regulation 26 visits. Alternative arrangements should be made for these to ensure an independent view of the service is obtained. Residents’ monies were checked and found to be correct. Supporting petty cash vouchers are issues when money is given to resident. The resident then signs these, although receipts for purchases are nor retained or expected from residents, as this is part of budgeting skills for independent living . Residents are enabled to open bank accounts and are assisted with financial transactions. Residents meetings had been held May and June 08 and the minutes outlined the key areas of discussion and reflected attendees. Meetings are held monthly, the annual development plan was available in the entrance hall for viewing. Quality assurance forms sent out and of those returned the comments were favourable. These were collated and circulated. A selection of health and safety service certificate were inspected and on to be current. The portable appliance testing was simply a statement confirming it had been addressed August 2007. The stickers on the plugs were without dates the Manager stated they had worn off. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 24 The fire risk assessment was updated July 07. Weekly fire alarm checks take place and records confirmed this. Fire drills include staff and residents three had been conducted in 2008. Staff signatures confirmed their attendance. Fire equipment had been serviced June 08 and monthly fire doors and fire escape route checks are undertaken. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 26 no Are there any outstanding requirements from the last inspection? 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 YA6 2 YA39 26 Standard Regulation 15 Timescale for action Care plans must be specific when 30/09/08 detailing the actual problem and interventions appropriate to address the problem. The Regulation 26 visits need to 30/08/08 be conducted by an appropriate person external to the home. Requirement 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 YA20 2. YA22 Refer to Standard Good Practice Recommendations The self medication assessment should be reviewed to include the advice received from the pharmacist. The Manager should ensure the complaints log is comprehensively completed. Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burstow Lodge DS0000006919.V366378.R01.S.doc Version 5.2 Page 28 - 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!