Care Home: Burwood Nursing Home

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What the care home does well No one moves into the home without having their needs assessed which means that the home and the person considering moving in can be clear that this is the right place to care for them. People living in the home are encouraged to participate in activities, which interest them and to maintain their social, religious and cultural interests. People living in Burwood are able to keep in touch with the people in their lives that are important to them. People living in the home have control over their own lives. They are supported to maintain a healthy balanced diet and to socialise during meals. People living in the home should be confident that they would be listened to if they were unhappy with any aspect of the care they receive. Staff receive training in safeguarding, which ensures that the people living in the home are protected. The environment people live in is safe and well maintained. The home is clean pleasant and hygienic which demonstrates that people who work there take pride in the work they do to ensure that the home is somewhere you would want to live. There is enough staff on duty each day to ensure that people`s needs are met. Good recruitment practices means that people are in safe hands. A well-established quality assurance process means that people living in the home can be assured that it is run in their best interests. The home does not manage anyone`s money. Systems are in place to ensure that the health, welfare and safety of the people living in the home are protected. One person who visits relatives in the home said, " I can not speak more highly of this service, it truly is based on patient care. Patient happiness is paramount" What has improved since the last inspection? At the end of the inspection in September 2007 there were six requirements and four recommendations. People living in the home have individual plans of their care which are reviewed and updated with any changes so that nursing staff have the information they need to provide good care. People living in the home have their health care needs clearly recorded and are aware of the decisions being made in their care plans. The home has a detailed and well-audited system for recording medicines including creams and nutritional products. This ensures that people living in the home are well protected by the procedures in place. Staff are offered and receive training they need to fully understand the conditions of old age. The home receives information on approved equipment for use in the home and acts on this information. The home is free from hazards that could compromise the safety of the people living in the home. The wording in care documentation is clear and in plain English so that all staff understand how care is to be provided. The nursing staff ensure that medication policy and procedure is clearly followed ensuring the safety of people living in the home. Action has been taken to address the issues of privacy with regard to glass vision panels, which are opaque. What the care home could do better: At the end of this inspection there are two recommendations.The manager has identified the need to encourage staff to undertake national vocational qualification training (NVQ) in the annual quality assurance assessment (AQAA). The manager should record all visits to the home, which are part of the ongoing quality assurance monitoring of staff and the service and add this information to the annual report. CARE HOMES FOR OLDER PEOPLE Burwood Nursing Home 100 Dunyeats Road Broadstone Poole Dorset BH18 8AL Lead Inspector Tracey Cockburn Unannounced Inspection 9:00 18 September 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burwood Nursing Home DS0000067456.V365278.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burwood Nursing Home Address 100 Dunyeats Road Broadstone Poole Dorset BH18 8AL 01202 693224 01202 695047 burwood.nh@ntlworld.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sarah Jane Jessup Mrs Dawn Holbrook Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2007 Brief Description of the Service: Burwood Nursing Home is registered with the Commission for Social Care Inspection to accommodate twenty-six people providing 24-hour nursing and personal care, all meals, laundry and domestic services. The home is situated close to the centre of Broadstone, which has a good selection of amenities. A bus stop is located near the home’s entrance and there is ample off-road parking available for visitors in front of the home. Burwood Nursing Home comprises two main buildings, the original house and a more recent extension. Both buildings are linked by a corridor, which opens into a very large conservatory, creating a pleasant sitting area that can also be used for dining. There is a separate dining room and, in addition, a smaller lounge on the first floor. Accommodation is provided in twenty-two single and two shared rooms. All rooms except one have en suite facilities. The remaining room has a wash hand basin. All rooms are currently used for single occupancy. Residents are encouraged to participate in a programme of activities organised within the home. The home is set in spacious, well maintained grounds with mature trees and shrubs. Well-maintained gardens surround the home. There are accessible patio areas. The weekly fees for the home start from £740.00 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries, aromatherapy and newspapers. A copy of the home’s inspection report is made available to anyone wishing to read it. Further information on contract and fees can be found on the office of fair trading website: www.oft.org.uk Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 5 Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The key inspection took place without warning and was conducted over 3 days a total of 10 hours were spent in the home and in planning the inspection. As part of the planning of the inspection survey forms were sent out. Fifteen were returned, five from people who live in the home, two from General Practitioners, five from relatives and three from staff working in the home. Comments from these survey forms are used throughout the report in relevant sections. The Annual Quality Assurance Assessment (AQAA) form had been completed by Mrs Holbrook and provided to the Commission for Social Care Inspection in advance of the inspection. The completed assessment is one of the ways in which the Commission for Social Care Inspection will assess how well the service is delivering good outcomes for the people using it. As part of the inspection process an expert by experience, who is someone with knowledge and experience of using services, visited the service toured the home, spoke to people who live and work there and their comments and observations are used throughout the report. The expert by experience visited nineteen bedrooms, spoke to five people who work in the home and spoke to nine people who live in Burwood. We also looked at staff records, training records, personal care records of people living in the home, medication and menu planning. We also spoke to staff and the people living in the home. What the service does well: No one moves into the home without having their needs assessed which means that the home and the person considering moving in can be clear that this is the right place to care for them. People living in the home are encouraged to participate in activities, which interest them and to maintain their social, religious and cultural interests. People living in Burwood are able to keep in touch with the people in their lives that are important to them. People living in the home have control over their own lives. They are supported to maintain a healthy balanced diet and to socialise during meals. People living in the home should be confident that they would be listened to if they were unhappy with any aspect of the care they receive. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 7 Staff receive training in safeguarding, which ensures that the people living in the home are protected. The environment people live in is safe and well maintained. The home is clean pleasant and hygienic which demonstrates that people who work there take pride in the work they do to ensure that the home is somewhere you would want to live. There is enough staff on duty each day to ensure that people’s needs are met. Good recruitment practices means that people are in safe hands. A well-established quality assurance process means that people living in the home can be assured that it is run in their best interests. The home does not manage anyone’s money. Systems are in place to ensure that the health, welfare and safety of the people living in the home are protected. One person who visits relatives in the home said, “ I can not speak more highly of this service, it truly is based on patient care. Patient happiness is paramount” What has improved since the last inspection? What they could do better: At the end of this inspection there are two recommendations. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 8 The manager has identified the need to encourage staff to undertake national vocational qualification training (NVQ) in the annual quality assurance assessment (AQAA). The manager should record all visits to the home, which are part of the ongoing quality assurance monitoring of staff and the service and add this information to the annual report. 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. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 9 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 Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Standard 6 is not applicable in this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Pre-admission assessments, and consultation with people considering moving into the home and their families ensures that people do not move into the home without having their needs assessed and being assured that they will be met. EVIDENCE: The annual quality assurance assessment submitted to the commission by the home says: “All prospective residents are visited by Matron and in her absence her deputy. All prospective residents, their relatives and friends are invited to visit the home to assess the quality, facilities and suitability of Burwood.” “Pre-admission assessments include consultation with prospective residents and their families to ensure that people do not move into the home without Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 11 having their needs assessed and being assured that they will be met. Trial visits are welcomed.” AQAA also states: “Quality Assurance questionnaire May 2008 results. When residents were asked ‘Do you feel your needs were properly assessed?’ 100 replied yes.” Plan for the future includes: “We are in the process of compiling a folder of photgraphs and information to take out to prospective residents, hopefully this will help them make an informed choice about where to live. We are currently formatting this to be included on a digital picture frame.” We looked at two care files and they all contained pre admission assessments. They were undertaken either by the manager or the deputy. Each person has a plan of care based on the initial assessment. One person we spoke to said that she had seen her care plan and had agreed with its contents. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home have individual plans of their care needs, there are clear systems for recording health care needs are met. People are protected by the homes stringent policy and procedures on medication. People living in the home are treated with respect. EVIDENCE: Care plans detail each persons individual needs and the tasks needed to ensure that each person has their needs met. One person’s care plan detailed what to do if their blood sugar level was either too low or too high on testing. It gave specific details of each figure and how to recognise the other signs that there might be a problem. There was also evidence that the staff were following National Institute of Health and Clinical Excellence (NICE) clinical guidance on care of people with diabetes in nursing homes. There was evidence in each of the files we looked at that reviews were taking place and changes were being made to the care plan when necessary. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 13 People living in the home told us that the manager talked to them about their care plan. Clear records are maintained of each person’s healthcare needs, including contacts with General Practitioners and other healthcare professionals. Risk assessments are carried out in respect of manual handling, pressure sore and nutritional risk assessments and corresponding plans of care describe how risks are to be addressed or minimised. During the visit pressure area equipment was seen in use to protect skin integrity, including pressure relieving mattresses and cushions. Nutritional screening is done on admission and there is good recording of weight and action taken. The home has efficient procedures in place for the ordering, receipt and disposal of medicines received into the home. Accurate tracking of residents’ medication needs, including the auditing of medicines management, supports the home to maintain and support good practice. Medicines received into the home are checked and Medication Administration Records (MAR) charts are signed to confirm medicines received. Two Registered nurses sign to confirm medicines sent for disposal. At the time of the inspection no residents were administering their own medication. A controlled drugs register is maintained and accurate records were evidenced for one resident. Records for one person living in the home were checked against the MAR chart; medicines held corresponded with records maintained. Residents’ medication is kept in people’s rooms in lockable storage cupboards. Allergies were recorded within individual records and on MAR charts. A survey forms returned from a general practitioner said “ excellent nursing home” Both survey forms returned by the general practitioners stated that the home communicates clearly and works in partnership. People who visit the service tell us “ excellent respect for residents” One person who visits their relative in the home told us “ that X is always in his own clothes and is always fed decent food” they also said that even although their relative cannot communicate, staff continue to talk to him” One person said that it was “ a comfort to me that he is in such a lovely place cared for by lovely people” One person who lives in the home said, “ The home meets all my needs and is well run” The AQAA submitted by the home says “Risk Assessments correspond to plans of care to describe how risk is to be addressed or minimised, balancing a safe environment with resident choice and needs. These assessments include client handling risk assessment, bed rail risk assessments, nutritional assessment, Waterlow, Wound assessment plans and accident audit.” The survey undertaken by the homes found: “Our Quality Assurance questionnaire results from fellow healthcare Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 14 professionals show that 100 felt that Burwood communicated clearly and works in partnership with them. When asked Are you happy with the homes ability to act on advice and guidance you give them 100 said Yes. ‘Do staff show a clear understanding of care needs’ 100 replied Yes.” People told us that their privacy is respected. All the doors where there are glass panel inserts have this covered with opaque film. People also told us that staff knock on the door before they enter. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are able to lead the life they want to with support and feel their individual wishes are respected. They are able to maintain contact with those who are important to them, have control over their lives and eat food they enjoy. EVIDENCE: People tell us that they are able to participate in activities if they wish. One person said that they really enjoyed the trips out. They also said that they appreciated the time it takes to organise such a trip. People also told us that they are able to have visitors when they like. One person said that when she has visitors, the staff always bring tea and biscuits, which is nicely presented, on a tray. People who visit the home tell us that they are “ always welcome any time of the day” Care files detail peoples interests and how they like their meals and daily routine such as when they get up or when they prefer to go to bed. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 16 There was information on a notice board of forthcoming activities. The manager also explained that they have someone with a pet dog who comes to the home and indeed the registered provider has a dog, which comes to the home regularly. There were pictures in the home of residents with the dog. People who live in the home told us that they could see visitors at any time. At the time of the inspection the cook was working to the summer menu, but said that in the next few weeks they would be changing to a winter menu. The cook has lists of what people don’t like to eat and everyone who spoke about the food said that they always like the food. One person said “ they know what I don’t like and make sure I never get it if its on the menu” On the first day of the inspection the cook was preparing roast beef, Yorkshire pudding, two vegetables and roast potatoes. Alternatives included fish/port or salad and the pudding was trifle. One person said that there are always homemade cakes. There was a good supply of fresh vegetables and fruit. One person who lives in the home said of the food “ well cooked and tasty – like home cooking” The homes own quality assurance process found: “Our Quality Assurance questionnaire results show that 100 of residents felt carers are able to understand their needs. 100 said they enjoyed the meals provided. 100 also said if they do not like something offered, they would be offered an alternative. 100 said that they felt the food is of good quality/home cooked. 87 of residents enjoy the entertainment/activities provided (13 (2 residents) prefer their own complany).” Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at Burwood Nursing Home and their families and friends can feel confident that any concerns that they have will be listened and responded to. The home is ensuring that policies, procedures and training protect people living at the home from abuse. EVIDENCE: The home has a detailed complaints procedure, which is very clear and is made available to residents and people visiting the home. One person who contacted us said “ I always feel able to speak to any member of staff about issues of concern” The expert by experience spoke to people who live in the home and found that people knew who to complain to if they were unhappy and comments included: “I haven’t had to yet” and “ Well not much to complain about really” “ I have no doubt if I had to complain I would be listened to” Staff received training in safeguarding. They have also been given leaflets on safeguarding. The registered manager had arranged for training to take place for staff but it was cancelled. They are currently seeking another trainer. The manager demonstrated the work they have done to try and secure training. Burwood Nursing Home DS0000067456.V365278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People live in a well-maintained environment where there is a plan of refurbishment. The home is clean and homely making it a nice place for people to live. EVIDENCE: The expert by experience visited nineteen bedrooms and said in her report that they all smelt fresh and looked clean. The expert also said that they were spacious and had lovely views. She also thought that the décor looked a little tired. The manager said that they paint and decorate every room before someone else moves in. The home has a programme of renewal of the fabric and decoration of the home and this is detailed in the annual quality assurance assessment. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 19 There is a small lounge on the first floor and a large conservatory on the ground floor. There is a dining room on the ground floor. At the time of the inspection the dining room was not being used, there was a large table in the conservatory, which is used for meals in the summer time. The home has a spacious laundry, which is well organised. Several people who live in the home said that the person who does the laundry puts their clothing away and sorts out their wardrobes for them. There were no unpleasant odours in the home. The expert by experience said in her report that all the bedrooms visited were clean and smelt fresh. Infection control training is part of the home’s mandatory programme of training for staff members. In the next 12 months the home is planning a complete new ARJO bathroom. Burwood Nursing Home DS0000067456.V365278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is working hard to support staff members to achieve National Vocational Qualifications (NVQs) in Care. Continuity in staff working in the home and the support and development of their skills ensures that people are cared for in safe hands. Recruitment procedures ensure that people living in the home are protected. Monitoring of training needs, and thorough training programmes enables people to be cared for in safe hands. EVIDENCE: There are thirty-eight people working in the home. There are five health care assistants and one registered general nurse (RGN) on each morning and four health care assistants and one RGN in the afternoon. There are two health care assistants on duty at night as well as one RGN. Satisfactory recruitment records were seen for two members of staff working in the home. A thorough interview is conducted. It is ensured that new members of staff do not start work in the home prior to the receipt of a satisfactory POVA First (check of the Protection of Vulnerable Adult’s register.) Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 21 A new member of staff had completed a detailed induction. Great care is taken to ensure that staff members complete a thorough programme of training ensuring that they develop the skills necessary to keep residents in safe hands. A summary list and individual training records are maintained to ensure that staff members maintain the competencies required to safely care for residents. Staff told us in the survey forms they returned that they are taking part in regular training both mandatory courses such as infection control and moving and handling but other courses such as understanding dysphasia. Staff also tell us that they are encouraged to undertake national vocational qualifications (NVQ) at level 2 and above. Staff also told us that they: “ Are given the opportunity to choose and request topics in training that they need and want”. One person told us “ their request for training is always met” One member of staff wrote:” written and verbal communication between fellow members of staff regarding the care of the residents is excellent” Another member of staff said, “ it is a genuine pleasure for me to work at Burwood and I look forward to my shifts” One relative who contacted us said, “I am always more than happy with the level of care that I see, junior members of staff are accompanied/supervised by senior staff members” AQAA states: “Stringent recruitment procedure for all staff. All are POVA checked before resident contact. Quality Assurance shows feed back from staff and residents indicating that staff members are supported to develop the individual skills they need to meet the needs of our residents. Great care is taken to ensure that staff members complete a thorough programme of training and maintain the competencies required to safely care for residents. On-going training of mandatory and non-mandatory opportunities. Maintaining full staffing levels, rarely using outside agencies for health care and RGN cover.” Burwood Nursing Home DS0000067456.V365278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is managed by someone who understands their role very well and ensures that the home is run in the best interests of the people living there. People can be assured their financial interests are safeguarded and that the health, welfare and safety of people living there are protected. EVIDENCE: The manger has completed the Registered Managers Award (RMA) There are clear lines of accountability within the home and the registered provider, registered manager and the deputy manager meet on a regular basis. Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 23 People who live in the home and those who visit the home tell us:” the matron is always available, approachable and more than happy to help anyway that she can” The home sent out questionnaires to people who live in the home, their relatives and friends, people who work in the home and other people who have an interest in the home. 25 surveys were sent out and 22 completed questionnaires came back. In the annual quality assurance assessment completed by the home they state that they do not manage the finances of any person living in the home. Examination of the fire records shows that appropriate procedures are in place to ensure the safety of residents and staff. Regular maintenance of the fire warning system, emergency lighting and fire fighting equipment is arranged. Routine checks are carried out at appropriate intervals. Both in-house training and training from an external training provider takes place to ensure that staff are fully aware of the action to take in the event of a fire. All staff receive training covering the mandatory courses such as moving and handling, infection control and first aid. The home has put in place a Fire Risk Assessment. Burwood Nursing Home DS0000067456.V365278.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 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Burwood Nursing Home DS0000067456.V365278.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. 1. Refer to Standard OP28 Good Practice Recommendations The registered manager should work towards 50 of care staff working in the home have a National Vocational Qualification (NVQ) in Care. The registered manager should ensure that all visits to the home that happen outside her normal working hours are recorded as they form part of her quality assurance process and need to be formally recorded. 2. YA33 Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Burwood Nursing Home DS0000067456.V365278.R01.S.doc Version 5.2 Page 27 - 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. 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