Inspection on 10/07/06 for 33 Burgh Heath Road

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

33 Burgh Heath Road 28/12/08

33 Burgh Heath Road 17/11/05

33 Burgh Heath Road 16/06/05

33 Burgh Heath Road 20/07/04

33 Burgh Heath Road 07/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Burgh Heath Road (33) 33 Burgh Heath Road Epsom Surrey KT17 4LP Lead Inspector Lisa Johnson Unannounced Inspection 10th July 2006 09:40 X10029.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 Burgh Heath Road (33) DS0000013488.V303694.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 and 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. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burgh Heath Road (33) Address 33 Burgh Heath Road Epsom Surrey KT17 4LP 01372 741025 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) www. Burghheathlodge. Co.uk Mrs Mala Jagutpal Mrs Mala Jagutpal Care Home 6 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (3) Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: 33, Burgh Heath Road is a large semi detached house situated in a residential area close to the town centre of Epsom. The home is presently registered for six service users. The accommodation is on two levels. There are six single bedrooms on the first floor. There is a large lounge and dining area. There is a large kitchen, which is accessible for service users to make snacks and drinks. There is a large garden, which is well maintained and accessible. There are car-parking facilities at the front of the house. The weekly fees range from £350- £700 Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over eight hours and was carried out by Mrs. L Johnson. Mrs. M. Jagutpal the registered manager represented the establishment. Since the previous inspection an additional random inspection has been completed and a copy of this report can be obtained by contacting the Commission for Social Care Inspection Surrey office. A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to three service users to gain their views on the care provided and to two members of staff. The inspector would like to thank the service users, relatives and staff for their hospitality and cooperation during this inspection. What the service does well: The service is provides a homely atmosphere, which was friendly and relaxed. Service users are supported to maintain their independence in and outside of the home by accessing recreational and leisure activities. During the inspection one individual told the inspector “I am going out to meet friends then I am going to buy fish and chips”. Another service user stated that he goes to the gym”. Two service users confirmed that meetings are held in the home and quality assurance systems are implemented with evidence provided that service user questionnaires have been updated with questionnaires also expanded to include stakeholders. Discussions held with three service users confirmed that they were happy with the care and support they receive and included comments “staff respect my privacy” and the “food is good staff and staff know what we like”. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Two care individual care plans sampled had not been signed by service users and a requirement was made that this is completed to ensure that service uses are consulted and agree to their care plans. The homes complaints procedure should be amended to provide up to date contact details for the Commission for Social Care Inspection should a service user or relative wish to raise a concern. The home needs to expand its local safeguarding adult protection procedure to make reference to the local authority multi- agency safeguarding policies and procedures. This is to ensure that service users are protected from abuse. While sampling staff training records it was seen that some staff have not received training in moving and handling and a requirement was made that this is completed. It was further recommended that the home maintain a staff-training schedule to record all training undertaken by staff. Opened packets of dried food and cereals were observed in the food store cupboard and a requirement was made that these items should be stored in sealed containers. This is to ensure that health and wellbeing of service users is protected by the homes food hygiene practices. A further requirement was made that a radiator cover needs replacing in one bedroom. This matter is to be completed to ensure the health and safety of service users. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 7 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. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users and their relatives are provided with adequate information so that they are able to make an informed choice about the suitability of the home as a place to live. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. Each service user is provided with written contract/statement terms and conditions with the home. The home does not support service users for intermediate care. EVIDENCE: Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 10 The home has produced a statement of purpose and service user guide detailing the aims and objectives and services that the home is able to offer with individuals being issued a copy. Each service user is provided with a contract which detailed the terms and conditions with the home. The individual had signed one contact sampled. There have been two new admissions in the home and it was clear that preadmission assessments had been completed which were comprehensive and were maintained on individual’s files. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is provided with an individual care plan, which details that individual’s health, personal, emotional and social needs are met. Service users and/or their representatives should sign their plans where possible to ensure that they are fully involved in the process. Service users are protected by the homes medication policy and procedures. Service users privacy and dignity is respected. EVIDENCE: Each service user is provided with a care plan. Two individual plans were sampled based on physical needs, daily living skills, community skills and Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 12 emotional health. Goals and objectives were clearly recorded with review dates recorded on the plan. However service users had not signed the plans to confirm their agreement. A requirement was made that service users should sign to agree their plans to ensure that they are fully involved in the care plan process. Service users are supported to access a range of health care professionals including for example the local GP, community psychiatric nurse, chiropody and one persons care plan confirmed that this individual is supported by the district nurse for monitoring and support with his diabetes. Daily records were maintained of visits received. Detailed risk plans were in place for individuals, which were sampled for example included falls, community access and emotional needs. The homes medication administration systems were examined and records were maintained adequately. A list is maintained of staff authorised to administer medication and photographs of individuals were available with their medication card. Medicines were stored appropriately. A homely remedies protocol is in place. Two individuals self medicate and appropriate risk assessments were completed. The staff work closely with the district nurse in respect of one individual who is diabetic. This individual is able to administer his insulin, which is prepared by the district nurse but is supervised by staff. Risk plans, records and guidance were recorded in the care plan. The pharmacist has visited the home recently to carry out medication training. Staff were seen to be talking to service users respectfully and one individual spoken to state “ staff respect my privacy”. Another individual said, “ I have my own key to the front door of the house to let myself in”. During the inspection one individual was involved in a review meeting, which was being held in a closed room to maintain privacy and confidentiality. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Service users are supported to make choices and individual preferences are respected. Service users receive well balanced meals. EVIDENCE: A number of service users who live in the home are able to access the local community independently. During the inspection two service users were going Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 14 out to local town and told the inspector they were going out for a fish and chip meal. One individual stated, “I like to help with little jobs around the house and I enjoy gardening. One person is waiting to start at a day centre and there are opportunities to go shopping, visit cafés and restaurants. Another individual works in a garden centre. One individual told the inspector he is allowed to visit friends and another service user visits her relative. A number of the service users are able to manage their own financial affairs. The home offers a varied menu and alternatives can be accommodated. During the inspection some service users had gone out for lunch. The lunch in the home was well balanced. One service user stated, “ I like the meals and I can have a choice and the staff know what we like”. “One of the staff cooks Shepard’s pie which is my favourite”. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure should be updated to ensure that service users and their representatives have access to an effective complaints procedure. Policies and procedures need improvement to ensure that service users are protected from abuse. EVIDENCE: The commission for Social Care Inspection received one complaint, which was referred under the local authority multi- agency safeguarding adult’s procedure. An additional random inspection was carried out to make further enquiries in to this matter. A copy of this report can be obtained by contacting the Surrey area office. This matter has now been concluded. The home has not received any other complaints and there is a complaints procedure in place. However the information needs to be amended, as some contact details were out of date. This will ensure that service users will have the correct information should they wish to raise a concern. Service users spoken to during this inspection spoke positively about the care and support they receive from staff. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 16 The local authority multi- agency safeguarding adults procedures were in place and there was evidence to conclude that staff are receiving training in adult protection. The home has a local policy in place, however a requirement was made that this is expanded to make reference to the local authority multiagency safeguarding adult policies and procedures. This is to ensure that the health, welfare and safety is protected from abuse. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained with minor repair needed in one area. Service users bedrooms were viewed as comfortable. The home was clean and hygienic on this inspection ensuring that service users have a pleasant home to live in. EVIDENCE: The home is situated in a residential street and is accessible to Epsom town centre. During the inspection the house was currently having some work Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 18 completed due to some structural problems and this work is near to completion. The inspector was informed that the sitting room was going to redecorated. The home was generally well maintained. However a requirement was made that a toilet seat should be repaired in the upstairs bathroom. There service provides a homely atmosphere and a pleasant garden is provided and one individual told the inspector he likes to help with the gardening. The home was clean and hygienic ample hand washing facilities were available and separate laundry facilities were provided at the rear of the house. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to fully meet the needs of service users. On the whole service users were in the safe hands of the staff who were competent and trained to do their jobs EVIDENCE: The home employs six staff including the registered manager. The rota was examined and concluded that there are two staff and on some occasions three staff through out the day and at nighttime there is one waking and one sleepin staff. Fifty percent of care staff hold National Vocational Qualifications (level 2) of above. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 20 Two staff files were sampled which contained the required information including evidence of police checks with all staff having been issued copies of the General Social Care Council (GSCC) code of conduct. Staff training certificates were examined on staff files and included training in safeguarding adults, infection control, health and safety. Staff have recently received up to date medication administration training and five staff hold first aid certificates. Evidence was available on files that new staff have received induction. However during discussion with the registered manager not all staff have completed moving and handling training. A requirement was made that this training is completed. It was also recommended that the home consider completing a training schedule for each member of staff to record dates of training completed Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home and has implemented quality assurance systems. The home is able to demonstrate that the financial interests of service users are protected. Two health and safety matters should Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 22 be actioned to ensure that the health, welfare and safety of service users is protected EVIDENCE: The registered manager is qualified nurse and holds the registered managers award. The home has recently updated its quality assurance questionnaires for service users and relatives with the questionnaire being extended to stake holders. The home also holds regular service user meetings. Most service users manage their own monies, but one individual has chosen not to go to the bank with the manager obtaining finances on her behalf. Records sampled concluded that the individual has signed on receipt of her monies. No cash is maintained in the home on behalf of service users. The manager is appointee for one individual and records were maintained which are monitored by the local authority care manager. There was a range of policies and procedures un place with read and sign systems implemented. The fire records were examined with regular checks carried out and recorded. Control of harmful substance (COSHH) records were in place. Records were maintained of regular water temperature checks with records maintained for fridges and freezers. Examination of records and certificates identified systems are in place for routine service and maintenance arrangements for the environment. However two matters were identified that need actioning. Opened packets of dried food and cereals were found open in the kitchen store cupboard and a requirement was made that these items should be stored in sealed containers. This is to ensure that the health and wellbeing is protected by the homes food hygiene practices. At the previous inspection a requirement was made that a radiator cover is supplied in one upstairs bedroom and this has not been completed yet. A further requirement was made the radiator cover should be installed to protect the health and safety of service users. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 24 yes 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 Standard OP7 Regulation 15(2)(c) Requirement The registered person must ensure that service users are consulted and agree their care plans. The homes complaint procedure must be updated. The homes local safeguarding adult policy must be amended to make reference to the local authority multi- agency safeguarding adult procedures The toilet seat in the upstairs bathroom must be repaired. The registered person must ensure that all staff receive training in moving and handling All opened packets of dried foods and cereals must be stored in sealed containers The radiator cover must be installed in upstairs bedroom. Timescale for action 10/08/06 2 3 OP16 OP18 4(1)(c) 13(6) 10/09/06 10/08/06 4 5 6 7 OP19 OP30 OP38 OP38 23(2)(b) 18 (c) (1) 16(2)(j) 13(4)(a) 17/07/06 10/09/06 17/07/06 10/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 25 No. 1 Refer to Standard OP30 Good Practice Recommendations It is recommended that registered manager records all training for each member of staff on to a training schedule Burgh Heath Road (33) DS0000013488.V303694.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Burgh Heath Road (33) DS0000013488.V303694.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. 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!