Inspection on 30/04/07 for Bullsmoor Lodge

This inspection was carried out on 30th April 2007.

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

Bullsmoor Lodge 30/04/08

Bullsmoor Lodge 13/06/06

Bullsmoor Lodge 12/01/06

Bullsmoor Lodge 19/09/05

Bullsmoor Lodge 31/01/05

Bullsmoor Lodge 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Bullsmoor Lodge 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE Lead Inspector Mr David Hastings Key Unannounced Inspection 30th April 2007 10:00 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 Bullsmoor Lodge DS0000010662.V333151.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. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bullsmoor Lodge Address 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE 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) 01992 719092 01992 650603 BullsmoorLodge@ScimitarCare.co.uk Scimitar Care Hotels Plc Angela Christine Carter Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Bullsmoor Lodge is a modern purpose built home owned by Scimitar Care Hotels. There are four homes belonging to this organisation. The home is registered to care for forty-eight people of either gender who are over the age of sixty-five. Bedrooms are located on three floors. The main lounge, dining room and kitchen are on the ground floor. All but three rooms are single and have en-suite toilets. There is an attractive garden to the rear of the house. There are two lifts that give access to all floors. The home aims to provide support and care in a homely environment. Fees are between £450 and £550. This report is available through the internet. Copies may also be obtained from the provider of this service. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Monday 30th April 2007 and lasted eight hours. I was assisted throughout the inspection by the registered manager who was open and helpful. I spoke with seven staff and twelve residents of the home. I inspected the building and examined various care records as well as a number of policies and procedures. I also spoke with a visitor to the home. The majority of residents I spoke with said they were very happy with the care and support they received. One resident told me the staff were, “wonderful”. What the service does well: What has improved since the last inspection? What they could do better: A requirement that staff receive regular supervision has not been complied with. This supervision should ensure that staff are providing a consistent care approach to all residents. The requirement has been restated. Two requirements were issued at the last inspection relating to bedroom doors being left open. At this inspection a number of bedroom doors were being wedged open. This is not a safe practice and puts residents at risk from fire. Where residents wish their door to be left open door closure devices must be fitted that automatically close in the even of a fire. The requirements have been amended and are restated. Eleven new requirements have been issued as a result of this inspection. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 6 The assessment of potential residents to the home must be more detailed and the manager must write to all potential residents assuring them that the home can meet all their assessed needs. Systems for providing staff at short notice must be developed so residents have enough staff to support them at all times. Recruitment procedures must be more robust to ensure the safety of residents at the home. Residents’ views about how well the home is meeting their needs must be sought and results of any surveys must be made available to all interested parties. Residents must be informed of the cost of any item purchased at the home. The manager needs to have regular supervision. Residents are being put at unnecessary risk from chemicals being left unattended as well as the lack of staff fire drills. The manager must inform the CSCI of any incidents that affect the well being of residents. A test for Legionella must take place and a certificate provided. Four good practice recommendations have been made at this inspection. The temperature of the kitchen should be reduced to provide a more pleasant working environment. Residents should be aware of what is for lunch and tea. Residents views about the care they receive should be sought every time their care plan is reviewed. The manager should liaise with the tissue viability nurse to ensure that the staff at the home are up to date with good practice in the prevention of pressure sores. 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. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Initial assessments are not being carried out in sufficient detail to assure potential residents that the home they are moving into can meet all their needs. EVIDENCE: Three assessments where examined for people who had recently moved into the home. All three of these assessments were carried out by the home. Although the format of the assessments were satisfactory and covered all the elements of this standard, two of the three assessments did not contain sufficient information about the needs of the potential residents. This could mean that people are admitted to the home without them knowing if the home can meet their needs. Two requirements have been made to ensure that potential residents are properly assessed and that they receive written confirmation that the home can indeed meet their assessed needs Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 9 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Eight care plans were examined. These plans were detailed and clearly set out the health, personal and social care needs of the individual. The plans informed staff of not only the care deficits of individuals but also clearly explained what tasks the person could do themselves. This enables residents to maintain their independence and dignity. Care plans are being signed by either the resident or their representative. This indicates that people are being consulted about their care needs. This was a requirement from the last inspection that has now been complied with. A recommendation has been issued under Standard 33 Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 10 that service users’ views about the quality of this care provision are sought when their care plans are being reviewed with them. Residents that I spoke with said the staff were very supportive and treated them with respect. Staff were able to describe to me how they upheld peoples’ privacy on a day to day basis. There was evidence from care plans that people at the home have good access to health care professionals. People that I spoke with confirmed that they could see the doctor when they needed to. Three residents have pressure sores and are being given treatment by district nurses. Records monitoring these treatments are being maintained. One resident’s assessment by her doctor requests that the home liaise with the local tissue viability nurse. A recommendation has been issued that the manager get in touch with the tissue viability nurse in order to discuss best practice in the prevention of pressure sores at the home. It is important that the manager and staff are kept up to date with these good practice issues. Satisfactory records were examined in relation to the receipt, administration and disposal of medication at the home. The register of controlled drugs was accurate and the medication room temperature was being monitored. The head of care at the home confirmed that only staff who have completed medication training are permitted to administer medication. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 11 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose from a range of activities at the home and are kept suitably occupied and engaged. Visitors to the home are made to feel welcome and can visit at any reasonable time. Residents are helped to exercise choice and control over their lives. The food provided is of good quality and mealtimes are relaxed and enjoyable. EVIDENCE: People that I spoke with said they were satisfied with the activities available at the home. Staff were able to describe how they kept residents occupied and stimulated. Residents told me they enjoyed the activities at the home as well as the outside entertainment that the home organised. There is a bar in the lounge so residents can buy drinks. A small lounge on the top floor is used for small group activities. I spoke with a visitor to the home who was very positive about the manager and staff and commented that the management and staff, “are there for me as well as my mum”. The visitor confirmed that she could visit at any time. Care plans clearly identified the need to offer choice to Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 12 individuals and residents confirmed that they had choice and control over their lives. One resident told me that, “I can do what I like”. There were no records of residents meetings. This would enable people to have more of a say in how the home is run. A requirement has been issued under standard 33 relating to this. The kitchen was inspected. The cook on the day of the inspection was aware of individual’s likes and dislikes as well as any special diets people may require. The kitchen was clean and there was a good selection of fresh food. Fridge and freezer temperatures were being monitored and recorded. The cook told the inspector that the kitchen area could become very hot and uncomfortable to work in, particularly in the summer months. A recommendation has been given that the registered provider explore ways of reducing the ambient temperature of the kitchen in order to provide a more comfortable working environment. Lunchtime was a relaxed and enjoyable experience. Staff were observed providing discreet assistance were needed. I was very impressed by the genuine warmth and affection shown by staff towards residents and it was clear that the residents were benefiting from these positive relationships with staff. This was particularly important for those people with dementia who were enjoying the company of staff. A number of residents asked the staff what was for lunch and it would be useful for a menu of the day’s meals to be displayed. A recommendation relating to this has been made in the relevant section of this report. Residents were positive about the variety and quality of the food provided. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 13 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. One complaint has been received by the home since the last inspection. Records examined indicated that this complaint was being dealt with in an open and professional manner in line with the home’s procedures. Staff were able to describe to me how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that I spoke to said they felt safe and well supported at the home. Records indicated that staff have undertaken training in the protection of vulnerable people. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and maintained to a good standard. Residents are being put at risk from inadequate health and safety procedures. EVIDENCE: The manager showed me round the home and I visited some residents in their rooms. The home is clean and decorated to a good standard and has a homely atmosphere. Residents that I spoke with said they were happy with their rooms. A number of bedroom doors were being wedged open. This can be dangerous, particularly at night, as residents would not be appropriately protected from smoke if there were a fire in the home. This has been an issue in the past and two requirements were issued at the last inspection about this matter. It is unacceptable for doors to be wedged open and a requirement has been made that self-closing door guards are fitted to all bedroom doors that residents wish to remain open both during the day and at night. The Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 15 requirement issued at the last inspection has been amended and is restated under standard 38 of this report. During a tour of the building two domestic trolleys containing cleaning chemicals were left unattended. This could present a risk to residents, particularly for those people with dementia. A requirement has been made that no cleaning chemicals are left unattended in the home at any time. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All the staff at the home work very hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Residents are potentially being put at risk from poor recruitment practices. EVIDENCE: A satisfactory rota was examined which identified that there should be seven carers in the morning, six in the evening and three waking staff at night. People that I spoke with said there was generally enough staff to meet their needs. Residents were very positive about the staff team and it was clear from discussion with staff that they understood the individual needs of the residents in their care. A number of residents commented to me that sometimes, when staff phone in sick there is not enough cover and this has caused staff to become rushed. This issue was discussed with the manager who stated that sometimes it was a problem. There is currently no agency or bank usage at the home, which may help to avoid staffing shortages. A requirement has been made that the organisation review the systems for staff to cover sickness at short notice. I was able to meet with the training, development and safety manager who was visiting the home on the day of the inspection. Records indicated that over 50 of care workers have now completed NVQ level 2 or equivalent. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 17 This exceeds the requirement of Standard 28 of the National Minimum Standards. Staff were very positive about the training offered to them and the training manager was able to show me individual staff training profiles which indicated that staff at the home receive the training required to do their jobs effectively. I examined three staffing files from staff recently employed at the home. Some of the references obtained for staff had been completed over the phone. This is not acceptable and a requirement has been issued that all staff must have two written references before they care permitted to commence employment. One newly appointed staff member had no references and there was no CRB or POVA First on her file. The manager told me she would not be using this staff member until a POVA First had been received. A requirement relating to CRB disclosures has been made in the relevant section of this report. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 18 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have few opportunities to have a say in how the home is run. Residents’ financial interests are not being properly safeguarded when they purchase items at the home. Staff are still not being effectively supervised. This impacts on the continuity of care provided by the staff at the home. Residents are being put at risk from some inadequate health and safety procedures. EVIDENCE: Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 19 The manager has been in post for about three years and both residents and staff were very positive about her work at the home. One resident said the manager was “very helpful”. Staff confirmed that the manager is approachable and that she has a “hands on” approach. The manager has not yet started the registered managers award, which is a requirement of Standard 31 of the National Minimum Standards. There is a quality monitoring system in place at the home and I saw questionnaires for residents as well as other stakeholders. A requirement has been issued that the results of any quality monitoring must be published and made available to all interested parties. There is a comment and suggestions book in the entrance lobby which some relatives have made comments in. In each case the manager has responded in writing to each comment in a constructive way. There was no evidence that residents meetings take place at the home and a requirement relating to this has been made. A recommendation has also been issued under the standard relating to quality that residents’ views about the care they receive are sought every time the person’s care plan is reviewed. The home does not usually hold money on behalf of residents. Some money is held and this was found to be accurate. If residents need anything the manager told me that this is purchased by the home and a monthly bill is sent to the resident or their representative. I looked at receipts given to residents for items purchased at the home such as toiletries. These receipts were not dated and did not record how much the resident had been charged. This means that people do not know the cost of the items they are buying. This could lead to mismanagement of residents’ finances. A requirement has been issued that all items in the home that are available for purchase by residents are priced and all receipts clearly record the amount and date of purchase. A requirement was restated at the last inspection that all staff receive formal supervision at least six times a year. Records indicated that this was still not happening and the requirement has been restated again. Some staff have received supervision and said they have benefited from the process. The manager told me that she does not receive formal supervision and a new requirement has been issued in this report to address this matter. Records in relation to health and safety were examined. These were generally satisfactory however there was no record that staff have undertaken fire drills. The manager assured me that a fire drill had been carried out on 26th April 2007 but had not been recorded in the right place. A requirement has been issued that fire drills are recorded and evidence that drills are taking place on a regular basis and that night staff undertaken fire drills every three months. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 20 As detailed earlier in this report, some bedroom doors were being wedged open and chemicals were left unattended. There was no certificate available to indicate that a test had been carried out for the risk of Legionella. The manager said that the handyman checks the temperature of water but samples also need to be taken of the water in tanks to identify any bacterium present. Records indicated that staff are undertaking the required health and safety training. The accident book was examined. A requirement that all accidents are reported to the CSCI has been issued, as there is no evidence that this is currently taking place. The number of accidents in the home has recently increased and the manager told me she would be carrying out a falls analysis to highlight any possible trends. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 1 X 2 Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP36 Regulation 18(2) Requirement The registered persons must ensure that all staff receives supervision at least six times a year. (The timescales of 01/08/06 and 28/02/07 were not met). This requirement is restated. 2. OP38 23 The registered persons must ensure that an automatic door closure device is installed on any bedroom door where the resident wishes to leave their door open. (Timescale of 30/01/07 not met). This requirement has been amended and is restated. 3. OP3 14(1) (a) The registered person must ensure that all potential residents to the home are properly assessed so they know that the home can meet their needs. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 23 Timescale for action 01/06/07 30/05/07 15/06/07 4. OP3 14(1)(d) The registered person must ensure that written confirmation is given to all potential residents stating that the home can meet all of the individual’s assessed needs. This written confirmation must be provided before the person moves in to the home. 15/06/07 5. OP27 18(1) (a) The registered person must ensure that there is a system in place to provide staffing cover at short notice at times when staff phone in sick. 15/06/07 6. OP29 19(1) The registered person must ensure that no staff are employed at the home without first having the required checks including a CRB disclosure and two written references. 30/05/07 7. OP33 24(2) The registered person must ensure that the results of any quality assurance surveys are published and made available to all interested parties. This includes residents and potential residents to the home. 15/06/07 8. OP33 24(3) The registered person must ensure that residents’ meetings take place on a regular basis and are recorded. 15/06/07 9. OP35 13(6) The registered person must ensure that any items purchased by residents at the home clearly identify the cost of each item. The registered person must ensure that the manager of the home receives regular supervision and that this supervision is recorded. DS0000010662.V333151.R01.S.doc 30/05/07 10 OP36 18(2) 30/05/07 Bullsmoor Lodge Version 5.2 Page 24 11. OP38 23(4) The registered person must ensure that staff undertake fire drills on a regular basis and that night staff undertake fire drill every three months. These fire drills must be recorded. 30/05/07 12. OP38 13(4) The registered person must ensure that cleaning chemicals are not left unattended at any time. 30/05/07 13. OP38 13(4) The registered person must ensure that a certificate is provided confirming that the home has been tested for Legionella. 15/06/07 14. OP38 37 The registered person must ensure that the CSCI is notified of any incident listed under Regulation 37 of the Care Homes Regulations 2001 30/05/07 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. 2 3. 4. Refer to Standard OP8 OP15 OP15 OP33 Good Practice Recommendations The registered person should ensure that the tissue viability nurse is contacted and advice is sought on the prevention of pressure sores at the home. The registered person should ensure that ways of reducing the ambient temperature in the kitchen are explored. The registered person should ensure that forthcoming meals are clearly displayed for residents. The registered person should ensure that the views of residents are sought every time care plans are reviewed. Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Bullsmoor Lodge DS0000010662.V333151.R01.S.doc Version 5.2 Page 26 - 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. 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