Inspection on 26/07/07 for Burkitt Nursing Home

This inspection was carried out on 26th July 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

Burkitt Nursing Home 07/10/08

Burkitt Nursing Home 23/04/08

Burkitt Nursing Home 04/12/07

Burkitt Nursing Home 22/01/07

Burkitt Nursing Home 07/11/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Burkitt Nursing Home Burkitt Care Home 41-47 Melton Road West Bridgford Nottingham NG2 7NE Lead Inspector Richard Ramsden Unannounced Inspection 26th July 2007 09:30 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 Burkitt Nursing Home DS0000065667.V340435.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. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burkitt Nursing Home Address Burkitt Care Home 41-47 Melton Road West Bridgford Nottingham NG2 7NE 0115 981 4046 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) Mr David Hetherington Messenger Mrs Vicky Rotelo Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr David Hetherington Messenger is registered to provide personal and nursing care and accommodation at Burkitt Care Home for service users of both sexes whose primary needs fall within the following categories: Old Age, not falling within any other category (OP) 55 One named service user shall be accommodated at Burkitt Care Home within category Physical Disability (PD). One named service user under the category PD named in the variation application number V38564 dated 8th February 2007 can be accommodated at Burkitt Care Home. One named service user under the age of 65 years, named in variation application number V39491 dated 7th March 2007, can be accommodated at the Burkitt Care Home. The maximum number of service users to be accommodated within Burkitt Care Home is 55 22nd January 2007 2. 3. 4. 5. Date of last inspection Brief Description of the Service: The Burkitt is a care home registered for 55 people, providing both nursing and personal care for older people. The home was first registered by the Nottingham Health Authority on 20th January 1986. The home is an older, converted and extended detached property, with bedrooms on the ground, first and second floor. There are 2 passenger lifts, which facilitate access to the upper floors. Handrails and adapted toilet and bathing facilities are available. There are 30 single bedrooms, 11 of which have en-suite facilities and 6 double bedrooms, none of which have en-suite facilities. There is a lounge and dining room on the first floor and a large lounge and small dining area on the ground floor. The home is situated on one of the main roads running through West Bridgford and is thus convenient for public transport. The centre of West Bridgford is also close by which offers facilities such as shops, cafes, a library and public houses. The home has an enclosed garden to the rear of the property. The weekly accommodation charges are between £290 and £450 dependent on the type of accommodation and the care package provided. Information of what is not included within the fees charged is in the Service Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 5 user guide and includes newspapers, personal toiletries and Chiropody. There was no copy of the most recent inspection report available when the inspector arrived at the home however this had been made available on the following day. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over two days it took approximately 10 hours. It included the inspection of care and other records, a discussion with the manager, two qualified nurses and two members of care staff. The inspector spoke with four residents and two visitors to the home. A partial tour of the building was also completed. Two residents were Case tracked, which means that their care plans were examined against the actual care they receive. Before completing this visit the inspector assessed the home service history, the information provided by the registered manager and the last inspection report. At the time of completing this report three residents and two relatives/advocates completed satisfaction questionnaires had been received. The inspector also discussed the Commission for Social Care Inspections proposals to possibly, reduce some of the restrictions placed on the homes registration categories. What the service does well: The residents who are able to express an opinion said that staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between residents and staff was of a very good standard. Both of the visitors who were spoken with confirmed that they could visit their relatives in the home at any time. They said that the staff are friendly and welcoming and confirmed that they are always kept fully informed about their relatives health and welfare. Service users needs are assessed prior to them moving into the home and care plans contain sufficient information and are reviewed frequently enough to ensure that staff are always aware of what support and assistance each resident requires. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 7 The homes medication is well managed and residents have the opportunity to administer their own medication if they are assessed as safe to do so. Two residents said they are very satisfied with their bedrooms and confirmed that they had been in courage to personalise them with small items of furniture photographs etc. Residents stated that they are generally satisfied with the meals provided by the home and confirmed that there is always a choice of food available. Residents and their relatives are confident that their complaints will be listened to and appropriate action taken. What has improved since the last inspection? What they could do better: The literature supplied to prospective residents does not contain sufficient information for them to make an informed choice about whether they wish to live in the home. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 8 Staffing levels need to be reviewed to ensure that residents are receiving appropriate care, support and social stimulation. The security of the premises must be reviewed taking into account the vulnerability of the residents. Members of the public must not have unrestricted access to residents and their property. The residents’ health and safety has potentially been put at risk by a number of environmental issues, which need to be rectified. Records which are required to be kept in the home, must be available for inspection at all times. More work needs to be completed on the homes fire risk assessment and systems must be in place for the prevention of Legionella within the home. 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. Burkitt Nursing Home DS0000065667.V340435.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 Burkitt Nursing Home DS0000065667.V340435.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): 1,3, The literature supplied to prospective residents does not contain sufficient information to enable them to make an informed choice about whether they would want to live in the home. All residents except emergency/urgent admissions have detailed assessments prior to their admission to the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The literature supplied to prospective residents does not include a copy of the most recent inspection report summary, the residents’ views of the home or details of staff qualifications. Consequently there was insufficient information Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 11 to enable residents to make an informed choice about whether the home would meet their needs and aspirations. When the inspector arrived at the home residents and visitors had no access to a copy of the most recent inspection report. This had been made available on the second day of inspection. The manager stated that the inspection report had been displayed in the main reception hall and must have been removed. One of the residents whose records were examined as part of this visit had a nursing assessment produced prior to her admission to the home. The second person did not have a preadmission assessment however the inspector was informed that this resident was admitted as an urgent admission and that he was already known to staff as he had previously been a regular visitor. Senior staff stated that residents are never admitted without a preadmission assessment excepting as emergency/urgent admissions. The home does not provide intermediate care. Burkitt Nursing Home DS0000065667.V340435.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. Residents care plans contain sufficient information and are reviewed regularly, to ensure that staff are always aware of what support and assistance in each resident requires. However residents are not always receiving the care they require. The homes medication is well managed and residents are treated with respect. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents’ care plans were viewed as part of this inspection, the care plans contained sufficient information and were reviewed regularly enough to ensure that staff are always aware of what support and assistance of each resident requires. Where possible residents had been encouraged to sign their care plans to confirm their involvement in the planning and review process. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 13 However residents stated that they do not always receive the care they require. People said that they often have to wait long periods, sometimes up to half an hour when they wish to use the toilet and need assistance from staff. The staff spoken with also confirmed that this happens on occasions when they are busy providing support to other residents. Two relatives stated that although the staff always appeared to work hard, it is difficult to assess if their relatives are always receiving adequate care. One person said that her mother is cared for in her room and that her mother often has little contact with staff and even the care charts in her bedroom are often poorly maintained. She has made a formal complaint about this issue to the registered manager. The qualified staff stated that staff check those residents who are cared for in their rooms at least once every two hours. However records show that one resident who should be ‘turned’ every two hours had been left in the same position for up to six hours and there were no other entries on the charts for a further seven hours. This could be putting residents at serious risk of developing pressure sores. The qualified staff informed the inspector that staff have provided appropriate care but have failed to complete the appropriate records. The records of residents’ health care appointments were well documented. The medication was assessed and had been well maintained. None of the current residents have been assessed as safe to administer their own medication. However an appropriate risk assessment has been produced, to be completed with any residents who wish to manage their own medication. All of the resident spoken with said that the staff are friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between residents and staff was of a good standard. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents do not find that the lifestyle experienced in the home matches their expectations and preferences particularly in relation to their recreational and social interests and needs. Residents are encouraged to maintain contact with their family and friends and people are generally satisfied with the food provided by the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the residents and staff spoken with during the inspection said that there have been virtually no activities provided for residents, in the home, for several months. The manager stated that the activities coordinator is on maternity leave, a replacement was appointed but this person left after a few weeks. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 15 She confirmed that she has employed singers etc to entertain residents. However the staffing levels within the home are insufficient for staff to provide regular entertainment and activities as well as completing their other duties. Residents and two visitors confirmed that visitors are made welcome in the home at any time. Leaflets about advocacy services are available in the main reception area. Individual residents care plans give details of how residents can be encouraged to make decisions about their daily lives. There have also been some residents meetings where people are encouraged to express their opinions about the way in which the home is run. The residents spoken with confirmed that they are encouraged to make choices within the daily routines. One relatives survey receive prior to this inspection stated that the food provided for residents needs to be improved. However most of the residents spoken with during the inspection said that they are very satisfied with the meals provided. They confirmed that there is always a choice of food and that alternatives will be provided if they do not want the meals suggested on the menu. Two people said that they find the portions provided to large and that it put some of eating the meal. A new menu has recently been provided in consultation with the residents. (This is good practice). Since the last inspection the manager has changed the routines within the home to ensure that residents who require assistance from staff to eat their meals, are not sat at the dining table for long periods before being served their meals. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home has a robust, accessible complaints procedure and staff are generally ensuring that residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure was prominently displayed in the main entrance hall on the day of this inspection. The Service User Guide informs people how to make a complaint and that this will be responded to within 21 days. The residents and relatives spoken with during the inspection were confident that their complaints would be taken seriously and dealt with appropriately. The homes complaints records were not available on the first day of this inspection as they were locked in the main office and only the homes manager and administrator had keys, neither of these members of staff were available. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 17 The complaints records were viewed on the second day of inspection and only one complaint had been received since the last inspection. The manager had responded to this complaint within 21 days. Staff have received basic training in safeguarding adults and the home has an appropriate Whistle Blowing policy. There have been no allegations of abuse in the home since the last key inspection. Burkitt Nursing Home DS0000065667.V340435.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): 19,22,26. Some areas of the home were being refurbished and the home was appropriately clean at the time of this inspection. However there were a number of issues relating to the premises, which are compromising residents’ health and safety. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the building was completed as part of this inspection. Some resident’s bedrooms were well decorated and comfortably furnished. Residents confirmed that they can use their rooms at any time and that they had been encouraged to personalise them with small items of furniture photographs etc. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 19 All areas of the home observed during the inspection were appropriately clean and free from offensive odours. Since the last inspection new non-slip flooring has been provided in the toilet near to the main lounge. The doorframe to one of the sluice rooms has been repaired and ‘safety restrainers’ have been fitted to the window specified in the last inspection report. The drainage fault has been addressed and the smell of sewage has been eliminated. It was noted that there was a serious leak in the ceiling of bedroom 31, a bucket was being used to catch the rainwater and the carpet in this room was very wet. At the time there were two residents being cared for in bed in this room, the inspector was advised that one of these residents had only recently recovered from a chest infection. This was seriously compromising the residents’ health and safety. The residents were moved to an alternative room and the manager provided assurances that no residents would be admitted to bedroom 31 until the leak had been repaired and the room has dried out. It was also noted that there was a leak in the bay window in bedroom 26 and in the conservatory used by residents, both of these areas require repair. The manager has received a complaint about the homes ‘call bell’ system. Some call bells cannot be heard in some areas of the home. At the time of this inspection a ‘baby monitor’ was being used to amplify the call system. This was unsatisfactory as it could not only potentially compromise residents and visitor’s privacy but was also often ineffectual. The inspector was advised that the monitor could often not be heard when staff were vacuuming in the lounge area and that it had been removed when entertainment was provided. The complainant stated that her mother was not always getting the assistance she required when she attempted to contact staff using the call bell system. It is essential that all call bells be answered promptly to ensure the health, safety and comfort of the residents. The inner door to the shaft lift, outside the residents’ dining room, was not closing and consequently residents and staff were at risk of serious injury when using the lift. This lift must not be used until it has been appropriately repaired. The registered person must make alternative arrangements for people to have safe access to their bedrooms. A Parker Bath has been fitted to one of the ground floor bathroom to provide assisted bathing facilities for the residents. However staff stated that they are unable to use the hoist appropriately, in this room and consequently heavy residents have to be showered and other residents physically lifted into the bath. This is putting residents and staffs health and safety at risk. The Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 20 qualified nursing staff were also unable to demonstrate how this bath could be used safely. An area of the home’s cellars was flooded at the time of this inspection. This area contained the plant equipment for one of the homes shaft lifts. The manager stated that maintenance staff regularly monitors this area of the home to ensure that it remains safe. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 21 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. Residents’ needs are not being fully met due to the staffing levels provided within the home. Staff are completing appropriate training. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have reported that they are not receiving the care and support they require as there are, on occasions, insufficient staff employed. People said that sometimes they have to wait long periods of time before there any staff available to offer them assistance with personal tasks. A relative has complained that their mother who is cared for in bed does not receive enough care and assistance from staff. There are not enough staff to provide social activities for residents. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 22 The inspector was informed that out of 22 care staff four have completed NVQ level 2 training and 4 other people have completed the training but are waiting for their work to be verified. The registered person is clearly attempting to ensure that at least 50 of the care staff are trained to NVQ level 2 or above. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 23 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): 31,37,38. The manager is well qualified and suitably experienced. Record keeping within the home is in generally good however a number of records were not available on the first day of this inspection. There are some areas of health and safety, which require urgent action to protect the welfare of residents and staff. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was registered shortly before the last Key Inspection in January 2007. She is a Registered General Nurse (RGN) and has completed the registered managers award. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 24 Residents and relatives said that the manager is a very approachable and that she responds promptly and appropriately to any concerns they may raise. The records required by regulation for the protection of service users and for the effective running of the home are generally maintained to a very good standard. However many of these records were not available on the first day of inspection as they were locked in the main office and only the manager and the administrator had keys to this room. Neither of these people were available. Records identified in Schedules 3 and 4 of the Care Home Regulations 2001 must be available for inspection at all times. When the inspector arrived at the home, on both occasions, there were no staff in the main entrance area. After some considerable time he managed to locate a member of staff in the homes kitchen. The inspector expressed concern that any member of the public could have entered the home & have had access to residents’ bedrooms without being challenged by staff. This is putting residents and their property at risk. Although some improvements have been made, the premises section of this report identifies a number of health and safety issues, which present a risk to residents, staff and visitors. A fire assessment has been completed since the last inspection however this does not take into account the wedging open of fire doors. A significant number of residents’ bedroom doors were wedged open at the time of this inspection. The registered person has still not identified a company who will ensure that systems are in place for the prevention of Legionella within the home. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X 3 X X 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 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X 2 X X X 3 STAFFING Standard No Score 27 1 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 2 1 Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation Requirement Timescale for action 26/07/07 2. OP12 3. OP19 4. OP19 12 (1) Residents must receive the care (a). (b). and support they require in a timely manner. Care records must always be accurately maintained. 16 (n). A programme of regular activities & entertainment must be implemented to provide stimulation for residents & as far as possible meet their social and recreational needs. 13 (4) The shaft lift outside the (a). (b). residents dining area must not (c). 23 be used until it has been (2) (c). repaired and made safe, Time scale Immediate. 23 (2) The leaks in bedrooms 31 29 (b). and in the conservatory area must be repaired. No residents can be admitted into bedroom 31 until the leak has been repaired and the room is dry. 23 (2) (c) The registered person must ensure that the homes call bell system is fully operational, that staff can always hear it and that staff respond quickly to ensure DS0000065667.V340435.R01.S.doc 26/07/07 26/07/07 03/09/07 5. OP19 26/07/07 Burkitt Nursing Home Version 5.2 Page 27 6. OP19 23 (2) (j) (n) 7. OP19 23 (2) (b) 8. OP27 18 (a) 9. OP37 17 (1) (2) (3). 10 OP38 4 (a) 11. OP38 23 12. OP38 23 (4) the health, safety and comfort of the residents. Staff must be trained how to transfer residents into the Parker Bath in the small ground floor bathroom safely. If this cannot be achieved then a different form of assisted bathing will need to be provided. The registered person must provide written confirmation from a suitably qualified professional that the flooded cellar where the plant equipment for one of the homes shaft lifts is located does not pose a health and safety risk to residents staff and visitors to the home. The registered person must carry out an assessment of service users needs and ensure that there are appropriate staffing levels to meet the health, safety and welfare needs of the service users accommodated in the home. All of the records identified in schedules 2, 3, & 4 of the Care Homes Regulations 2001 must be kept in the home available for inspection at all times. The registered person must ensure that members of the public do not have unrestricted access to residents and their property. This will help to ensure the safety of the residents and there property. Ensure a system is in place for the prevention of Legionella. Timescale of 18/02/07 not met. A fire risk assessment must be completed, which takes into account the wedging open of fire doors. Note a fire risk assessment had been completed but this did not DS0000065667.V340435.R01.S.doc 26/07/07 26/07/07 26/07/07 26/07/07 26/07/07 03/09/07 26/07/07 Burkitt Nursing Home Version 5.2 Page 28 address the wedging open of residents’ bedroom doors. Timescale of 18/02/07 not met. 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 OP1 Good Practice Recommendations The literature supplied to prospective residents should include the following information. 1. A copy of the most recent inspection report. 2. The residents’ views of the home. 3. Details of staff qualifications. Burkitt Nursing Home DS0000065667.V340435.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 - 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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