Inspection on 23/06/05 for Burleigh House

This inspection was carried out on 23rd June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burleigh House 26/06/07

Burleigh House 29/08/06

Burleigh House 10/11/05

Burleigh House 04/10/04

Burleigh House 24/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Burleigh House Foxearth Leek Road Cellarhead Stoke on Trent ST9 0DG Lead Inspector Linda Clowes Announced 23 June 2005 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 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. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burleigh House Address Foxearth Leek Road Cellarhead Stoke on Trent ST9 0DG 01785 780380 01782 550920 none Day Care Services Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jane Day Care Home 15 2 2 6 15 4 Category(ies) of DE registration, with number MD of places MD(E) OP PD(E) Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) MD - Registered for 2 - Minimum age 55 years and over on admission. 2) Maximum number of service users in the combined categories MD(E), MD and DE(E) at any one time - 8. Date of last inspection 4 October 2004 Brief Description of the Service: Burleigh House was an impressive detached property set in its own mature gardens in a pleasant rural location. It was registered to offer care and accommodation for fifteen older people and provided 13 single bedrooms, one shared bedroom and ample communal space. The home had good access by road to local towns and was within a couple of miles of the village of Werrington which had extensive community facilities including GP surgery, library, churches, post office, shops, pubs and restaurants. There was ramped access to the front door. Accommodation covered two floors and access to the first floor was by staircase and a shaft lift. There were two main lounges with a large dining area and a conservatory for use by service users. Externally there was a decked area with table and seating. There were several other areas in the grounds and on the patio with seating and shading so that service users could enjoy the sunshine and the gardens. The home was warm, clean and pleasantly decorated. It was equipped with appropriate aids to daily living to meet the needs of its service users. There was an on-going commitment to training at all levels that was reflected in the good quality of care provided. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Burleigh House was a well organised home, owned and managed as a family business. There was a calm and homely atmosphere. All service users were spoken with on the day by the inspector. They expressed satisfaction with the care and services they received. The home was fully staffed with care workers who were experienced to meet the needs of service users. Several staff had left the home since the last inspection and as a consequence the home did not meet the minimum ratio of 50 trained staff (NVQ level 2 in care or equivalent). Five staff were currently undertaking NVQ level 2 in care training. It was disappointing to find that building alterations to the family’s other care home had impacted on the maintenance and refurbishment of Burleigh House and the proprietors have been asked to address this situation. A letter was forwarded to the registered manager following the inspection visit. What the service does well: The home was well managed and was fully staffed by experienced care staff. The home had a friendly, relaxed atmosphere and all service users indicated that they were satisfied with their lives in the home. Comprehensive assessment procedures were in place to ensure that the needs of all prospective service users could be met. Sensitive and kindly interaction and relationships were observed and service users appeared relaxed and comfortable in their approaches to staff and managers. Relatives in the home at the time of the inspection and those who responded to questionnaires confirmed that they were very satisfied with the care that was provided and considered that the home appropriately met the care needs of their relative. Arrangements for service users health care needs to be routinely monitored were in place and residents confirmed that staff immediately responded to any concerns regarding their health and ensured that General Practitioners were asked to visit them. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There were concerns regarding the condition of some areas of the home both internally and externally. The registered manager was asked to carry out risk assessment audits in order to reduce/eliminate risks in relation to the external areas of the home and grounds where service users and staff had access. The registered manager was also asked to carry out an audit of the maintenance and refurbishment needs of the building both internally and externally. The manager was asked to ensure that copies of the risk assessments and maintenance audits were forwarded to the Commission. The registered manager was also asked to ensure that a full and accurate record is maintained of the monthly statutory visits carried out to comply with Regulation 26. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 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. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4, and 5. Standard 6 was not applicable. Burleigh had up to date written information about the care home and the services it provided. Service users were invited into the home prior to decisions being made regarding admission. The Registered Manager carried out thorough assessments on all prospective service users and confirmed in writing whether the home had the ability to meet their needs. EVIDENCE: The home had a current Statement of Purpose and Service Users Guide that had been reviewed on 15.3.05. Each resident had a contract covering the terms of residency in the home. This included the rooms to be occupied, fees payable and by whom. Sign copies of the contracts were seen on the small random sample of files inspected on the day. The current fees ranged from £317 to £347 per week that included a £30 topup fee. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 10 The registered manager carried out thorough assessment procedures to ensure that the home was able to meet service users health and social care needs. Prospective service users were offered trial visits so that they had the opportunity to consider whether the home met their needs. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. The inspection identified that the home was providing good quality care. All service users confirmed that they were satisfied with the home and considered that staff treated them with dignity and respect. Observations made on the day confirmed sensitive interaction between service users and staff. EVIDENCE: The home completed a comprehensive Service User Plan that covered the service users personal and social care needs. Plans were regularly updated to reflect any changing health needs and/or personal needs at least monthly. It was identified that of the thirteen service users in the home on the day of the inspection, three had medium dependency needs and the rest were low dependency. A small random sample of Service User Plans was inspected. These showed that residents were being appropriately referred for GP consultation as and when required. The record also showed that routine medical care needs were accessed e.g. dental, chiropody, hearing, etc. on a regular basis. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 12 Members of the Community Nursing team visited residents when required and a District Nurse was seen in the home on the day of the inspection. The inspector observed the lunchtime medication round and checked medication records and medicines and all were satisfactory. All Service users daily nutritional and fluid intake was routinely monitored and recorded, particularly those with diabetes. The home reported that they were currently experiencing difficulties with the local pharmacy but had taken steps to rectify the situation. It was reassuring to note that thorough checking of medication by the home was taking place. The inspector spoke with all residents on the day and all confirmed that they were satisfied with the care they received in the home. The home operated a “home for life” policy and one service user had died and been cared for in the home since the last inspection. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The home supported the lifestyle and wishes of its residents. Those who wished to spend the majority of their time in their rooms were accommodated and sensitively monitored during the day. Those who regularly used the communal areas of the home were observed in their favourite spots chatting with other residents and visitors. All confirmed that they enjoyed the food provided and that there was an alternative choice at each of the three main meals of the day. Meals were served in the pleasant dining area or in service users own rooms if they wished. EVIDENCE: The home had an activities programme that was organised by the Deputy Manager and was displayed on the notice board in the entrance hallway. Relaxation music was being played on the day and listened to by those who wished to do so. As the day of the inspection was a hot, sunny, mid-summer day several service users were observed playing boules in the garden and others sat out on the patio watching the birds, flowers and visitors coming and going. Others watched TV, knitted or sat chatting. Staff provided facials and manicures to those who wished. Service users confirmed that they went shopping with staff on occasions. Several continued to be supported by family Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 14 and maintained visits to family homes and special occasions. The Visiting Gardener visited three monthly to show videos and discuss garden related issues – apparently his visit was much enjoyed by all. Formal entertainment was discussed at the Residents Meetings and arranged accordingly. Service users in the home were looking forward to the forthcoming marriage of the deputy manager as all had been invited to the celebrations. Some had decided just to attend church, others planned to attend the day’s celebrations. Service users were able to choose where they took their meals either in the attractive dining room or in their own rooms. The home provided a threeweek rotational menu and food was always and agenda item on Residents Meetings in order to ensure that personal preferences were met. One service user had stated in the questionnaire as part of this inspection that they did not like sandwiches being served for the main meal. This situation had been resolved by the day of the inspection. The service user had raised the issue with the home. The situation apparently occurred when a buffet lunch was served which several residents liked. The service user has been assured that a meal of their choice will be served as an alternative. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18. The home had a Complaints Procedure that was displayed in the main hallway and outlined in their Statement of Purpose. Service users and relatives confirmed that they were aware of the complaints procedure but that the staff of the home were approachable and responded promptly to any issues raised. EVIDENCE: The home had an appropriate complaints procedure. The Complaints Record was inspected and no formal complaints were recorded. The Commission had received no complaints in respect of the home since the last inspection. The statement of purpose stated that service users would be encouraged to continue to take part in voting in local and general elections. Arrangements were made for postal voting forms to be used. The home had a Vulnerable Adults Procedure and staff were advised of this during their Induction Training. Sensitive, patient and kindly interaction was observed between staff and service users. Service users confirmed that staff were good with them and several were very fond of individual staff members. Relatives spoken with on the day confirmed to the inspector that they were satisfied with the care provided in the home. One relative had indicated on their questionnaire that they were “very happy with the home. Staff are always very pleasant and very caring. The home has a lovely family atmosphere is and very friendly”. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 16 The home was not involved in the finances of any service users preferring family members to take on this responsibility Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 25. It was disappointing to see that the home was in need refurbishment internally and that externally urgent maintenance and repair was required to the fabric of the building. The grounds were overgrown to the extent that some areas were unsafe for service users. The registered manager was asked to address this issue with some urgency. EVIDENCE: Burleigh House was owned and managed as a family run business together with another residential home, Four Seasons in Meir. Two of the directors had been involved in building an extension at Four Seasons and this was nearing completion. It was disappointing, however, to see how this had had an impact on the redecoration, refurbishment and maintenance of Burleigh House. It was found that the following areas needed addressing: Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 18 1. A risk assessment audit needed to be undertaken of the paths and grounds around the care home to maintain the health and safety of service users and strategies implemented accordingly. The pathways around the home were uneven and presented a trip hazard to residents and staff The pathways around the garden and lawned area at the front of the building were overgrown by shrubs and brambles and were a risk to service users. Other areas of the grounds needed clearing of rubbish (old lawn tidy, old washing machine, old bicycle, etc). Many of the gutters around the care home were full of growing weeds and debris, one drain appeared blocked, one downspout appeared to be missing, all of which appeared to be causing water damage. The outlet for the tumble dryer was full of fluff. Garden walls were cracked and appeared unsafe. The raised garden area to the rear of the home (overlooked by two residents bedrooms) was unkempt. Although new double glazed windows had been fitted to the front of the building approximately twelve months ago, stickers had not been removed from some panes. Cladding to the front, upstairs bay window needed to be replaced/repaired. Two resident’s bedrooms (rooms 2 and 4) had reduced light levels affected by a large beech tree growing just outside. 2. 3. 4. 5. 6. 7. 8. The registered manager was asked to carry out a risk assessment audit on the external areas of the home where service users and staff have access and to take measures to reduce/eliminate these risks as soon as possible. With regard to the internal environment it was found that the following needed addressing: a) b) c) The bed head needed fixing/replacing in room 5. Plugs should be secured in baths and basins throughout the home. The soap dispenser in room 2 should be repaired/re-fixed as there were health and hygiene implications Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 19 d) The communal washing areas throughout the home should be fitted with disposable paper towel dispensers and liquid soap to promote health and hygiene and reduce risk of cross-infection in the home. The laundry room and sluice area should be fitted with hand washing facilities, paper towel dispensers and liquid soap in order to promote health and hygiene and reduce risk of cross-infection. e) It was noted that the two bathrooms in the home and particularly the ground floor bathroom and adjacent toilet were in need of refurbishment. Wallpaper was damaged in a number of areas and needed replacing. There was damage to the wallpaper on the back staircase that appeared to be due to damp. The registered manager indicated that there was a planned refurbishment of the kitchen facilities to address the need for repairs to flooring and plumbing that may involve an extension to provide more working space. The flooring had been sealed as a temporary measure but the plumbing continued to be a problem with a persistent leak under the sink in the COSHH cupboard. Under these circumstances, therefore, requirements were not made. The commission will await the registered manager’s audit of the maintenance and refurbishment needs for the home that has been requested as part of this inspection report. It was considered that the laundry area needed to be tidied and for the unused/broken laundry equipment, broken chair and other items to be removed. Service users confirmed that they were satisfied with their bedrooms and many were personalised with small pieces of furniture, photographs and ornaments from home. The home had appropriate specialist equipment available to meet individual service users needs, e.g. handrails, hoists, passenger lift, etc., to assist service users. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The home had a full complement of staff. Staff were in the main appropriately recruited. Induction training had been carried out. Six care staff had moved on since the last inspection. As a consequence, the home did not meet the minimum ratio of 50 of trained members of care staff (NVQ level 2 or equivalent). Experienced carers were, however, employed within the home in sufficient numbers to meet the needs of service users. EVIDENCE: Deployment of staff provided for a minimum of two care staff throughout the 24-hour day, plus a manager and deputy manager during the busiest part of the day. A new cook/carer had been appointed since the last inspection. There were two waking night staff. The deputy manager confirmed that there were sufficient care staff with appropriate first aid training to be deployed on each shift. The home had five staff currently undertaking NVQ level 2 training in Care. The Deputy Manager was continuing with NVQ Level 4. All mandatory training had been undertaken and refreshers were planned where necessary. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 21 It was noted that in relation to one member of staff there was a need to obtain a recent photograph, full employment history, copy of passport and birth/marriage certificates. A requirement was made in relation to this issue. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38. The home benefitted from the management of an experienced management team. There were good working relationships throughout the home and service users confirmed that staff and managers were approachable and reliable. Service users appeared to be on relaxed and friendly terms with staff and management. EVIDENCE: The home was managed by an experienced and competent manager who was currently undertaking her NVQ level 4/Registered Managers Award. Staff and service users confirmed there were good relationships within the home and considered that management were approachable and responsive. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 23 There was a need for a director to complete a full and accurate record of the statutory monthly visits/audits required under regulation 26 and a requirement has been made as part of this report to address this situation. The home carried out quality audits of its users and held regular residents meetings. The registered manager was reminded of the need to ensure that the outcomes of quality audits are included in the Statement of Purpose when it is reviewed annually. The Registered Manager indicated that the home had no involvement with the finances of any of its services users, preferring relatives to take responsibility. Evidence was seen on the small random sample of personnel files of a range of staff supervision at appropriate intervals. It was found that fire records and equipment maintenance records were up to date. The following health and safety issues were highlighted and the home was asked to address these to ensure health and safety of service users and staff: 1. There was a lump in the carpet/flooring by the bath in the upstairs bathroom that presented a trip hazard. The pole used to open the loft inspection cover should be stored somewhere other than the upstairs bathroom. 2. Items were being stored on the top of wardrobes throughout the home and should be removed to protect the health and safety of service users. 3. The television in room 1 should be removed from the Etwall trolley as this was a health and safety risk. 4. All unwanted, unused and broken items are to be removed from the laundry room. Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 2 2 x x 3 3 1 Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 25 n/a 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 19 Regulation 23(2)(o) Requirement The registered manager shall ensure that a risk assessment audit is undertaken and appropriately acted upon of the paths and grounds around the care home to maintain the health and safety of service users The registered manager shall ensure that an audit is undertaken of the maintenance needs of the building both internally and externally and CSCI informed of the programme for implementation. The registered manager shall ensure that the bedhead in Room 5 is repaired/refixed. The registered manager shall ensure that a remedy is sought to address the low light levels in rooms 2 and 4 for the benefit of service users. The registered manager sshall ensure that plugs are secured to baths and basins throughout the home. The registered manager shall ensure that the soap dispenser in room 2 is repaired/refixed as there are health and hygiene implications. Timescale for action 30.6.05 2. 19 23(2)(b) 31.7.05 3. 4. 19 19 and 25 13(4)(c ) 23(2)(c ) 27.6.05 15.7.05 5. 21 23(2)(b) 15.7.05 6. 26 23(2) and 13(3) 27.6.05 Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 26 7. 29 19(a)(b) and (c ) 8. 32 26 9. 38 13(4) (a) and (c ) 10. 38 23(2)(l) 11. 38 13(4)(a) and (c ) 23(2)(c ) 12. 38 13. 26 13(3) 14. 26 13(3) The registered manager shall ensure that as part of the recruitment procedure and personnel record the following are in place in all instances recent photo, full employment history, copy of passport and birth certificate and appropriate criminal record bureau enhanced disclosure. The registered manager shall ensure that a full and accurate record is maintained of the monthly statutory visits carried out by a director. The registered manager shall investigate the lump the the carpet/flooring by the bath in the upstairs bathroom which presents a trip hazard and repair/replace as required. The registered manager shall remove items stored on top of wardrobes throughout the home to protect the health and safety of service users. The registered manager shall remove the television in room 1 from the Etwall trolley as this is a health and safety risk. The registered manager shall ensure that all unwanted, unused and broken items are removed from the laundry room. The registered Manager shall ensure that disposable paper towels and liquid soap are provided in communal washing facilities throughout the home to promote health and hygiene and reduce risk of cross infection in the home. The registered manager shall ensure that the laundry room and sluice area are fitted with hand washing facilities, paper towels and liquid soap in order to promote health and hygiene and An ongoing requiremen t An ongoing requiremen t 24.6.05 An ongoing requiremen t With immediate effect. 30.6.05 31.7.05 31.7.05 Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 27 reduce risk of cross infection. 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 Good Practice Recommendations Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Burleigh House E51 E09 S4922 Burleigh House V184605 230605 Stage 4.doc Version 1.30 Page 29 - 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!