Inspection on 26/06/07 for Burleigh House

This inspection was carried out on 26th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Burleigh House 29/08/06

Burleigh House 10/11/05

Burleigh House 23/06/05

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 Staffordshire ST9 0DG Lead Inspector Rachel Davis Key Unannounced Inspection 26th June 2007 10:15 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 Burleigh House DS0000004922.V338321.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. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burleigh House Address Foxearth Leek Road Cellarhead Stoke On Trent Staffordshire ST9 0DG 01782 550920 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) burleigh.house@virgin.net Day Care Services Limited Mrs Jane Day Care Home 15 Category(ies) of Dementia (5), Mental disorder, excluding registration, with number learning disability or dementia (2), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (15), Physical disability over 65 years of age (4) Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. MD - REGISTERED FOR 2 - MINIMUM AGE 55 YEARS AND OVER ON ADMISSION NUMBER OF SERVICE USERS IN THE COMBINED CATEGORIES MD(E), MD AND DE(E) SHALL NOT EXCEED A TOTAL OF 8 PEOPLE. 29th August 2006 Date of last inspection Brief Description of the Service: Burleigh House is a detached property set in its own mature gardens in a pleasant rural location. The home was warm, clean and satisfactorily decorated. The home provides care for a maximum of 15 service users; their needs may range from old age to dementia, a mental disorder and/or physical disabilities. The home can accommodate 5 people with dementia, 2 with a mental disorder and 4 with a physical disability. Burleigh House charges the people who use the service £ 377:00 per week, this information was accurate on 26/06/07. The exterior and interior of the property are adequately maintained. Service users are offered easy access throughout the home by the use of stairs or a lift. There are 13 single rooms and one double room. Bathrooms and toilets are appropriately situated. There are garden areas for the people who use the service and their visitors with the appropriate seating facilities. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over six hours. This was a ‘key inspection’ and all the core standards were assessed. During the visit the inspector met and spoke with the majority of people living in the home and all members of working staff, there were no visitors on this day. Observations were made of staff and resident interaction around non-personal care tasks. The medication administration, storage, recording and stock control procedures were examined and a tour of the environment was undertaken. The service users financial records were also checked. A random selection of the Health and Safety records was seen including maintenance records. Care plans were inspected and the records of two staff (both employed since the last inspection) including their recruitment and training documents. This is the first key inspection since September 2006, a random inspection was made in January 2007. There have been no complaints about the service delivered at Burleigh House since the last inspection, people living in the home know who to speak to if they want to know something or feel unsure or unhappy. What the service does well: All of the people involved in this inspection were positive about the staff and their caring attitudes to the people using the service. The people who use the service have access to a range of medical professionals to maintain their health and wellbeing. The management of residents’ monies is robust and safe. Activities are available for those people using the service who are able to participate and trips have been organised. The staff spoke with people who use the service in a respectful manner. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 6 The food is home-cooked and there is a plentiful supply of fresh fruit and vegetables. Choices are available, which are taken advantage of by some of the people using the service. Comments from the relatives were positive regarding the quality of care provided in the home. “You can openly discuss things.” “ It is a nice, friendly, homely atmosphere.” “Overall the home has made my relative happy and contented.” The manager supports the team of staff on a daily basis and continues to communicate well with the staff and the Commission for Social Care Inspection. Staff in the home work well as a team and advised the Commission for Social Care Inspection that they support each other to provide consistent care for the people who use the service. The people who use the service spoke highly of the staff team and respectful attitudes were observed, comments relating to staff included, “The staff are very good.” “They are wonderful.” “The staff are lovely, very nice and kind.” What has improved since the last inspection? Suitable storage is now in place for all medication. People who use the service have been consulted about activities. Since the last inspection 2 outside entertainers have been included within the activities programme, one to promote progressive mobility and the other for a ‘singalong’. The manager has ensured complaints are suitably recorded and has encouraged people to use the comments, concerns and compliments book. The manager has ensured that all the staff have received fire and evacuation training. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 7 The manger now holds an inventory of furniture brought by a resident into a room occupied by them. The recruitment procedures have been strengthened to comply with legal requirements, and now fully safeguard the people using the service. What they could do better: 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. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate assessments are undertaken prior to admission however, the lack of written information offered does not ensure that people who use the service and prospective residents can make an informed choice about the home. EVIDENCE: The service has developed a Statement Of Purpose and Service User Guide, these set out the aims and objectives of the home, and includes information about the service, these are now outdated and not necessarily a current reflection of the service, they need to be reviewed. The Service User Guide must be made available to all people who use the service. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 10 Before people are admitted to the home, their needs are assessed so that all parties can be confident that they will be fully supported in the way they require. People referred by the Local Authority are also assessed and the manager obtains copies of these assessments before the person moves into the home. Potential residents and/or their families are able to visit the home to aid them in their decision-making. Although the home meets the needs of the people who use the service they should consider ways in evidencing equality and diversity and how they support people with more complex needs. Examples of this would include• Name badges or named photographs, how do people with dementia identify with staff? and how do visitors, whether professionals or family and friends know who they are speaking with? • A means to enable people who use the service to identify their own bedrooms. • Pictorial information to help people who use the service make informed choices. • Orientation to date, time and place. Standard 6 is not relevant to this home and therefore not assessed. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care needs that people who use the service receive are individualised but could be improved upon. The principles of respect, dignity and privacy are practiced. EVIDENCE: The care record of one person who used the service was checked during this inspection. A plan of care has been developed, but it had not been reviewed. It is recommended that the information be expanded to ensure that staff know exactly what support is required especially where people who use the service are not able to express themselves easily. Care plans could become more person centred and contain more succinct information around areas of need such as personal care, recreation, nutrition, spiritual needs, sexuality, life skills, hobbies etc. People who use the service are very happy and commented: Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 12 “They look after me well.” “I like them.” ”They are very kind.” The care plans and other records show evidence that the residents’ health is monitored and the appropriate professionals contacted on their behalf. All of the people who use the service have general practitioner and community support from local practices when necessary. Staff were observed in their approach to residents during the visit, they were seen to afford dignity and respect. For example, one member of staff was seen escorting a resident to the toilet, they allowed them to go at their own pace and talked to them in a calm and reassuring way, footplates on wheelchairs were used at all times, staff knocked on doors before entering, and were heard speaking with people who use the service in a kind and reassuring manner. Medication was checked on this inspection and observed. Controlled Drugs were stored appropriately, Medication Administration Sheets had been completed and the drugs store was clean and tidy. Overall medication practices are good. On checking controlled drugs records one of the two records did not tally with the amount of medication on the premises. The manager will undertake a full audit of this discrepancy. A requirement has been made to this affect. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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. 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. Activities and stimulation for people who use the service are in place, this provides daily variation and interest for people living at Burleigh House. The home encourages and welcomes visitors. EVIDENCE: Since the last inspection the activities co-ordinator has left but the home is in the process of recruitment. In the interim period care staff are spending a couple of hours a day (usually in the afternoon) to support and stimulate the people who use the service. Activities include games, quizzes and crafts. Some outside trips have been Enjoyed such as a trip to Trentham Gardens. On speaking to a number of people using the service it was evident that they enjoyed the activities and looked forward to spending time with the staff. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 14 Since the last inspection two outside entertainers have been included within the activities programme, one to promote progressive mobility and the other for a ‘sing-along’. The home offers the people using the service the opportunity to take communion on a monthly basis. People who use the service were able to receive visitors whenever they choose, the home has an open visiting policy. Unfortunately, on the day of the inspection no visitors came to the home so the Commission for Social Care Inspection were unable to discuss this further. The manager has recorded on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) that they “ want to develop links with the local community ensuring continuing meeting social needs of clients.” A choice of two cooked meals is offered at lunchtime and alternatives are available if desired. A discussion was held at this inspection as to whether choices could be expanded. It is particularly difficult to offer choices to people with dementia, who either forget what they asked for or in many cases cannot communicate their wishes. The manager could look at offering more visual choices such as developing menus in photo format. Or for example, the meals are ‘plated up’ and the residents may like to choose their own vegetables from a separate dish or decide whether they fancy gravy or a sauce that day by having them in jugs. The quality of the food is considered to be good. All those spoken with confirmed they had enjoyed their meal. All of the meals are ‘home-cooked’ and home-baked cakes and puddings are available. The cleanliness of the kitchen is well maintained and the staff reported that a recent visit from the environmental health officer was satisfactory. The kitchen was inspected and found to be clean and tidy. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures were kept. The home must ensure all opened jars that have a recorded expiry date are labelled. Staff were seen assisting some people to eat their lunch. This was done in a sensitive manner. Lunch was observed and was seen to be a relaxing and pleasant experience. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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. 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. The home has a suitable complaints procedure and ensures the people who use the service are protected from abuse in accordance with written policies. EVIDENCE: The complaints procedure is displayed in all bedrooms, the information about how to make a complaint is also contained in the Service User Guide. There has been one complaint made to the home since the last inspection, suitable steps were taken to address the complaint and also following the outcome. An informal folder is also kept offering people the opportunity to raise comments, concerns or thanks. The manager confirmed that all staff have received recognition of abuse training. The Commission for Social Care Inspection is satisfied that the vulnerable adult issues dealt with by the manager of the home were dealt with, and concluded in an appropriate manner. Relevant induction training is provided which meets the criterion including value base and an understanding of equality and diversity, records and Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 16 certificates were seen to confirm that mandatory and specialist training are delivered to the staff group. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is suitably maintained to ensure the people who use the service are comfortable. Some improvements are necessary to ensure the safety of vulnerable people at all times. EVIDENCE: Overall the home is safe and well maintained with adaptations to suit residents’ specific needs. It is decorated and furnished to a satisfactory standard that creates a comfortable and homely environment. The home was fresh and clean throughout on the day of the inspection. The bathrooms provided sufficient aids and adaptations for those people who required assistance and support. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 18 The laundry area is adequate, the manager should consider purchasing a washing machine with a sluice programme when the present washing machine needs replacing. The residents’ private accommodation seen was kept to a good standard of cleanliness and reflected individual residents personal tastes. The home employs a maintenance person who carries out any required maintenance on an ongoing basis. The following health and safety issues were noted and need to be addressed. • All radiators and pipework within the home must be assessed for the risk they present to the people who use the service and action taken to minimize the risk. Communal water temperatures must be taken and recorded on a monthly basis. The shower room floor is inadequate and does not meet with infection control standards. The home should consider purchasing foot operated bins to meet with infection control standards when disposing of incontinence wear. Control Of Substances Hazardous to Health must only be stored in a lockable area. The toiletries of the people who use the service should not be left in communal areas. • • • • • Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 19 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 good This judgement has been made using available evidence including a visit to this service. Staff at the home are trained, competent and sufficient in numbers to meet the needs of the people who use the service. Recruitment procedures are robust and support the need to protect vulnerable adults. EVIDENCE: The number of staff on duty during the inspection was satisfactory to meet the needs of the people who use the service. Two staff files were examined and both demonstrated that a thorough recruitment practice was in place, this included 2 written references, criminal records bureau checks, application forms, identification certificates, a health declaration and a photograph. Unfortunately the gaps in employment history on one file had not been followed up as necessary, this was a requirement on the previous inspection. The Commission for Social Care Inspection reminded the manager of the need to implement this procedure. All staff within the home have received training, the registered manager has recently completed the Registered Managers Award, this is a legal requirement for managers of a care service. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 20 It is considered that a consistent and needs led service offered to those people who use the service. National Vocational Qualification training is high priority for the staff working at Burleigh House, out of 16 staff 5 have National Vocational Qualification 2 in care and 3 have National Vocational Qualification level 3. Four staff are presently doing their National Vocational Qualification 2 and 4 staff are doing their National Vocational Qualification 3. Regulation states that 50 of the workforce must be trained, Burleigh House presently meets this requirement. Staff spoken to were very happy working at Burleigh House, one care worker stated she had been given time to read all the care plans which had proved really helpful. Others said Burleigh House was “homely”, “not stressful but relaxed.” and that “ communication was good.” Everyone considered the manager to be approachable and supportive. The manager has recorded on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) that “ We have continued to improve and update all our staff training/development needs over the last 12 months.” It would be beneficial to record these on a training matrix. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 21 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 and 38. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. An experienced manager manages the home and offers leadership. It is imperative that the responsible individual carries out his legal obligations to monitor the standard of care provided at Burleigh House. This will further demonstrate that it is run in the best interests of the people who use the service. EVIDENCE: There is an ethos of warmth and openness in the home and staff deliver a good standard of care and are well organised. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 22 Generally, the health, safety and welfare of staff and people who use the service are as far as reasonably practicable protected. The home has a quality assurance process that covers all aspects of living within residential care. The manager confirmed the results are not presently evaluated or made available to the people who use the service, this needs to be undertaken and will demonstrate that the home strives to ensure that people who use the service are aware of the facilities, resources, options and activities available to them. Where the home is responsible for resident’s money it works to a safe system and maintains clear records. A sample of individuals’ money was scrutinized on this visit and all records tallied. It was noted that the home did not have their most recent inspection report available, the one on the notice board in the hall was dated November 2005. It is a legal requirement to make the most up to date inspection report is available to prospective users and the people who use the service Staff have received fire training including regular fire drills. The manager is aware of the changes to fire safety legislation and the need to undertake individual fire evacuation procedures for each person who uses the service. The manager has spoken with the fire officer and is awaiting a site visit. The registered person has not met their legal obligation by visiting the home and completing the Regulation 26 visits since January 2007. Prior to this they were only completed sporadically. This has been an ongoing requirement since November 2005. Not completing these means the responsible individuals is not able to form an opinion of or monitor the standard of care provided at Burleigh House. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 5(2) Requirement Timescale for action 26/08/07 2 OP7 15(2)(b) 3 OP9 13(2) 4 OP25 13(4)(a) Burleigh House must supply a copy of the Service User Guide to each person who uses the service. This then enables people to understand what is available, how to complain, terms and conditions, the address for the Commission for Social Care Inspection and will assist people to make informed choices. The manager must ensure that 31/07/07 all care plans are kept under review. This ensures information within the plan is up to date and a true picture of what support is required. When controlled drugs 03/07/07 medication is administered to people who use the service it must be accurately recorded, to ensure people receive the correct levels of medication and therefore maintaining their wellbeing and safety. Radiators and pipework within 31/07/07 the home must be assessed for the risk they present to the people who use the service and action taken to minimize the DS0000004922.V338321.R01.S.doc Version 5.2 Burleigh House Page 25 5 OP26 13(3) 6 OP33 26 7 OP33 24(2) risk. The manager needs to undertake 26/07/07 health and safety audits of the environment and address any areas that would compromise any resident’s safety, in this instance not recording communal water temperatures on a monthly basis, the unsuitable flooring in the downstairs bathroom which does not stop the ingress of liquids and the need to remove toiletries and Control Of Substances Hazardous to Health products from toilets and /or bathrooms. The registered person shall 01/07/07 ensure that a responsible person shall carry out the unannounced monthly visits and complete an appropriate record of such visits to comply with regulation. Monthly regulation 26 visits must demonstrate the registered person has carried out interviews with people who use the service and their representatives Previous requirement not met: Nov 05 September 06 January 07 June 07 The results of service user 26/09/07 surveys need to be published and made available to current and prospective users, their representatives and other interested parties, including the Commission for Social Care Inspection. Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP4 Good Practice Recommendations The home should consider ways in evidencing equality and diversity within their service and how they support people with more complex needs. It is recommended that some of the information in the care plans be expanded to ensure that staff know exactly what support is required by each individual and any associated risks. The manager and staff should explore further how they can enable the people using the service to make choices within their daily lives, including meals. The manager should consider purchasing a washing machine with a sluice programme when the present washing machine needs replacing. The home should consider purchasing foot operated bins to meet with infection control standards when disposing of incontinence wear. The manager should provide staff with name badges to assist the people who use the service and visitors. The manager should consider implementing a training matrix. OP7 3 4 5 6 7 OP14 OP26 OP26 OP27 OP30 Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside STAFFORD ST18 0ES 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 Burleigh House DS0000004922.V338321.R01.S.doc Version 5.2 Page 28 - 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!