Inspection on 29/08/06 for Burleigh House

This inspection was carried out on 29th August 2006.

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 26/06/07

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 29 August 2006 10:30 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.V296594.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.V296594.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) 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.V296594.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. 10th November 2005 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 pleasantly 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 its service users between £333 and £350 this information was accurate on 26/09/06. The exterior and interior of the property are adequately maintained. The residents 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, but assisted bathrooms do not presently meet the required ratios. There are garden areas for residents and their visitors to use with the appropriate seating facilities; adequate parking is available to the side of the property. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 29/08/06 and 26/09/06. This visit was a key inspection and therefore covered all of the core standards. The inspection included an examination of records, direct observation of care staff, and discussions with residents, the deputy manager, registered manager staff and visitors. The pre-inspection questionnaire was sent to Burleigh House by the Commission for Social Care Inspection at the beginning of May 2006, this has been completed and returned by the home in June. Evaluations from feedback received in questionnaires sent by the Commission are included within this report. People living at Burleigh House are referred to as residents throughout this report, except under the regulations where they are referred to as service users. Fifteen residents were in accommodation at the home on the day of inspection. Two residents files were examined, on the second day 2 staff files were seen, including training and recruitment records. Three members of staff were spoken with, as were a number of residents, visitors and a visiting professional. A partial tour of the building was undertaken. During the inspection process both the registered manager and the deputy manager assisted the inspector in providing the relevant information and documents required. The registered manager was not on duty on the first day of this inspection. One serious concern was identified during this visit, the content of which is within this report. Nineteen requirements and nine recommendations were made as a result of this inspection. What the service does well: Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 6 The relationship between residents and staff was observed and seen to be positive and relaxed with staff demonstrating a respectful and friendly approach to residents. Feedback and discussions with visitors confirmed their levels of satisfaction “I am generally very happy with the care given to my mother.” “ If I have any concerns or queries regarding the care they are immediately dealt with.” “Overall I am very satisfied with Burleigh House, more importantly my mum is happy and at ease there.” “ The staff have been excellent.” Visitors are made very welcome. Since the last inspection there have not been any complaints made to the Commission for Social Care Inspection regarding the service provided at Burleigh House. Residents and relatives spoken to gave positive feedback in relation to their privacy and dignity. Observations carried out during the inspection reinforced this, and staff were noted to have a very pleasant manner. Complaints handling was satisfactory, as was the policy. Two relatives stated that complaints had been dealt with appropriately however, the home must improve its recording systems in this area. Residents finances were appropriately managed. The management team work in partnership with other professional bodies to ensure the best outcome for the residents. What has improved since the last inspection? The home has provided separate hand washing facilities within the laundry. The management of infection control has continued to improve. The identified risks of residents, such as falling has been recorded within a plan of care which set out the action that needed to be taken to ensure that the residents needs were met, this ensured the staff team had clarity on how to manage a residents needs safely. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 7 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. Burleigh House DS0000004922.V296594.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.V296594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is “poor”. This judgement has been made using available evidence, including a visit to this service. Complete assessment information is not available to staff potentially leaving the residents vulnerable. EVIDENCE: The Statement of Purpose and Service User Guide were not inspected on this occasion. The care records of a recent admission were checked; it did not contain the needs assessment from the local authority as required. The management team had assessed the needs of the resident prior to admission but a subsequent care plan has not been developed for over 2 months. This does not afford staff all the information necessary to provide individualistic care. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 10 National Minimum Standard 6 is not applicable to this home because it is not registered to provide intermediate care. Burleigh House DS0000004922.V296594.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 at least once during a 12 month period. 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. Care planning is satisfactory and staff have access to this information. However, this information must be further developed to ensure that plans of care address identified risks. The home’s medication storage systems do not fully protect the residents. EVIDENCE: Generally care planning information was satisfactory and the deputy manager had undertaken a monthly summary and review of the care plans. Where possible the residents were involved in planning their care and in some cases families. Records are kept of all instances when medical intervention is sought for the residents and these provide evidence that appropriate services are accessed. Fluid charts have been set up where needed and charts confirmed intake. Staff on duty were unaware of the intake required and totals over a 24 hour period were not collated. The deputy manager will ensure that all staff are aware of Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 12 the procedure to follow and will provide “ownership” to the outcome, necessary action etc. Discussions with a visiting professional confirmed that communication was “professional and appropriate”, they felt the staff were “courteous and polite” and “treated residents in a respectful manner.” They stated that a recent complaint had been dealt with well and that staff always treated residents as “individuals.” One Health and Social Care professional questionnaire was returned to the Commission and offered positive responses to the questions asked. For example: Do staff demonstrate a clear understanding of the care needs of service users? “Yes.” Medication administration was observed; this was carried out in a hygienic manner. The medication is stored securely in a locked cabinet however the cabinets are not appropriate and do not meet Safe Custody Regulations. Neither receptacles are secured to the wall, one could be wheeled away and the other is not tamper proof. A requirement has been made to address this shortfall. The NOMAD system is used and has been reviewed by the pharmacy. Records confirmed that instruction given is not as robust as required examples include, No dosage recorded on peptic acid, “please follow directions of the doctor” and “one to be taken daily.” Residents who self medicate (in this instance inhalers) must be risk assessed and the management of risk recorded. Controlled medication was stored appropriately and a robust record maintained. One member of staff was observed safely administering the medication during the lunchtime meal. The home contained excessive stock and the obligatory returns of medication had not been completed since May 2006. A requirement to rectify this situation was made. Residents spoke highly of the staff team saying that the care workers are very good and kind. Visiting relatives said, “they’re very good, they always keep me informed, I can visit anytime, the improvements in my relative are pronounced” and a visiting nurse said that “the staff are very good, it is a well run home.” Burleigh House DS0000004922.V296594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. A range of activities provided within the home was in place but not necessarily undertaken, people with dementia and physical disabilities would benefit from ‘specialist activities’. Family and friends were welcomed and encouraged to maintain contact with the residents in the home. EVIDENCE: A sample of staff, residents, visitors’ questionnaires and other professionals all revealed, “ Activities could be improved upon.” Three of the nine questionnaires returned asked for more activities, one person recorded: “Although some activities are done with residents these are not on a regular basis. I think the home needs to offer more activities to the residents and on a regular basis, the residents need the stimulation.” Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 14 Another response, “ I have been at many times of the day and I have not seen many activities taking place, no entertainers, quizzes etc, it could definitely be improved upon.” Staff confirmed there was not always enough time to provide this support. A regular visitor was spoken with and confirmed that open visiting was actively encouraged and residents were able to come and go as they please with appropriate support. During the inspection there was sound evidence to confirm that, on the whole, individuals privacy and dignity were upheld. A written response from a General Practitioner stated that “ residents are sometimes seen in the conservatory immediately adjacent to the lounge, although not ideal it is usually possible to examine patients without compromising their privacy or dignity.” The home should consider providing a blind to the conservatory door to further improve this situation. The kitchen was visited on the second day of inspection, meals were recorded and there was evidence that choices were offered everyday. Staff were recording fridge, freezer and probing temperatures as required, but were not identifying a date of opening to ensure consumption was managed in a timely manner, for example mint sauce, mayonnaise and salad cream. The menu appeared to run on a two-week rota, which could be considered repetitious, the registered manager needs to evidence variety, a balanced diet good nutrition and a varied diabetic choice in a more robust manner. It was noted that the potatoes are peeled and placed in water the night before and that semi-skimmed UHT milk is being provided, this is not appropriate to the nutritional needs of older people. Burleigh House DS0000004922.V296594.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Positive relationships between staff, residents and families is conducive to people feeling comfortable enough to grumble, comment or complain about the service. Staff are provided with training and information relating to the protection on vulnerable adults. EVIDENCE: The Commission for Social Care Inspection has not received any formal complaints about the home since the last inspection. The complaints procedure was also available in the Service User Guide and by the homes’ notice board and in residents’ rooms. During the inspection process the Commission became aware that a few complaints had been made but the manager did not record these; the outcome of complaints must also be evident. Minor concerns were recorded in a ‘grumbles and compliments book’ and seen on this occasion. Feedback from family and friends evidenced these were followed through. The staff are trained to recognise the signs and symptoms of adult abuse during their induction and when undertaking NVQ 2. There have not been any vulnerable adult referrals made since the last inspection. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 16 It is recommended the home obtain Staffordshire’s Vulnerable Adult Policy, the home do hold a copy from Stoke on Trent. Burleigh House DS0000004922.V296594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Burleigh House is maintained to a suitable standard to ensure the comfort and safety of the residents. However, security systems for residents with dementia are not fully robust and need to be addressed. EVIDENCE: Generally the home was to a satisfactory standard, this was the inspectors first visit to the home and is not presently aware of the homes maintenance programme because the manager was on annual leave. Four requirements were made under this outcome as a result of this visit. One resident did not have an appropriate bed and it needs replacing, the home needs to demonstrate that everyone has been offered all of the furniture recorded under National Minimum Standard 24. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 18 Bathing ratios are not as required, presently there is only one assisted bathroom for 15 residents. National Minimum Standard 21.3 states that there is a ratio of 1 assisted bath to 8 residents. The homes lounge windows by the conservatory are not restricted and there is a substantial drop to ground level, this home is registered to support people with dementia, windows of this nature are therefore unsatisfactory. The home has a ‘homemade’ lockable gate at the top of the stairs, which is considered by the Commission to be inappropriate. The home must liaise with the fire officer to confirm if it is acceptable, the registered manager must then comply the fire officers advise. At the previous inspection the Commission requested the following two areas to be addressed, these still require attention. The registered person shall ensure that the cupboard door in the downstairs bathroom is kept locked at all times. The registered person shall ensure that the extractor fan in the downstairs toilet is repaired and maintained in good working order. The home meets infection control standards, the Commission was advised that the home has a policy and procedure, uses soap dispensers, paper towels, protective clothing and has a weekly clinical waste collection. Burleigh House DS0000004922.V296594.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is “poor”. This judgement has been made using available evidence, including a visit to this service. On arrival there were not enough staff on duty to meet the needs of the residents, therefore the home did not ensure the safety of vulnerable adults. All staff were suitably trained to carry out their duties, the homes recruitment practices are generally in line with the National Minimum Standards. EVIDENCE: On arrival at the home there were two staff on duty, the deputy manager Mrs Rowson and one care worker, there were 15 service users in the home at the time of inspection. These two staff were also expected to cook lunch as well as provide personal care, supervise and monitor residents, receive visitors, assist the district nurse and complete administrative tasks. The number of staff on duty at the time of the inspection was not satisfactory to meet the needs of the residents within the home. The rotas and staff confirmed that this was not an isolated incident. The registered person must ensure that the home has appropriate numbers of staff to meet the needs of residents at all times. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 20 The home was revisited by the Commission to discuss this shortfall with the registered manager on her return from holiday. It was ascertained that the manager had ensured full and appropriate staffing levels were in place before her departure, and the lack of staffing occurred as a result of staff sickness. It was agreed by the manager that this situation had not been dealt with appropriately in her absence and totally unacceptable. Appropriate steps are being taken to ensure that it does not happen again. Presently 3 care staff have obtained a level 3 NVQ in care and a further 3 staff are in the process of undertaking the award. Two staff have obtained a level 2 NVQ and 3 are in the process of completion. Moving and Handling training is up to date (however two staff do require refresher training), the deputy manager is the approved manual handling trainer and her certificate is current. Fire training for a number of staff is out of date; a requirement to up date this training has been made. Health and Safety training, recognition of abuse training and Basic Food Hygiene are in place. Two staff files were viewed and contained the majority of information required to protect vulnerable adults, all staff were in receipt of a Criminal Record Bureau Enhanced Disclosure, the registered manger was made aware that these must not be destroyed prior to inspection. Staff files must also contain a photograph. Burleigh House DS0000004922.V296594.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 at least once during a 12 month period. 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 evidence verified that good working relationships were in place. Health and safety risk assessments need to be added to and strengthened ensuring that the residents and staff are as safe as is reasonably practicable. EVIDENCE: The manager is nearing completion of the Registered Mangers Award, this is the qualification required (or its equivalent) by the Commission for all managers of a care service. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 22 The manager ensures the residents control their own money except where they choose not to. The records of financial involvement were scrutinised on this occasion. Where the money of an individual was handled, appropriate recording and receipts were kept. All monies checked were as recorded. Fire risk assessments were in need of completion, the manager is also aware that she must complete a written contingency plan in the event of a fire or bomb threat regarding the evacuation and safe placement of residents. The registered manager ensures that all maintenance work, repairs, annual checks (the oxford hoist requires checks 6 monthly and was out of date), mandatory training and testing of equipment are undertaken. All records checked were up to date except fire drills; a requirement to ensure all staff are regularly trained in this area was made during this inspection. Burleigh House DS0000004922.V296594.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X 2 X 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Burleigh House DS0000004922.V296594.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 OP27 Regulation 18(1)(a) Requirement The registered person must ensure that the home has appropriate numbers of staff to meet the needs of service users at all times. Immediate Requirement Care Management assessments must be obtained prior to admission. Individual assessments must also be completed for all new service users, including mobility assessments and any other identified areas of risk. Suitable storage arrangements for medication need to be provided; the registered person must also return excess stock in a timely manner. Service users are to be consulted regarding activities in the home, and provide recreational activities accordingly The registered person must ensure that the nutritional needs of the service users are met and in doing so promote their health and wellbeing. The registered person shall keep DS0000004922.V296594.R01.S.doc Timescale for action 30/08/06 2 OP3 14(1)(a) 12/09/06 3 OP9 13(2) 12/09/06 4 OP12 16(2)(n) 30/09/06 5 OP15 16 (2i, 4) 12 (1a) 06/10/06 6 OP16 17(2) 12/09/06 Page 25 Burleigh House Version 5.2 Schedule 4 (11) 7 8 OP19 OP19 13(4)(a) 13(4)(a) 9 OP19 13(4)(a) 10 OP19 23(2) 11 12 13 14 15 16 OP21 OP22 OP24 OP24 OP26 OP29 23(2)(j) 13(4)(c) 16(2)(c) 17(2) Schedule 4 (10) 37(1)(2) 19(1)(b) a record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint. The windows in the lounge adjacent to the conservatory require restrictors. The registered person shall liaise with the fire officer regarding the appropriateness of the gate at the top of the stairs; it is considered by the Commission upon the fire officers’ approval that this should be removed. The registered person shall ensure that the cupboard door in the downstairs bathroom is kept locked at all times. Previous requirement not met. The registered person shall ensure that the extractor fan in the downstairs toilet is repaired and maintained in good working order. Previous requirement not met. The registered person must ensure that appropriate bathing ratios are maintained. The oxford hoist must be serviced on a 6 monthly basis. The home must provide an appropriate bed at a safe height in room 8. An inventory of residents’ personal furniture must be in place. The home must notify the Commission of all incidents recorded under regulation 37. The registered manager must ensure all gaps on application DS0000004922.V296594.R01.S.doc 30/09/06 30/09/06 12/09/06 12/09/06 13/10/06 30/09/06 12/09/06 30/09/06 12/09/06 06/10/06 Page 26 Burleigh House Version 5.2 17 OP30 18 OP37 19 OP38 forms are explored around the applicant’s employment history; photographs of all staff must also be on their file. 18(1)(c) The registered person must 23(4) ensure staff are provided with (d)(e) training appropriate to the work they are to perform, in this instance fire training, drills and evacuation procedures. 26 The registered person shall ensure that a responsible person shall carry out the unannounced monthly visits and complete an appropriate record of such visits to comply with regulation. Previous requirement not met. 24(4)(c)(ii The responsible individual must i) complete a written fire risk assessment and a contingency plan in the event of a fire or bomb threat regarding safe placement of service users. Schedule2 (1)(6) 06/10/06 30/09/06 01/11/06 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 OP7 OP10 Good Practice Recommendations The manager should ensure that all staff are aware of the procedure to follow when completing fluid charts and provide “ownership” to the outcome, necessary action etc. The manager should consider providing a blind to the conservatory door to ensure privacy and dignity is upheld when the District Nurse sees service users in this area rather than in their bedroom. The manager should consider obtaining a copy of Staffordshire’s Vulnerable Adults Policy The manager should consider the use of alginate bags for soiled linen The manager should consider using individual baskets in DS0000004922.V296594.R01.S.doc Version 5.2 Page 27 3 4 5 OP18 OP26 OP26 Burleigh House 6 7 8 OP27 OP30 OP31 9 OP31 the laundry to help avoid misplacement. The manager should provide staff with name badges to assist service users and their visitors. The manager should consider implementing a training matrix The registered person should become familiar with the changes in legislation from both the Commission for Social Care Inspection and Fire Regulations as of 30/07/06 and 01/09/06, and October 2006 respectively. The manager should ensure all staff are aware of the processes to follow when liaising with other professionals, all staff should be confident in this procedure. Burleigh House DS0000004922.V296594.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office 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 DS0000004922.V296594.R01.S.doc Version 5.2 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. 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