Inspection on 14/08/07 for Burnworthy House

This inspection was carried out on 14th August 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 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

Burnworthy House 16/08/06

Burnworthy House 25/01/06

Burnworthy House 04/10/05

Burnworthy House 07/01/05

Burnworthy House 26/05/04

Burnworthy House 27/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Burnworthy House South Street South Petherton Somerset TA13 5AD Lead Inspector Barbara Ludlow Unannounced Inspection 09:45 14 August 2007 th 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 Burnworthy House DS0000016077.V346830.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. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnworthy House Address South Street South Petherton Somerset TA13 5AD 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) 01460 240116 01460 241729 claire.smith@somersetcare.co.uk Somerset Care Limited Mrs Claire Smith Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/08/06 Brief Description of the Service: Burnworthy House is operated by Somerset Care Limited, a not for profit organisation. The home provides care and support for up to 37 older people. It is situated in South Petherton, with good proximity to the shops and other amenities in this large, south Somerset village. The home comprises of 31 single bedrooms, (14 of these having en-suite facilities) and 3 double bedrooms (also with en-suite facilities). Double rooms are used as doubles exclusively for married couples or close relatives who choose to share. There are 5 communal rooms and service users also have access to the gardens at the rear of the property. Day to day management of the home is under the direction of the manager and her deputy, who was appointed in January 2006. Both have many years experience working in the care sector. The home has a number of locally based volunteers who visit the home on a regular basis. The home is fully engaged with the local community and service users are encouraged and supported to maintain links with families and friends. Fees range from £373.00 to £460.00 per week. The fee varies according to the accommodation; en-suite rooms are the higher rate. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. This inspection visit was carried out over an eight hour period. The inspection was held open to allow the feedback of comments from service users, staff, relatives and visiting health care professionals. Their comments are included in the report. The manager and the deputy were on duty and gave their time to assist with the inspection process. The Annual Quality Assurance Assessment (AQAA) had been sent to CSCI before the inspection, this was completed by the Manager and her deputy. There were 30 residents out of a maximum of 35 places used. The home is registered for 37. The home has day care, which is not regulated. These service users were seen and spoken with, they seemed very satisfied with the day service they receive. They knew the day care worker by name and were very complimentary about the care given to them. A tour of the premises was made during the day. Daily life at the home was observed and mealtimes, both dinner and teatime. Relatives, residents, staff and visiting professionals were spoken with during the day. Feedback was given to the manager at the conclusion of the site visit. The inspector would like to thank all who contributed to the inspection process. What the service does well: The home has a welcoming and inviting entrance hall with photographs and posters displayed to interest the visitors and all the residents at the home. The feedback from residents and families and professionals was very positive and very complimentary about all aspects of the care and service given at the home. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 6 Families expressed their thanks for the support and level of care given at Burnworthy comment included, a’ ‘wonderful place’, ‘a special place with a happy atmosphere’ and ‘a happy and friendly environment’. The food received praise and comments were made about there being ‘choice’, and ‘plenty to eat and drink’. What has improved since the last inspection? What they could do better: The annex where the building work is in progress and where two residents have their rooms was very grubby. There was dirt on the carpets and a very sticky handrail on the stairs. There had been one error in the recruitment process Capillary blood sugar monitoring by care staff should be sharp safe in line with the guidance issued by the Medical Devices Agency (MHRA) to protect staff from the risk of needle stick injury. Care plans and risk assessments had small pieces of information missing, these should all be complete documents. One had no photograph or identification, one had an inaccurate falls risk assessment another an incomplete record of medical treatment recorded. These deficits were drawn to the attention of the manager at the time of the inspection. Please contact the provider for advice of actions taken in response to this Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 7 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. Burnworthy House DS0000016077.V346830.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 Burnworthy House DS0000016077.V346830.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): 3 Quality in this outcome area is good Admissions are made to the home on the strength of a needs assessment and the information gathered from health and social care professionals. Visits to the home are welcomed. A colour brochure with photographs is available; there is a statement of purpose and a service user guide to help the prospective resident make an informed choice of a care home place at Burnworthy. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home is used by people from the local area. One person said she chose to come here because it was ‘the closest’. Residents had visited the home or their families had come on their behalf to look around. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 10 The home has a statement of purpose and service user guide. There is a full colour brochure; one person said they received a brochure prior to coming to live at the home. Four care plans were sampled. In each case a pre admission assessment had been made by the manager or the deputy. This assessment is made to ensure that the prospective residents needs can be met at the home. The contract clearly sets out the detail of the terms and conditions of occupancy to enable the resident and their family to know what to expect from the service. The costs of care are clearly written on the contract. Burnworthy House DS0000016077.V346830.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): 7,8,9,10 Quality in this outcome area is good The care delivered at the home is person centred. Feedback was very complimentary about the care, and staffing. Medications were well managed. Comments such as ‘staff kindness’ ‘excellent care’, staff are attentive’, and call bells are answered promptly support this judgement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users had a care plan. These were sampled and four were examined in detail. One did not have a photograph and one did not have a life history. All had personal family contact details recorded. Care plans contained information and screening for ill health conditions such as diabetes. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 12 Risk assessments were in place for falls, one of these assessments was found to be inaccurate. The calculation did not reflect the level of risk a change in health had brought about. More care must be taken with such assessments. Pressure sore risk assessment was assessed and recorded. Residents were weighed and monitored. New scales had been purchased within the last year. Medications management and administration records were examined. Medications were stored appropriately. The room is air condition to keep the temperature below 25 degrees Celsius. All medication entries were double signed which is good practice. Controlled drugs were checked and these were stored and recorded satisfactorily. The returns book was seen and was appropriately used. Staff undertake blood sugar monitoring. One staff asked explained how care staff work sharp safe when taking capillary blood samples for blood glucose testing. Staff are not working in the safest and least risky way, it is there advised that the homes manager refers to the medical Devices Agency ( MHRA) to check what equipment is safer and can be accessed for the resident on prescription. The change to working sharp safe must be made. Burnworthy House DS0000016077.V346830.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): 12,13,14,15 Quality in this outcome area is good The home has a welcoming ambience and a pleasant atmosphere. Visitors are welcomed and residents have access to activities and outings. Care staff are all friendly and helpful. The home has dedicated volunteers this adds value to the daily social life at the home. Mealtimes were well organised and efficiently managed and there was time to enjoy the food and the company. Assistance where needed was given very discreetly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents asked said they were happy at the home. Many said they had plenty to do each day. The home has a day care organiser who took time to explain how she cares for her day care service users. The service users here for a day Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 14 sit and mix with the residents. There are games and 1 – 1 activities for this small group. Residents were pleased with their accommodation and many had nick-knacks and personal items in their rooms making them feel more homely. One person who can access outside from her patio was pleased with her room. Many people commented that the residents are friendly and get along well. The home has a quarterly newsletter called the Burnworthy Bulletin. There is a list of the regular activities available these include organ music, discussion groups, flexercise, bingo, a visiting pet dog and the religious services, which includes one to one communion. Staff asked said that ‘when the weather is nice they take people out for walks’. Other activities mentioned were dominoes, cards and painting. The sing a long was popular and staff commented that residents seem to love the singing and dancing; residents also agreed that this is fun. One person on short stay at the home also said it was fun being there as there was always ‘lots going on’. There is a monthly trip out; the last one was to a garden centre for coffee and a look around. A trip to the donkey sanctuary was planned for the next month. Residents were observed during the inspection day and all seemed to be doing things they had chosen to do. Visitors were present in the morning were seen in the communal rooms and visiting privately with their relatives. Staff were welcoming and helpful towards them. Visitors asked said they were made welcome. One person had written that they were made welcome when their relative was admitted and were pleased to have been invited to stay to lunch then and on other occasions since. Three of the four care plans sampled had life stories that are helpful for staff to get to know the person and their background. Residents were complimentary about life at the home and day care users were pleased to be there. Residents said they could get up and retire when they choose. Three service users said they had made a lot of friends at the home. The inspector met and spoke to one of the homes regular volunteers from the local community who had come in to exchange resident’s library books. There were very friendly exchanges with residents who said they appreciated the help given by the volunteer. One resident commented at the time that ‘nothing could be better’, ‘if you need more help or care you just ask’ ‘it’s more personal here, it’s like a family with friends’. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 15 There were good social and caring relationships between residents and with staff. One day care user said that the organiser made ‘it pleasurable’ to come to day care. Another resident at lunchtime said they ‘love it here, the foods alright and they have no complaints’. The mealtimes were observed. Tables were laid in the two dining rooms, residents and day care service users congregated for lunch at 12.45. The menu at lunchtime was fishcakes, potatoes, peas and tomatoes or lasagne. Sauce was offered separately. Dessert was a rhubarb crumble and custard, rice or exotic fruit salad and cream. The food was quickly presented and served hot. The atmosphere was very friendly and unhurried. Seconds were offered and staff checked around to make sure residents had what they wanted. Drinks were served and it was well managed and a social occasion. Two people had chosen to eat in their rooms and one person was having soup and bread, as they felt unwell. One relative who visits regularly said the food was always nicely presented and when they had had eaten at the home they found the food to be very good. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good The home has a complaints procedure that is accessible and user friendly. The homes management deal sensitively and quickly to address any concerns raised with them. Service users are protected from harm by the attention to recruitment practices. Legal and civil rights are upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear company complaints policy and procedure. The company use a statement called ‘Seeking Your Views’ to enable service users and families to raise concerns or complaints. The service user guide also has the advice on how to raise a complaint with the service and with the Commission for Social Care Inspection and how to contact the head Office. Three complaints have been dealt with in the past twelve months. Two complaints had been made since the last inspection. Both had been investigated appropriately. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 17 Residents and families asked said they would speak to the manager or the deputy if they had any concerns. Residents spoke confidently saying they would speak to staff if there was something making them unhappy. Residents who have been at the home for more than a year were asked if they had been included on the electoral register. This was confirmed with one person recalling having received a postal voting paper. Five staff personnel files were seen, these contained evidence of good recruitment with references, work history, health declaration, proof of identity and the screening applicants by Criminal Record Bureau checks (CRB) and checks against the Protection of Vulnerable Adults list that has names of people who are excluded from care work. Only one reference had been received in writing for two staff, one had left and one was still at the home. This was discussed with the manager and must be remedied for the staff member concerned. See recruitment. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good The home was generally clean and hygienic. The premises are well maintained and safety checks including regular fire safety checks are carried out. The annex where the alterations are being carried out must be kept cleaner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the main premises was made. The home was found to be clean, fresh smelling and suitably adapted to meet the needs of the resident client group. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 19 There are hand wash facilities available for staff around the home. Staff have access to personal protective clothing with gloves, aprons and tabards to wear when serving at meal times. The second assisted bathroom has been tastefully upgraded since the last inspection and provides an attractive assisted bathroom facility for the residents. Communal areas were clean and comfortable. Bedrooms seen had been personalised with photographs and personal effects making the rooms quite homely. A slight malodour was detected in one bedroom; this was brought to the attention of the manager at the time of the visit. Feedback from residents and relatives was received that said handrails could be cleaner. The inspector found one handrail that was sticky and in need of cleaning and this was brought to the attention of the manager at the inspection. This handrail was in the annex where building work is underway to install a lift. An old bathroom had been removed and the work was safely managed, as there are two residents who have chosen to stay in their rooms and who do not wish to move to a quieter and cleaner part of the house during the building work. The carpets were soiled with bits on them and they were stained, these are due to be replaced when the work is completed. This part of the home requires more attention to cleaning in the interim period. One relative commented on the shabby state of some of the bedroom furniture, although clean some look well used and dated. The paths that are used around the outside of the house were looking green with moss growth, they could be slippery and require attention to cleaning or treating the surface. Records were inspected including those for maintenance and fire safety checks. See management section. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good Staff work at the home in sufficient number to deliver a good level of care. Staff recruitment checks are made and the process is generally very thorough. There is a commendably high percentage of staff with an NVQ qualification in care or working towards the award. Staff received praise from relatives and residents for delivering an ‘excellent’ and ‘caring’ service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the inspection day there were sufficient staff on duty. The staff team went about their work cheerfully and all interactions observed between staff and residents and relatives were kindly and respectful. Staff were asked about their training and confirmed having received regular training and updating. Five staff personnel files were examined for recruitment practice and induction training. All staff had proof of identity, CRB checks and POVA First checks in place before commencing work at the home. Two Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 21 references had been taken up for three staff but for the other two staff there was only on e reference on file. One of these staff had left the home; the other reference must be obtained. CRB checks for 15 staff and 5 volunteers were examined. These should be checked and recorded in line with the CRB guidance, which is available on CSCI Professional webpage. Staff are well liked by the service users and relatives. Praise was heard for their kindness and attention. Relatives referred to staff as ‘excellent’, ‘quick to respond’ ‘knowledgeable’ and give ‘skilled and loving care’. Staff receive regular supervision, and appraisals are completed on an annual basis. Staff stated that they enjoyed working at the home, and received appropriate support. Staff have undertaken mandatory training such as Fire Awareness, Moving and Handling, Food Hygiene and Infection control. Care staff are encouraged to undertake NVQ training in Care. Of the 38 staff employed at the home 28 have an NVQ qualification and nine are working towards NVQ Level 2 or above. This is a very good achievement. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 38 Quality in this outcome area is good The Registered Manager is experienced and provides effective leadership to the staff team. There are company quality assurance monitoring systems in place to obtain the views of service users. All records are stored securely. Health and safety management and record keeping is of a good standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 23 The registered manager is very experienced; she has open door policy and knows staff and residents well. The manager was seen to be very in touch with the day to day running as well as all the management of the home. The manager is approachable and residents and relatives were clear that they could speak to her or the deputy manager and would be supported and helped with any concerns they may have. Quality Assurance is undertaken and questionnaires are sent out to families and friends of residents to monitor the quality of the service provision. Records are securely stored. Residents can have small amounts of money held for them, this is recorded and receipts are obtained for purchases, access to the money is appropriately restricted. Staff receive supervision and annual appraisal. These are recorded, records were examined and evidence was seen in the staff files sampled. Meetings are regularly held to support staff in their work. The home is well maintained, records were seen that support the regular checks of fire safety equipment and servicing of the hoists, the lift, mains services and appliances. Records included, Maintenance file and fire records were seen. Fire safety including alarm and detector servicing, fire extinguishers, emergency lighting and smoke detectors. Lift servicing: 17.01.07 Hoist and wheelchair servicing by Somerset County enterprises. Fire training, one member of staff needs updating all others have had recent fire training Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 23(2)(d) Requirement The home must be kept clean in the areas where building work is being carried out. The paths around the home must be kept clear of moss growth, which could make them slippery. 2. OP29 19(1)(b) (i) Schedule 2 18(1)(c) (i) One outstanding staff reference must be obtained in writing to complete the recruitment process. Staff who have not attended fire safety training within the last year must be updated. 08/10/07 Timescale for action 08/10/07 3. OP38 08/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations Staff must work sharp safe in line with the guidance from the medical devices Agency (MHRA) DS0000016077.V346830.R01.S.doc Version 5.2 Page 26 Burnworthy House 2 OP8 Care should be taken to accurately score and record falls risk assessments. Burnworthy House DS0000016077.V346830.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Burnworthy House DS0000016077.V346830.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!