CARE HOMES FOR OLDER PEOPLE
Burroughs, The Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector
Robert Bond Key Unannounced Inspection 18th April 2007 10:00 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 Burroughs, The DS0000027126.V335191.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. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Burroughs, The Address Mill Road West Drayton Middlesex UB7 7EQ 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) 01895 435 610 01895 435611 manager.burroughs@careuk.com Care UK Community Partnerships Limited Care Home 75 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (39) of places Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th December 2006 Brief Description of the Service: The Burroughs is a care home for 75 older people situated in a pleasant residential area, not very far from West Drayton High Street and associated shops, facilities and public transport. The home was originally built and operated by the London Borough of Hillingdon but is now operated by Care UK Community Partnerships Ltd. The London Borough of Hillingdon remain the sole purchaser of all the places, hence referrals have to be via the Council. The home is divided into six residential units, three of which are for ‘elderly frail’ and three are for people with dementia. The latter are on the ground floor. There are 67 single bedrooms and 4 double rooms. The home was extended in 2001 and all of the bedrooms in the new extension have an en-suite toilet. There is a large enclosed garden to the rear of the building and a large car park to the front. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was a ‘key inspection’ that considered the performance of the home against the anticipated outcomes of the key National Minimum Standards (NMS) for care homes for older people, as published by the Department of Health. The Manager Designate completed and returned a questionnaire in advance of the inspection. During the inspection, the Inspector toured the home, interviewed the Manager Designate, met other staff members, talked to service users and relatives, and examined a range of documents. Several of the service users are members of ethnic minorities, and the Inspector made a point of making sure that their needs were being met, which they generally were. In total, the Inspector assessed 24 of the NMS, and found that the anticipated outcomes of 10 were fully met, whereas 14 outcomes were only partly met. This led the Inspector to make 19 requirements, 4 of which are restated from the last inspection having not been achieved within the time scale set. The Inspector also made 3 recommendations. Since the previous CSCI inspection, the CSCI registration of the home has been changed at the request of The London Borough of Hillingdon who purchase all the places, and Care UK Community Partnerships who operate the home. The number of registered places for people with dementia has increased from 10 to 36. This change is in line with perceived need, and has been subject to consultation by Care UK with existing service users and their relatives. The process of change is still underway, and on the day of the inspection, the home had 13 vacancies, awaiting additional referrals from the London Borough of Hillingdon. Eight of these vacancies are within the four double bedrooms, which are difficult to let. Enhanced staffing levels have been agreed by Care UK, and will be applied when the home is reaching its full occupancy level once more. There are currently 327 weekly care hour vacancies. Hence a high dependency is currently placed on the use of temporary agency staff, but a recruitment drive has recently taken place, and 11 new permanent staff are going through the reference checking process. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection?
The registration of the home has changed so that the number of places for people with dementia has increased from 10 to 36. Refrigerators within the units of the home have been replaced. Damaged bedroom furniture has been removed. The reporting of maintenance faults by staff has been improved. The hot water supply to Linnett unit has been improved. Additional redecoration of bedrooms has taken place. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 7 Security of the building has been improved by the installation of additional key-pad lockable doors in relation to increasing the number of units providing dementia care. The computerised care planning system is now fully operational, and reviews are almost up to date. The range of activities provided has been increased. A recruitment drive has taken place and additional permanent staff members are soon to start work. Formal staff supervision is taking place more frequently. The premises have been fully risk assessed. The contents of First Aid boxes are regularly audited. What they could do better:
Although the registration of the care home changed in February 2007, various administrative processes need to take place to advertise the change. The revised CSCI registration certificate must be displayed in the home’s entrance, the home’s Statement of purpose must be amended, and the home’s Service Users’ Guide must also be updated. It is recommended that when a member of staff from the home undertakes an assessment of a prospective service user, the summary part of the form is completed as well as the main part. This should aid the decision making process concerning which aspects of the assessment information should become part of the initial care plan. The home must find a way to take photographs of service users, with their permission, so that a copy can be kept on the care plan and on the medication file. This will assist in the correct identification of service users when medication is being given out, and will assist the Police if ever a service user is reported missing from the care home. An audit must be undertaken of all the falls risk assessments. These assessments must then be regularly reviewed and updated. Whenever significant changes in service users’ weights are found, action must be taken immediately to double check the finding, and to take the appropriate action concerning nutritional and fluid intake. Activities suitable for people with dementia must be available every day of the week.
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 8 The home’s table place-mats should be replaced in order to make the home’s dining areas more attractive for the benefit of service users. The home’s complaints procedure leaflet must make reference to the role of the CSCI. All complaints must be recorded in a way so that the CSCI can inspect the complaint, the investigation, and the outcome. The damaged and worn kitchen units must be replaced together with obsolete cookers and air-conditioning units. The source of all malodours must be ascertained and appropriate action taken. Additional care staff members must be enabled to undertake NVQ awards in care so that the 50 target for staff who have qualifications is exceeded. The home’s record of staff training undertaken must be kept up to date. The home must maintain a training plan for the year ahead. It is recommended that staff appraisals and individual training needs analyses are undertaken. The home must be managed by a person who has been registered by the CSCI as being a fit person to manage the home. It is recommended that the Manager Designate establishes a system of auditing to show how often each member of the permanent care staff team are receiving their formal supervision. The hot water system to the Linnett unit must be improved further by fitting the correct type of mixer valves. The maintenance man must be trained in implementing the self-audit system for hot water temperature monitoring. Insurance certificates and service reports on hoists and elevators must be closely examined upon their receipt, and action must be taken to correct any faults identified. 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. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives do not have the full and correct information to make an informed choice about where to live. The contract issued to each service user is very clearly written and contains the essential information. Adequate assessments are undertaken before new service users move into the home. The home does not offer Intermediate Care. EVIDENCE: The change in the registration status of the home is not yet reflected in the documents displayed or available to service users and their relatives. The new Registration Certificate was not displayed in the foyer. The displayed Statement of Purpose did not refer to the change of registration or contain
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 11 details of the revised staffing levels. The displayed Service User’s Guide did not provide the correct registration details. The Inspector examined a sample terms and conditions contract, which he found to be clearly written and containing the required information. An examination of the papers for two recent admissions to the home showed that the London Borough of Hillingdon had undertaken thorough and comprehensive assessments in advance. The home had also undertaken its own assessments but in one case the assessment summary had not been completed. This summary is useful for determining the aspects of the assessment that should be included in the care plan. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8. 9, and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are well set out in individual plans of care, but risk assessments for falls are not up to date. Service users’ health care needs are generally well met, but appropriate action must be taken where severe weight loss is identified. The service users are well protected by the home’s medication procedures. Service users are treated with respect and their privacy is well maintained. EVIDENCE: The Inspector case-tracked four service users, which involved a close examination of their care plans, review notes, and daily notes. The service users were selected according to their variety of assessed needs. Two were recent admissions, one was a respite care user, one was bed-bound, two had dementia, and one was a member of an ethnic minority. Where possible, the Inspector met with those service users to confirm that they were satisfied with their care. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 13 All four care files contained printed versions of the relevant computerised care plan. The care plans were fully complete, up to date on the computer, had been reviewed by the home on a monthly basis, and had been agreed by the service user or their relative where possible. Personal care needs, and how to meet them, were documented. However, only two out of the four files contained a photograph of the service user. The Manager Designate said this was because the local pharmacy was no longer able to process Polaroid photographs. Social interests and needs were also documented. The Inspector found that the long term placement of one service user had been formally reviewed by the London Borough of Hillingdon one year after the service user had moved in, but had not been reviewed during the two years since then. The Manager Designate reported that all service users except two use the same General Practitioner who visits the home at least weekly. The GP’s practice nurse also visits weekly. District nurses visit twice daily, and give insulin injections. The Regulation 26 report dated March 2007 refers to District Nurses having praised staff for the care that they provided the service user who had had a pressure sore that is now healed. A community psychiatric nurse visits as necessary to give depot injections. A speech therapist visits as required. The Inspector noted that nutritional and fluid charts are completed for the first two weeks after admission for all new service users, and thereafter as necessary. Service users weight is recorded monthly. The Inspector noted that for one service user a weight loss over the month of 4.7 kg was observed and recorded, but no further action had apparently been taken. When this was pointed out to him, the Manager Designate took immediate action and had the service user reweighed in case an error had been made (he found that only 2 kg weight had been lost) and he arranged for the service user’s fluid and nutritional intake to be monitored. The March 2007 Regulation 26 report contains details of risk assessments of falling by service users that have not been completed or that have not been reviewed. In the light of this, a full audit of all such risk assessments is required. The Inspector examined the medication storage and records kept on the ground floor of the home. No errors or omissions were discovered. In terms of privacy and dignity, the Inspector observed care being provided in a caring and sensitive manner, noted that bedroom doors were generally kept closed, that staff knocked on bedroom doors before entering, and that care plans identified how each service user liked to be addressed. Service users were seen to be appropriately dressed. Those service users the Inspector Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 14 spoke to confirmed that they were well looked after at The Burroughs. None of the double rooms are currently in use. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 15 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. A wide range of social activities is provided during the week, but greater emphasis must be placed on the need for stimulation of people in the dementia care units at weekends. Good links with relatives and the local community are actively promoted. Service users views are sufficiently taken into account. The meals are nutritious, attractively served and include ethnic options. EVIDENCE: The assessments and care plans examined contained details of service user’s interests and social care needs. The care plans also documented the wishes of service users concerning time to be woken, and time to go to bed. This is evidence of a flexible regime within the care home. Service users confirmed this to the Inspector. The home employs two activity co-ordinators, who operate a weekday activity programme according to a 5 week schedule. Activities include eating out, manicures, bingo, sing-a-longs, coffee mornings, film shows, hairdresser, tap dancing display, church service, arts and crafts, exercise, and reminiscence. Some of the above activities are specifically designed for use in the dementia care units. When asked about weekend activities, the Manager Designate
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 16 replied that boxes of games are available, and that the care staff are encouraged to engage in Activity Based Care (ABC). With the home increasingly focussing on dementia care, it is essential that sufficient emphasis is placed on appropriate activities for people with dementia, seven days a week. The Manager Designate reported that two members of staff are now qualified to drive the community bus (Hillingdon Community Transport) and hence outings for pub lunches, to the local school to see a play and to a nearby garden centre now take place. A trip to the coast is planned. The Inspector met two relatives visiting the home, and noted the number of visitors signing the visitors’ book. The Manager Designate reported that he had started holding monthly coffee mornings to which relatives were invited, and that this proved to be a good opportunity for him to consult informally with them. He also makes a point of touring the whole of the home morning and evening to ask service users and staff how they are. The Inspector examined the four week menu cycle, observed a lunch being served, and confirmed with service users that they liked the food. They said they did. During case-tracking, the Inspector noted that at least one service user was Muslim and that Halal meat dishes were indicated. The Inspector confirmed that the service user in question had a lunch that suited his needs, and that the service user was enjoying his meal. The dining rooms are pleasant places to eat, the meals were seen to be well presented and served, but the ambiance could be improved further by renewing the place mats. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Complaints are investigated and responded to but the system for recording the complaints is not sufficient. Service users are satisfactorily protected from abuse. EVIDENCE: The Inspector noted that the complaints leaflets on the wall of the care home, and in the Service Users’ Guide, do not refer to the CSCI at all. The Manager Designate investigated and found that Care UK nationally were aware of this omission. The Manager Designate reported that one complaint had been received since the previous CSCI inspection, and the complaint had been received and responded to by email. The Inspector pointed out that the Regulations required that details of the complaint, the investigation, and the outcome, all have to be recorded in a way that can be inspected. Regulation 37 reports received by the CSCI from the care home demonstrate that since the previous CSCI inspection, two allegations of abuse by staff members have been made (one was an agency member of staff), and are being investigated. Both instances have been referred by the Manager Designate to the London Borough of Hillingdon’s Safeguarding Adults Unit, and the members of staff are suspended pending appropriate investigations. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 18 Staff within the home are being trained in the Protection of Vulnerable Adults by Care UK. Training dates so far this year are 22nd January and 6th February. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is satisfactorily safe, but where additional redecoration and refurbishment are required. Most parts of the home are sufficiently clean and tidy but malodours linger in several parts of the home. EVIDENCE: The Inspector toured the premises in the company of the Manager Designate. The Inspector noted that some redecoration had taken place but noted that more was required. The Manager Designate provided details of obsolete cookers and obsolete air conditioning units that were to be removed from kitchen/diners. The Inspector also noted that a bathroom was out of action pending the installation of a new bath. The Inspector noted a malodorous small of urine in three places throughout the care home. Linnett and Palm units are particularly affected. The Regulation 26 report for March 2007 identifies the same problem. Efforts must be made to
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 20 identify the source of the smells, and appropriate action then taken to alleviate them and stop them reoccurring. Otherwise, the home as a whole is clean and tidy. The kitchen and food store were seen to be especially clean and tidy, which is commended. Furnishings were seen to be adequate, other than the tablemats, which must be replaced. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff numbers are deployed but the use of temporary staff is too high, and less than half of the permanent care staff have an NVQ in care award. Service users are well protected by the home’s recruitment policies and practices. New staff members are properly inducted but training records and plans are insufficiently developed. EVIDENCE: The Inspector was provided with a staffing rota for the home. This and the Inspector’s observation suggested that sufficient staff were working in the home. However the home has currently 19 vacant places for service users as the changeover from 10 to 36 dementia care places takes place. The Manager Designate reported that the staffing ratios will be increased when the number of service users with dementia has increased. At this time, 7 instead of 5 care staff will be on duty downstairs, and 7 instead of 6 night care staff will be on duty throughout the home. The Manager Designate reported that the home has 13 care staff vacancies (327 day and night care hours per week). Interviews have taken place and 11 new staff have been appointed subject to references and CRB checks. In the meantime a high reliance continues to be placed upon temporary agency staff, who are bussed to West Drayton from Barking.
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 22 The Manager reported that 42 of the current care staff have NVQ’s level 2 or 3 in care. The Department of Health target is 50 or more. The Inspector examined the recruitment file of the one new permanent employee to commence work since the previous CSCI inspection. All the references and were in place, and all appropriate checks had been undertaken. The high standard of the administrative recruitment records is commended. The Inspector noted that a full induction programme had been undertaken. The Inspector examined the home’s training records and found they were not up to date. He asked to see the home’s training plan for the year ahead and was shown a list of dates and courses. It is recommended that staff appraisals are undertaken on each member of staff and that individual training needs analyses are completed. These analyses should then be compiled together so that the training needs for the care home as a whole can be identified and planned for in a way that is manageable and affordable. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is satisfactorily managed but not by a manager who has been CSCI registered. Satisfactory consultation with service users and relatives takes place. Service user’s financial interests are safeguarded well. Records do not adequately demonstrate whether staff members are receiving formal supervision frequently enough. The health and safety of service users are not yet sufficiently promoted and protected. EVIDENCE: The Manager Designate has made good progress in implementing improvements throughout the home at a time of great change. Although now appointed as the Home Manager by Care UK, he has not yet sought to be the
Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 24 CSCI’s Registered Manager for The Burroughs. The Manager Designate confirmed to the Inspector that he intends to seek registration and that he is currently undertaking the NVQ level 4 in care award, and will then do the Registered Managers Award. The Inspector noted evidence of relatives being consulted by questionnaire, and service users being consulted in individual meetings (about the changes in registration then being considered). The Manager Designate undertakes his own audits, and a ‘Mentor Home Manager’ undertakes monthly Regulation 26 visits to the care home. The Inspector examined the records of money held for a service user, selected at random. The records were well kept and demonstrated that the money had been spent appropriately. The Inspector requested to see staff supervision records to ascertain that all care staff were receiving formal supervision at least six times per year. The records kept were found to be insufficient to demonstrate this. Hence the requirement made at the previous CSCI inspection, has been restated. The Inspector examined a sample of fridge and freezer and water temperature records and confirmed the findings in practice. No errors or omissions were found. As regards the previously found lack of hot water in the Linnett unit of the home, the Manager Designate reported that a new pump had been fitted but that mixer valves on individual taps were of the incorrect kind, and had not yet been replaced. Hence the requirement made at the previous CSCI inspection is restated. The Manager Designate also reported that although a self-auditing system for hot water temperatures has been provided to the home, the system is not yet in operation as the maintenance man has not been trained in using the system. Hence the requirement made at the previous CSCI inspection is restated. The Inspector checked the maintenance certificates for the various hoists in use at The Burroughs, which were all in order, and for the two elevators. One of the elevator insurance certificates however identified faults with the mechanism and it was unclear whether remedial action had been taken. The Manager Designate subsequently investigated and found that the certificate had been filed without any action having been taken. An elevator maintenance contractor has now been called in to deal with the faults, which the Manager Designate reports are not serious enough to warrant ceasing use of the elevator. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 25 The Inspector noted that a full and thorough risk assessment of the property has now been undertaken. Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 26 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 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 2 Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 27 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 4 Requirement The home’s statement of purpose must be updated to be in line with the home’s changed registration conditions and the agreed revised staffing levels. The home’s Service Users’ Guide must be updated to be in line with the home’s changed registration conditions. The home must keep on file a recent photograph of all service users. Falls risk assessments must be audited and then regularly reviewed and updated. Whenever significant changes in service users’ weights are found, action must be taken immediately to double check the finding, and to take the appropriate action concerning nutritional and fluid intake. Activities suitable for people with dementia must be available every day of the week. The home’s table place mats must be replaced. The home’s complaints procedure leaflet must make
DS0000027126.V335191.R01.S.doc Timescale for action 01/06/07 2. OP1 5 01/06/07 3. 4. 5. OP7 OP7 OP8 17(1)(a)S ch3(2) 14(2) 12(1)(a) 01/06/07 01/07/07 01/05/07 6. 7. 8. OP12 OP15 OP16 16(2)n) 16(2)(g) 22(7) 01/07/07 01/06/07 01/06/07 Burroughs, The Version 5.2 Page 28 9. OP16 22 10. OP19 23(2) 11. 12. OP26 OP28 23(2)(d) 18(1)© 13. 14. 15. OP30 OP30 OP31 18(1)© 18(1)© 8&9 16. OP36 18(2) 17. OP38 21(1) 18. OP38 23(2)(j) 19 OP38 23(2)© reference to the role of the CSCI. All complaints must be recorded in a way so that the CSCI can inspect the complaint, the investigation, and the outcome. Damaged and worn kitchen units must be replaced. This is restated as the timescale of 01/05/07 has not been met. The source of the malodours must be identified and remedial action taken. Additional numbers of care staff must be enabled to undertake the NVQ in care awards so that at least 50 of the care staff become qualified. The home’s records of training undertaken must be updated regularly. The home must maintain an overall training plan for the year ahead. The care home provider must put forward the name of their manager for registration as a fit person to manage the home. All care staff must receive formal supervision at least six times a year. This is restated as the timescale of 01/02/07 has not been met. An improved internal audit system is required in order to detect faults with the hot water supply. This is restated as the timescale of 01/01/07 has not been met. The hot water supply to Linnett unit must be made good as soon as possible. This is restated as the requirement has not been fully met within the timescale of 18/12/06. Insurance certificates and service reports on hoists and elevators must be closely
DS0000027126.V335191.R01.S.doc 01/06/07 01/10/07 01/06/07 01/05/08 01/06/07 01/08/07 01/07/07 01/06/07 01/06/07 01/06/07 01/06/07 Burroughs, The Version 5.2 Page 29 examined upon receipt and action taken on any faults identified. 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 OP3 Good Practice Recommendations The summary part of the home’s own assessment of prospective service user’s should be completed as well as the full assessment, as the summary is useful when determining which aspects of the assessment should become part of the initial care plan. The home should implement staff appraisals that include developing training needs analyses for all staff members. The Manager Designate should develop an auditing system so that he is aware exactly how often each member of the permanent care staff team is receiving formal supervision. 2 3 OP36 OP36 Burroughs, The DS0000027126.V335191.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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
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