Inspection on 02/10/07 for Burroughs, The

This inspection was carried out on 2nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burroughs, The 18/04/07

Burroughs, The 07/12/06

Burroughs, The 28/04/06

Burroughs, The 25/11/05

Burroughs, The 26/04/05

Burroughs, The 08/11/04

Burroughs, The 14/06/04

Burroughs, The 28/07/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Burroughs, The Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector Robert Bond Key Unannounced Inspection 10:00 2nd October 2007 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.V342969.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.V342969.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 Ltd 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.V342969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 18th April 2007 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.V342969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This 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. During the inspection, the Inspector toured the home, interviewed the Manager Designate, met other staff members, talked to residents and relatives, and examined a range of documents. No issues concerning equalities and diversity came to light during the inspection. The home is able to provide ethnic meals and is able to meet the needs of residents with physical disabilities. In total the Inspector assessed 26 of the NMS and found that the anticipated outcomes of 2 were exceeded, 14 were fully met, whereas 10 outcomes were only partially met. This led the Inspector to make 15 requirements, 5 of which are restated from the last inspection having not been achieved within the time scale set. The Inspector also made 2 recommendations. On the day of the inspection, the home had 10 vacancies, mostly within the elderly frail section of the home. However the dementia care section of the home is not exclusively occupied by residents with a diagnosis of dementia. This is because the number of places for people with dementia was increased earlier this year, but the demand for places has not been as high as expected, and some existing residents in the dementia care units who do not have dementia have declined to move into other parts of the home. As the number of residents with dementia is not as high as anticipated, the care staffing levels have not yet been fully increased. The home still relies quite heavily on relief agency staff travelling from East London. On the day of the inspection, the Manager Designate reported that 8 day care and 5 night care whole time equivalent staff posts were vacant and proving difficult to fill. The Manager Designate has not yet fully completed his application to the CSCI to become the Registered Manager of the home despite being the Manager for almost a year. He has however made substantial efforts to improve the performance of the home, but there is still some way to go. The ground floor interior of the home was in the process of being redecorated at the time of the inspection. Some communal carpets were seen to be very dirty but the Manager Designate reported that funding had been received to replace soiled carpets with wooden laminate flooring. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: As there is an expectation that residents and relatives will be able to see and have a copy of the current care plan, an up to date hard copy must always be kept on file. The medication part of each resident’s care plans must be reviewed and updated whenever there is a change in medication prescribed. Individual care plans must show how the resident’s assessed and identified specific health needs are to be met. Consideration should be given to the preparation of individual health action plans so that proactive preventative measures can be put in place that enhance good health for each resident. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 7 Whenever a resident suffers a fall, an accident report must be completed, and a risk assessment undertaken or updated concerning the possibility of further falling and how to avoid them occurring. Old and worn tablemats must be disposed of. Soiled carpets in lounges and corridors must be removed as they are unsightly and smelly. Where obsolete cooking equipment has been removed from kitchenettes, making good must be completed. Redecoration is required for many communal areas on the ground floor. Toilets must be easily accessible to residents who are physically frail, and electro-magnets or door-guards must be fitted so that corridor doors may be kept open where appropriate. All ventilation units in toilets and bathrooms must be checked to see if they are in full working order. Additional numbers of care staff must be enabled to obtain the NVQ in care awards so that at least 50 of the care staff become qualified. All care staff must receive formal supervision at least six times a year. It is recommended that all staff receive an annual appraisal. Staff must be retrained to take action when a refrigerator is found to be operating at too high a temperature, and the management of the home must have systems in place for auditing that this is being done. The hot water supply to the wash-hand basins in toilets within the Linnett unit of the home must be improved. An improved internal audit system is required in order to detect faults with the hot water supply. 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.V342969.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 Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good quality written information to assist prospective residents and their relatives make an informed choice about where to live. No resident moves into the care home without having his/her needs fully assessed in advance. The home does not provide immediate care. EVIDENCE: The Inspector examined the home’s revised Statement of Purpose and Service Users’ Guide and found that the required changes had been made. The Inspector selected two residents’ files at random, one being a respite care resident, and examined in detail the assessment information that had been obtained before they moved in to The Burroughs. In both cases sufficient information had been provided in advance by care managers, and had been confirmed by the home’s own assessment processes. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ personal and social care needs are satisfactorily set out in individual plans of care, but the hard copy available for residents and relatives is not always up to date. In order to help ensure that residents’ identified and assessed health needs are fully met, care plans should contain a health section. The care plans do contain a list of medication prescribed but this is not always up to date. Residents are not sufficiently protected regarding falls as the home’s procedures concerning accident reporting and risk assessment are not always followed. Residents are adequately protected by the home’s policies and procedures for dealing with medicines. Residents feel that they are treated with respect and that their privacy is sufficiently maintained. EVIDENCE: The Inspector examined two care plans selected at random. The home has a computerised care planning system known as Saturn but hard copies are generally printed out also. The care plans had been based on the residents’ assessments, and all appropriate aspects had been covered including social care and cultural needs. How to meet personal care goals was described in sufficient detail in the ‘hygiene’ part of the care plan. Unfortunately the hard Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 11 copy on file was not up to date as it did not show evidence of having been reviewed for several months. The computer version of the hygiene part of the care plan did however show that it had been reviewed monthly. A requirement is made concerning hard copies. The Inspector examined the records for a resident who had experienced substantial weight loss. An improved regime for regular weighing of residents had identified the issue, and the GP had prescribed a food supplement that had had a beneficial effect. The Inspector found that some daily records from the period were on the computer whilst others were hand written. The Manager Designate explained that until recently agency members of staff did not have access to the computer records, hence two systems of recording existed side by side, which was not satisfactory. Following a period in hospital, the medication prescription for the resident concerned had been changed, and whereas the medication administration record (MAR sheet) was correct, the medication list in the care plan was no longer correct as it had not been updated. The Manager Designate agreed that the care plan should have been updated to show the change at the time the resident returned from hospital. A requirement is made. The Inspector noted that the two care plans examined did not have a section on health needs. This was confirmed by the Manager Designate. As health needs are one of the key elements of the service user plan described in the Care Home Regulations, a requirement and a recommendation are made. Elsewhere in this report under the ‘Complaints Section’ are details of a fall that a resident suffered that was not properly recorded as an accident, and which did not lead to a risk assessment being undertaken. A requirement is made. The Inspector checked a sample of the medication storage arrangements, MAR sheets entries, and the record of medication returned to the pharmacist. Two of the medication returned sheets had not been dated. The Inspector noted that residents were treated with dignity and respect by the staff. Bedroom doors were kept closed and staff knocked on doors before entering. The Inspector spoke to approximately 10 residents, all of whom expressed great satisfaction with the home and the staff. A relative confirmed this view. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 12 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. An improved range of activities is provided throughout the week. Good links with relatives and the local community are actively promoted. Residents’ views are ascertained and sufficiently taken into account. The meals are nutritious and include ethnic options but old unattractive place mats are still being used. EVIDENCE: The Inspector examined the activity timetables prepared for the two client groups in the home on a four weekly rotating basis. The home employs two activity co-ordinators on weekdays. The Manager Designate said that care staff are encouraged to lead activities, particularly at weekends. The home makes use of a community bus. The Inspector saw residents being taken out in it. It was noted that good use is also made of the services of a physiotherapist, who the Inspector met. The Manager Designate reported recent trips to Guildford Cathedral, the London Eye, and Windsor, with in-house activities taking place such as a Barbe-que with an Hawaiian theme. Coffee mornings to which relatives are invited are now being held bi-monthly. The Inspector met several relatives in the home. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 13 The Manager Designate tours the home each day and makes a point of talking to all the residents in order to see how they are, and to obtain their views. The Inspector spoke to many residents on his tour and all said how pleased they were with the activities and with the meals. The Inspector observed that fresh fruit was on offer and he watched lunch being served. It was cottage pie, with salad as the optional choice. However despite new table mats being obtained as a result of a requirement the Inspector made at the previous inspection, the Inspector noted that in two dining areas old worn tablemats were still in use. The previous requirement is therefore restated. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that their complaints are listened to, taken seriously and are acted upon. Residents are also adequately protected from abuse. EVIDENCE: The Inspector noted that one formal complaint had been recorded by the home since the previous CSCI inspection, an investigation had taken place and a Director of Care UK Community Partnerships Ltd. was in the process of providing a response to the complainant. The complaint concerned a resident who had experienced a fall during a respite care stay in The Burroughs. The Inspector found that the complaint had been taken seriously, had been properly recorded and investigated and was being responded to. Residents who the Inspector spoke with had no concerns about any aspect of the home. The Inspector noted training records that evidenced that most of the staff team had been trained in the Protection of Vulnerable Adults. The Manager Designate demonstrated the system now in use for much in-house training which is a laptop software programme known as EL BOX, an interactive learning programme that trains and then assesses knowledge by asking multiple choice questions. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 15 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, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe but is not sufficiently well maintained. Some bathrooms and toilets are not adequately ventilated and access to one communal toilet is difficult. The ground floor communal areas of the home are not currently sufficiently clean, pleasant and hygienic. EVIDENCE: The Inspector toured the building in the company of the Manager Designate. He noted that in the Linnett unit, there was still a problem with the hot water supply to wash-hand basins in two toilets. There is also still a problem with malodours, which the Manager Designate puts down to soiled carpets in the corridors and lounges. The Manager Designate reports that these are due to be replaced soon by wooden laminate flooring. However in the meantime it appeared that shampooing of the carpets has ceased although the Manager Designate reports it has not. The previous requirement about tracing the source of the malodour and replacing carpets is restated as the timescale set has not been met. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 16 Obsolete cookers have been removed from the kitchenettes but the making good of the areas where the cookers were has not been completed yet. The wall units have had new fronts fitted but two were observed to be already damaged. Substantial redecoration of the communal areas on the ground floor is required. The Inspector noted that one of the communal toilets on the ground floor is accessed from within a vestibule that has a door that is heavy to open as it is a fire door. In order to make it easier for residents to access this toilet, the fire door should be held open by a door-guard or electro-magnet connected to the fire alarm system. The Inspector noted that three baths were not in full working order, although a new Arjo Malibu bath had been installed, and four extractor fans in toilets and bathrooms appeared not to be switched on. The latter had an adverse effect on room temperatures and the removal of malodours. The kitchen and stores were seen to be very clean, but much of the ground floor communal areas were not because of soiled carpets and dirty walls. However redecoration of corridors was taking place during the CSCI inspection. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff numbers are deployed but the use of temporary agency staff remains too high, and less than half the permanent care staff have an NVQ in care award. Residents, however, are well protected by the home’s recruitment policies and practices. Training records have been improved. EVIDENCE: The Inspector examined a current staffing rota. Currently 10 care staff are rostered to be on duty each morning and each afternoon, with 6 staff on the ground floor, and 4 staff on the first floor. The Manager Designate said these staffing levels would be increased to 7 and 5 respectively when the home is completely full, and the number of residents with dementia reaches the registration limit of 36. Currently the home has 10 resident vacancies and only 19 residents with dementia. At night 6 care staff are on duty. The Manager Designate reported that currently the home has 8 whole time equivalent day care staff vacancies and 5 whole time equivalent night care staff vacancies. This is a slight improvement on the situation at the previous CSCI inspection but is still high. There remains a dependency on temporary agency staff who are bussed in from the Barking area of East London. The Manager Designate confirmed that permanent recruitment is ongoing but that it is difficult to recruit staff of the right calibre. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 18 The Manager Designate reported that 37.8 of the care staff have an NVQ level 2 or higher in care. The target is a minimum of 50 . The Inspector examined a recruitment file for a recently recruited care worker and found that all appropriate checks had been undertaken. The standard of the recruitment files in terms of content and filing, is commended. The Inspector also examined training records, which now included a list of future training needs for each member of staff. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 19 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, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a care home that is run overall in a satisfactory manner. Residents are adequately consulted, and their financial interests are well safeguarded but staff members are not being formally supervised at the required frequency. There are shortfalls in some record keeping and health and safet aspects which could affect residents’ wellbeing. EVIDENCE: The Manager Designate reported that he has been advised not to complete the NVQ level 4 he was undertaking but to undertake instead the Registered Managers Award. He has applied to the CSCI to become the Registered Manager of the home. Improvements at The Burroughs under his management are still underway and progress is taking time but the number of requirements has reduced from 19 at the last CSCI inspection to 15 as a result of this inspection. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 20 No satisfaction survey of residents and relatives has been undertaken since before the previous CSCI inspection but the Manager Designate reported plans to undertake a survey during November 2007. He consults informally on an almost daily basis. The Inspector examined the records kept concerning residents’ monies held by the home. The records are very well kept, with a clear plastic zipped folder for each resident’s cash, records and receipts for money spent. The system is commended. The Manager Designate now keeps a supervision matrix that demonstrates who has received their formal supervision and when. It demonstrated that the required frequency has not yet been achieved, hence the requirement is restated. Appraisals are not being done on all staff members either. As reported elsewhere in this report, a resident had a fall that was not recorded as an accident, and which did not lead to a falls risk assessment being undertaken. Other examples of records not being maintained to a satisfactory standard are to be found in the health and personal care section and in the health and safety section of this report. In terms of health and safety, the Inspector noted that the home’s hot water supply had been tested for organisms and disinfected in April 2007. The excessively long time it takes for hot water for washing to arrive at the hand wash basins in two toilets in the Linnett unit however remains a serious concern as also does the admission by the Manager Designate that the handyman has not yet received training in how to successfully check for faults in the hot water temperature system. The Inspector expected a more urgent response to these requirements made at the previous CSCI inspection. The requirements are therefore restated. A similar health and safety failure concerns the reoccurrence of faults in the refrigerator temperature monitoring system. The Inspector found two refrigerators in residents’ kitchenettes that were operating at too high a temperature and had been doing so for many weeks despite those excess temperatures being written down on a daily basis. Some staff members are still not taking action when the temperature is seen to be consistently above 8 degrees Centigrade. Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 21 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x x x 2 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 2 2 2 Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(2)(a) Requirement As there is an expectation that residents and relatives will be able to have a copy of the current care plan, an up to date hard copy must always be kept on file. The medication part of each resident’s care plans must be reviewed and updated whenever there is a change in medication prescribed. Individual care plans must show how the resident’s health needs are to be met. Whenever a resident suffers a fall, a risk assessment must be undertaken or updated concerning the possibility of further falls and how to avoid them occurring. The home’s table place mats must be replaced. This is restated as the requirement has not been fully met within the timescale of 01/06/07. The communal areas on the ground floor must be adequately decorated. Toilets must be easily accessible DS0000027126.V342969.R01.S.doc Timescale for action 01/12/07 2 OP8 15(2)(b) 01/11/07 3 4 OP8 OP8 15(1) 14(2) 01/02/08 01/11/07 5 OP15 16(2)(g) 01/11/07 6 7 OP19 OP21 23(2)(d) 23(2)(n) 01/03/08 01/02/08 Page 23 Burroughs, The Version 5.2 8 OP26 23(2)(d) 9 OP26 23(2)(p) 10 OP28 18(1)(e) 11 OP36 18(2) 12 OP37 17, Sch3(3o) 21(1) 13 OP38 14 OP38 23(2)(j) 15 OP38 13(4)© to residents who are physically frail, and electro-magnets or door-guards must be fitted so that corridor doors may be kept open where appropriate. The source of the malodours must be identified and remedial action taken (by replacing soiled carpets). This is restated as the requirement has not been fully met within the timescale of 01/06/07. All ventilation units in toilets and bathrooms must be checked to see if they are in full working order. Additional numbers of care staff must be enabled to obtain the NVQ in care awards so that at least 50 of the care staff become qualified. 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. Complete and accurate records must be kept at all times, including records of accidents and falls by residents. An improved internal audit system is required in order to detect faults with the hot water supply. This is restated as the timescale of 01/06/07 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. Staff must be retrained to take action when a refrigerator is found to be operating at too high a temperature, and the management of the home must have systems in place for DS0000027126.V342969.R01.S.doc 01/01/08 01/12/07 01/05/08 01/02/08 01/11/07 01/12/07 01/12/07 01/12/07 Burroughs, The Version 5.2 Page 24 auditing that this is being done. 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 Consideration should be given to the preparation of individual health action plans so that proactive preventative measures can be put in place that enhance good health for each resident. The home should implement a staff appraisal system for all members of staff. 2 OP36 Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 25 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 © 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 Burroughs, The DS0000027126.V342969.R01.S.doc Version 5.2 Page 26 - 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!