Inspection on 07/12/06 for Burroughs, The

This inspection was carried out on 7th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/10/07

Burroughs, The 18/04/07

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 7th December 2006 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.V319784.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.V319784.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 (10), Old age, not falling within any registration, with number other category (65) of places Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include 10 DE and 65 OP Date of last inspection 28th April 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, five of which are for ‘elderly frail’ and one is for 10 people with dementia. The latter is 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.V319784.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection that took place on 7th December 2006 was a ‘key inspection’ that considered mainly those of The National Minimum Standards (NMS) created by the Department of Health for Care Homes for Older People that the Commission for Social Care Inspection (CSCI) consider to be the key ones. The previous key inspection took place on the 28th April 2006. However in between the two key inspections, additional ‘random’ inspections took place on 18th July and 19th September 2006. Thus when considering which requirements remain unmet on the date of this key inspection, it is those 15 requirements made in September that are being referred to. The inspection reports for additional random inspections are not published on the CSCI website, as are those for key inspections, but they can be made available on request to members of the public or other enquirers. In advance of this key inspection, the Inspector sent questionnaires to the home for completion by service users (residents), their relatives and by professional workers who visit the home. Completed questionnaires were received from 7 unnamed service users, one relative, and the home’s General Practitioner. The responses were generally positive, and those that were not were brought to the attention of the Manager Designate, the Registered Manager having transferred to work in a different Care UK home. As part of the inspection process, the Inspector toured the home, interviewed the Manager Designate, spoke to other staff, and examined a variety of records and files. An extra element of the key inspection was a ‘thematic probe’ to investigate the extent to which service users had been supplied with the home’s Service Users’ Guide, the home’s complaints procedure, and a statement of the terms and conditions of their stay within the care home. This information will be collated nationally for all care homes for older people inspected within a two week period, and will then be forwarded by the CSCI to the Government’s Office of Fair Trading. This aspect of the inspection required the Inspector to interview three service users. Several of the service users are members of ethnic minorities. Issues of equality and diversity are appropriately considered when assessments are undertaken and care plans compiled. On the day of the Inspection, an interpreter was being used to assist the visiting GP in undertaking a medical assessment of needs of a new service user. In total, the Inspector assessed 24 of the NMS, and found that the anticipated outcomes of 19 were fully met, whereas 4 outcomes were only partly met, and 1 outcome was not met. This led to the Inspector making 10 requirements, 1 Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 6 of which is restated from previous inspections as it has not been fully achieved within the timescale set. 1 recommendation was also made. On the day of this inspection, The Burroughs had 18 vacant places, 17 being in the residential units, and only one in the dementia care unit. Two additional random inspections were undertaken by the CSCI during the period since the last key inspection in order to monitor progress and make requirements concerning necessary improvements. Care UK Community Partnerships Ltd. has acted swiftly and decisively in an effect to bring the home back up to the required standard. On the basis of this inspection report, it is clear that some progress has been made but there is still a way to go. What the service does well: What has improved since the last inspection? The previous CSCI key inspection report is displayed in the entrance hall. A thorough assessment is now undertaken on prospective service users and the individual plan of care (care plan) is based on that assessment. Record keeping for service users receiving respite care has been improved. Care plans now include how to meet nutritional and social care needs. Most care plans are now reviewed as necessary. More activities are provided, particularly for those service users in the dementia care unit. Some new crockery has been purchased. Fridge operating temperatures are now accurately recorded daily, staff having been trained in how to do it. Old confidential care records are now kept under lock and key. Portable hoists are no longer generally stored in bathrooms. Additional storage areas have been created for hoists. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 7 A garden shed has been purchased for storage purposes. A new bath has been delivered and is awaiting installation. Improved internal auditing systems have been created in order to detect and correct inadequacies in assessments, care plans and review frequency. A partial risk assessment of the care home has been undertaken. Fire doors are no longer wedged open. Some areas of the home have been redecorated. The agency that provides temporary members of staff to work in the home supplies evidence that all the staff have had appropriate recruitment checks undertaken. What they could do better: Some refrigerators within the kitchenettes are operating at too low a temperature because the doors to their internal ice-boxes are broken, and hence the doors must be replaced, or the whole refrigerator must be replaced. Those kitchenettes units that are damaged or worn must be replaced. Damaged bedroom furniture must be replaced. Action must be taken to alleviate the smell of urine noted particularly in one part of the home. Staff must be trained to report for action any maintenance issue they see, particularly if there are health and safety issues associated. An improved quality control system is required in regard to water temperature monitoring. The hot water supply to the Linnett unit must be made good as soon as possible. All the care staff must receive formal supervision at least six times a year. The contents of first aid boxes must be audited regularly. The risk assessment of the premises must be completed. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 8 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.V319784.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.V319784.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 and 3. Standard 6 was not assessed as the home does not offer intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are adequately provided with all the information they need. Existing service users are satisfactorily provided with statements of terms and conditions. Prospective service users are properly assessed in advance of them moving in. EVIDENCE: The Inspector selected three existing service users for ‘case-tracking’. The Inspector examined the relevant care files and found that all had been appropriately assessed before moving in to The Burroughs. One of the service users had previously been in another nearby care home and had transferred to The Burroughs when that other home had closed for refurbishment. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 11 The Inspector interviewed the three service users, who all confirmed that they had been involved in the decision that they should move into The Burroughs. They confirmed that they had received all the necessary information at the time, and since. They confirmed that they had a copy of the Service Users Guide, which includes the home’s complaints procedure, and a copy of the home’s terms and conditions (contract). Burroughs, The DS0000027126.V319784.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 good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are all adequately set out in individual care plans. Service users’ health needs are well met. Service users are well protected by the home’s policies and procedures for dealing with medication. Service users are treated well in terms of respect and privacy. EVIDENCE: The Inspector examined the care plans for the three long-term service users whose care was case-tracked, and for the most recent service user who had received a respite care service. All had appropriate computerised care plans in place as hard copies on their files. The Manager Designate demonstrated on the computer screen that reviews of the care plans were up to date. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 13 The Manager Designate reported that one service user had kept their own GP, but all others used the one practice. The GP visits the home weekly, as does his practice nurse. The Manager Designate was pleased with the service received from the GP, and positive feedback was received by the Inspector in the questionnaire response from the GP. District nurses visit daily to undertake insulin injections, and treat any pressure sores. A community psychiatric nurse visits as necessary, as do dentist, optician and chiropodist. A physiotherapist attends three times a week. The Inspector noted that health visits and appointments are recorded in the multi-disciplinary section of the care plans. The Inspector examined the medication storage and record keeping in Sweetcroft unit. He found that the medication records included a photograph of each service user, brief medical summaries from the GP, and a photocopy of each service user’s most recent prescription. These practices are commended. No errors or omissions were noted. The Inspector noted that service users privacy was enhanced by having all bedroom doors closed, with staff observed to knock on the doors. Every door displayed the name of the service user, and sometimes the doors were personalised with additional welcome signs. The Inspector noted at first hand that service users were treated with respect by the staff he observed at work. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 14 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. Service users find the lifestyle in the home satisfactorily matches their expectations regarding social, cultural, religious and recreational needs. Service users are able to maintain contact with family and friends and local community to an adequate extent. Service users are helped to exercise choice and control over their lives to an appropriate extent. Service users receive a good balanced diet in pleasant surroundings and at appropriate times. EVIDENCE: The Inspector spoke to about 10 service users who all said they were happy living in the home, and had no complaints. The written feedback received was also mainly positive. The Inspector examined the home’s activity programmes, and found that the range of activities had been extended, and did include specialised activities for service users receiving care in the dementia unit. The home employs two full Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 15 time activity co-ordinators. Regular outings to Bell Farm take place for lunch. The home does not have its own vehicle but some staff are being trained to be able to drive the ‘community bus’ (Hillingdon Community Transport). The Manager Designate added that a Halloween party attended also by relatives had recently been held, a Catholic priest visits weekly, and a Church of England service is held on the premises every third week. Cub scouts are due to visit to sing Christmas carols. A Christmas party is planned for 14th December. Relatives are invited. The Inspector also noted the extent of relative visiting from the visitors’ book entries. The Manager Designate reported that he intends to convene a Residents’ Meeting shortly. The Inspector examined and approved a sample menu, and enjoyed a lunch with the service users who also appreciated it. The meal was pleasingly served, and in a garden room which made it extra enjoyable. Burroughs, The DS0000027126.V319784.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users adequately know how to complain and to whom. Service users are protected from abuse to a satisfactory extent. EVIDENCE: The three service users interviewed reported that they knew who to complain to if they needed to. Questionnaire responses said the same thing. None of the service users the Inspector spoke to had any complaints to make. The Inspector noted that the home’s complaints leaflet contained details of the most recent CSCI address. The Manager Designate reported that no complaints had been recorded since before the previous CSCI inspection. The Manager Designate reported in the pre-inspection questionnaire (PIQ) that 45 staff members had been trained in the Protection of Vulnerable Adults procedures. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in premises that are not sufficiently safe, and not sufficiently well maintained. Service users live in premises that are mostly clean, pleasant and hygienic, but with a small area smelling of urine. EVIDENCE: The Inspector toured the premises, mostly with the Manager Designate. A number of maintenance issues were identified. The Inspector found that there was no hot water issuing from the tap feeding the wash-hand basin in the staff toilet, nor in the adjacent service users’ toilet. This was subsequently traced to a fault in the valve below that particular was basin and in the hot water pressure covering the Linnett unit as a whole. As Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 18 there are quality monitoring and health and safety implications arising here, requirements will be made in those sections of this inspection report. Several of the refrigerators in the kitchenettes of units throughout the home were found to be operating without doors on their internal ice-boxes. This is causing the fridges to operate at temperatures that are too low (as identified when the Inspector checked the fridge temperature records) and which cause icing up of the fridge and some of its contents (as identified in the Regulation 26 report prepared by the Care UK Clinical Governance Manager on 27th October 2006). See Requirement 1. In the Palm Unit, the Inspector noted that a damaged cupboard door in a kitchen unit had been screwed shut. The unit as a whole was worn and should be scheduled for replacement. Requirement 2. The Inspector visited an empty bedroom known as the ‘emergency room’ as it exists to accommodate any one referred to the home in an emergency. Despite being one of the registered bedrooms, the furnishings were extremely poor in that the chair, the cabinet, and the dressing table were very shabby, and the carpet was stained. Other occupied bedrooms the Inspector visited at the request of their occupants were however properly furnished. The Manager Designate needs to undertake an audit of all the bedrooms, including the vacant ones, so that all the registered rooms can be brought up to the required standard. Requirement 3. In the Palm Unit the Inspector spotted a ceiling-mounted air-conditioning unit, the cover of which looked as if it was about to fall off. A dining table was positioned under it and the Inspector instructed staff to move the table until such time as the fitment could be made safe. The Inspector noted a strong smell of urine on entering the foyer of the Palm Unit. Requirement 4. Other maintenance issues noted were a loose plastic apron dispenser in a bathroom that could have fallen on the head of anyone sitting below it, an open inspection cover in a bathroom wall, and a sluice room unlocked because the bolt on the door was difficult to operate. The home’s handyman is commended for his swift action in assisting to correct the above issues, but he was not aware, as no one had reported them. Requirement 5. Some areas of the home have been decorated, but more redecoration is necessary. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are adequately met by the numbers and skill mix of staff. Service users are in adequately safe hands. Service users are well protected by the home’s recruitment policy and practices. Staff are satisfactorily trained and competent. EVIDENCE: The Manager Designate reported that the home was carrying 108 day care and 180 night care vacant hours weekly, and that the use of Polish staff had not worked out as well as hoped due to their limited knowledge of the English language. A high reliance is being placed on temporary agency staff, who are bussed to West Drayton from Barking in East London. However interviews are said to be taking place to recruit new permanent staff, so no requirement is being made concerning recruitment at this time. Because of the reduction in service user numbers, the Manager Designate reported that morning and afternoon shift numbers have been reduced by one, Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 20 so that 9 care staff are on duty in the mornings and 8 in the afternoons. Sample rotas were supplied to the Inspector. The Inspector examined two recent staff recruitment files and found that all appropriate checks had been undertaken. The Manager Designate described a three day induction programme for new staff to the Inspector, and said a computerised induction programme called LBox was being introduced by Care UK Community Partnerships Ltd.. The Manager Designate reported that 31.4 of the care staff had obtained NVQ level 2, and a further 10 members of staff had commenced the qualification. The home has a training plan for the year ahead that the Administrator has prepared and which will be faxed to the Inspector. The Manager Designate recognised the need for all the care staff to receive dementia care training in the future. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 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. The home is run adequately in the best interests of service users but good quality control systems are not yet fully operational. Service users’ financial interests are well safeguarded. Staff members are not appropriately supervised. The health, safety and welfare of service users and staff are not yet adequately promoted and protected. EVIDENCE: Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 22 The Manager Designate has only recently returned to The Burroughs and is there possibly only for a temporary period. In a short time he has achieved a lot in terms of improving the standard of assessments and the care plans that are produced from them. He understands the computerised care plan system and has put substantial effort into auditing the care plans in place. Further management input is required on staff and service user meetings, staff supervision, and health and safety issues. The Manager Designate is currently undertaking an NVQ level 4 in care. In terms of quality control, improvements have been made by management in recent times concerning assessments of new service users, and in care plans and reviews, as reported above. Monitoring of fridge temperatures is now much improved as well. An aspect of monitoring not yet improved concerns hot water temperatures. As noted in the Premises section, the Inspector uncovered the fact that one washhand basin had no hot water being supplied to it, and the adjacent part of the care home had a limited supply. No one had reported the faults, and it is unclear for many days this situation has continued. The importance of the issue is that one cannot maintain standards of hygiene and infection control without having hot water to wash in after using the toilet. The Inspector checked the hot water temperature records that are measured monthly by the handyman. He was no doubt following instructions by only measuring hot water temperatures for baths and showers, thus wash-hand basin water temperatures were never checked it seems. This is another example where staff must be trained to report maintenance issues, and management must implement quality control measures that are more in depth. Requirements 5, 7 and 8. See also Recommendation 1. The Manager checked at random the records and cash held for a service user chosen at random. The records were very clear and found to be accurate. Service users’ money was observed to be spent appropriately on ‘luxury’ items only, of their choice. The Manager Designate shared with the Inspector the fact that formal staff supervision had ceased to happen in the home, and hence staff appraisals were not happening either. He had plans to establish a staff supervision system that involved team leaders supervising the care workers under their control. Requirement 6. The Inspector checked at random the contents of a first aid box. The box did not contain a list of its contents, and the Manager Designate reported that the home did not have in place a system for routinely checking the contents of first aid boxes, and refilling them. Requirement 9 Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 23 The Inspector asked to see the home’s risk assessment of the premises, but it had not yet been completed. See Requirement 10, which is restated from the previous 3 inspection reports. Several of the issues mentioned here, and requirements made under the Premises section (above), have health and safety implications. Burroughs, The DS0000027126.V319784.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 3 3 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 1 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 2 Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23(2)© Requirement All refrigerators must have doors fitted to their internal ice-boxes in order that they operate at the correct temperature, or be replaced. Damaged and worn kitchen units must be replaced. All registered bedrooms must contain good quality furnishings. Efforts must be made to alleviate the smell of urine noted when entering the Palm Unit. Staff must be trained to observe and report maintenance items more effectively as many such items have health and safety implications. All care staff must receive formal supervision at least six times a year An improved internal audit system is required in order to detect faults with the hot water supply. The hot water supply to Linnett unit must be made good as soon as possible First aid boxes must have a contents list that is audited DS0000027126.V319784.R01.S.doc Timescale for action 01/01/07 2. 3. 4. 5. OP19 OP19 OP26 OP19 23(2)© 16(2)© 23(2)(d) 23(2)(b) 01/05/07 01/03/07 01/01/07 01/01/07 6. 7. OP36 OP33 18(2) 21(1) 01/02/07 01/01/07 8. 9. OP38 OP38 23(2)(j) 13(4) 18/12/06 01/02/07 Burroughs, The Version 5.2 Page 26 10. OP38 13(4) regularly. A risk assessment of all parts of the home must be undertaken. THIS REQUIREMENT IS RESTATED FROM THE PREVIOUS THREE INSPECTIONS AS THE WORK HAS NOT BEEN COMPLETED WITHIN THE TIMESCALE SET. 01/03/07 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 OP33 Good Practice Recommendations It is recommended that water temperature monitoring includes periodic checks of all hot water supply points. Burroughs, The DS0000027126.V319784.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area 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.V319784.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. 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