Inspection on 23/08/06 for Burrow House

This inspection was carried out on 23rd August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burrow House 02/09/05

Burrow House 12/08/04

Burrow House 05/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Burrow House Burrow House Highfield Road Ilfracombe North Devon EX34 9JP Lead Inspector Andy Towse Key Unannounced Inspection 23rd August 2006 1.15pm 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 Burrow House DS0000033415.V295832.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. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burrow House Address Burrow House Highfield Road Ilfracombe North Devon EX34 9JP 01271 863685 01271 866035 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) Devon County Council Mrs Stella Margaret Scoins Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: Burrow House is a detached, purpose built residential care home. It is situated on three floors with all areas being accessible to residents through the use of stairs or passenger lift The home has several lounge and dining areas, affording a variety of recreational areas for residents. It also offers accommodation to people requiring respite care and a day centre on the premises allows residents, on occasion, to participate in activities alongside day care service users. The home itself is well maintained. The fee charged for accommodation is £556.74 with additional fees levied for items such as newspapers, magazines, hairdressing and chiropody. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over two days and a period of thirteen hours. The registered manager was off sick at the time of the inspection and during her absence, the manager of the day centre was overseeing the running of the residential home in a ‘care taking’ capacity until the return of the registered manager. The information in this report came from responses to surveys which were forwarded prior to the inspection, to residents, staff and professionals involved with the home. During the inspection further information was obtained from discussion with residents, the management of the home, staff and visiting professionals together with observation, including a tour of the premises and examination of records including residents’ files and individual plans. What the service does well: What has improved since the last inspection? There has been an upgrading to the sluice facility on the second floor. The menu is being upgraded to show more choice. The home is putting into operation a supervision system which will ensure that all staff receive appropriate supervision. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 7 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 Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted when their needs have been appropriately assessed. The admissions process allows residents to make an informed choice about moving into the home. The home does not offer intermediate care. EVIDENCE: In discussion with the manager and with different residents it was apparent that many current residents at Burrow House had previously been in receipt of respite care or day care at the home. This means that as well as the prospective residents having some knowledge of the home to guide their decision about whether to move there, staff were also aware of the needs of these prospective new residents. One resident, being impressed by the home Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 9 whilst visiting a relative there decided to move into the home. Another spoke about having received day care at the home leading to her making a decision to move in despite having to find alternative accommodation for five weeks before a vacancy arose. As part of the admissions process assessments are carried out which detail the needs of prospective residents and using this information the management of the home decides whether these can be met by the home. The three files examined all contained shared assessments which had been compiled by experienced and qualified professionals such as Occupational Therapists, care managers and nurses and therefore supplied the home with the information required to assess whether they could meet the needs of prospective residents. Other records showed that a resident who had recently been admitted to hospital from the home was scheduled to be reassessed by one of the home’s assistant managers to ensure that his/her needs could still be met by the home. Files also showed that in addition to the shared assessment, an assistant manager had also carried out her own assessment, making use of information contained in the shared assessment for another prospective resident. The home offers interim care, but not intermediate care. Burrow House DS0000033415.V295832.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care needs are set out in an individual plan. Residents’ health is maintained by regular access to health care professionals. In order to protect residents’ health medication should only be used until the use by date stated by the manufacturer. Residents’ right to privacy and dignity is respected and upheld. EVIDENCE: The files of three residents were inspected. All these files were found to contain individual plans. Where residents had capacity they were seen to have signed their individual plans. The plans were subdivided into various sections with headings such as Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 11 medical conditions, communication, eating and drinking, oral hygiene, personal cleaning, mobilising, mental state and skin breakdown. The safety and wellbeing of residents is enhanced by all files listing any allergies residents were known to have. The compilation and maintenance of care of care plans is the responsibility of designated key workers supported by their line managers. All files were seen to contain separate sheets that showed that care plans were updated or reviewed monthly. Medical advice was seen to be incorporated into care plans. Examples of this being frequent contact with an optician for a resident with diabetes and the use of a district nurse when skin breakdown was anticipated on another resident. Files were seen to contain risk assessments. These were reviewed with additional ones being added when the needs of residents were noted to have changed. An example of this was the introduction of a risk assessment following a resident experiencing hallucinatory problems. The home has a written medication policy. In 2005 the home had a separate inspection from the CSCI Pharmacist which resulted in several requirements being imposed. During this inspection the system of recording administered medication was inspected, as was the storage and administration of medication. A staff member dispensing medication was seen to discuss this with a resident explaining what the medication was for. Records showed that residents did exercise their right to refuse medication. Records are kept of any change in the dosage or cessation of medication prescribed together with details of who authorised this. There are separate facilities for medication which requires being kept at a low temperature and records showed that this refrigerator’s temperature was checked daily. The staff member administering medication had received appropriate training. The home has a secure place for storing medication. This comprises a locked room with medications contained either in locked cabinets or trolleys, which for safety had been secured to the wall. Controlled medication was seen to be administered appropriately and there was a record of medicines received by the home. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 12 There was said to be a record of medication returned to the pharmacy and at the time of the inspection, this record book along with returned medication was at the pharmacy. From this inspection it was seen that generally medication was dispensed appropriately. However although there is a record on boxes regarding the start date of medication, an example, which may have been atypical, was found of an eye drop being used after its shelf life had expired. This was an issue raised by the pharmacist in his report and which must be addressed to safeguard residents. With regard to privacy and dignity, residents’ files were seen to contain details of their preferred terms of address. It was observed that in practice staff did refer to residents using the names recorded on their files. Residents were seen to receive their own ordered newspapers and to wear clothes of their own choice. Staff were seen to respect residents’ privacy by knocking on bedroom doors before entering. Visiting healthcare professionals confirmed that residents were treated with respect and dignity. The right to privacy is enhanced by all residents being accommodated in single occupancy bedrooms. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents would benefit from a wider range of activities. Visitors are made welcome. Residents have a varied diet which reflects their preferences. EVIDENCE: Leisure activities were a contentious issue. In the response to the 14 questionnaires received from residents prior to the inspection, four said that the home never provided activities that they could take part in, whilst a further five said that the home sometimes provided activities which they could participate in, compared with three who said the home always provided activities they could join in with. The home did have previously a designated activities officer however since her departure the post has not been filled. Observation showed that there were few activities being undertaken by staff with residents. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 14 The home does keep a list of activities available, which includes visits by the Chaplain, nail care, quizzes, sing-a-long and individual files did make reference to activities, however, these were sometimes as vague as referring to a person walking from the lounge to the bathroom. In discussion staff were aware that residents were not receiving the stimulation through activities that would improve their lives. In discussion there was evidence that there were attempts to address this with various trips out, a barbecue to take place on the forthcoming bank holiday, a trip to watch a local procession and key workers accompanying various residents on trips to Ilfracombe to do shopping. A resident spoken to confirmed that she had seen her daughter on the day of the inspection and that her daughter had taken her out. In discussion she said that her daughter visited regularly, could come to the home at any time and was made welcome by the staff. Other visitors were seen at the home during the inspection. One resident who was not well on the day of the visit had an unexpected visitor and staff were seen to ask the resident discretely if he/she wanted or felt well enough to entertain a visitor. This demonstrates that staff are pro active in ensuring that residents are able to choose whom they see or do not see and that restrictions are only imposed on visits when this is requested by residents. Observation of bedrooms confirmed that residents could bring with them items of furniture, pictures and objects of sentimental value to make their transition into residential care easier. Burrow House used to offer meals on wheels it has since stopped providing this service and the kitchen now caters exclusively for those either in receipt of residential care or attending the day centre at Burrow House. Of the 15 responses received from residents to the questionnaire submitted before the inspection, five said that they always liked the meals, eight that they usually liked the meals and two that they sometimes did. Residents spoken to during the inspection said that they liked the meals and one said that the meals at the home had improved. There was a discussion with the cook who said that different menus had been tried including curry and pasta type meals. She said that she had attended residents’ meetings when she had been involved in discussions with residents about what food should be available. Inspection of the minutes of Quality Group Meetings held in June and April 2006 at which 12 and 9 residents attended respectively showed that the menu had been a major agenda item and that suggestions made by residents had been put into operation. An example of this was the choice of four meals and sweets at dinner time. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 15 The kitchen looked clean and tidy. The cook said that fresh vegetables were used. She was also able to show a form prepared by care staff showing that they had consulted with residents, the day previously, about what they wanted to eat the following day. Burrow House DS0000033415.V295832.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their concerns and complaints will be listened to. Staff having training regarding abuse protects residents. EVIDENCE: Burrow House had on display in the entrance foyer a copy of the corporate complaints procedure common to all residential care homes run by Devon Social services and in addition a copy of the procedure specific to Burrow house. This is in a shorter form and gives clear detail of who to approach should a resident wish to make a complaint and includes their right to contact the CSCI directly at any time during the process. In response to the pre inspection survey sent to residents, 7 said that they knew how to make a complaint and only one said that he/she was unaware of how to make a complaint. When residents were spoken to they all demonstrated that they would be confident in approaching either the manager or their carers if they wanted to complain. Staff spoken to were aware of what constituted abuse and of the existence of the home’s Whistle-Blowing Policy which ensures that any staff, resident or relative of a resident who makes known concerns regarding abuse or poor practice will not suffer discrimination by the home for disclosing these. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 17 Records show that all but the very recently appointed staff members had received training relating to the protection of vulnerable adults. Records showed that those staff who had not received this training were scheduled to do so. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained. The home has comfortable internal and external areas. The home meets the needs of those who are accommodated there. The home has an acceptable standard of hygiene and cleanliness. EVIDENCE: Burrow House is well maintained. It has external areas which are level and provide seating for residents. These are easily accessible to residents and despite the changeable weather on the day of the inspection, some residents were seen sat outside or walking around outside. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 19 The grounds are kept tidy. The building meets the requirements of the local fire service and appropriate checking of emergency lighting and fire alarm system ensures the ongoing safety of residents regarding the danger of fire. The home has several lounge areas on different floors affording residents different places to congregate and also to engage, if required, in different activities. The home offers its occupants a variety of different baths and toilets were seen to be situated close to lounge areas. Bathrooms and toilets were seen to have the necessary adaptations to make them accessible to residents who had limited mobility or physical restrictions. Call systems were seen to be easily accessible to residents and throughout the inspection residents were seen to use these. Residents can access all areas by use of either wide stairs or by a passenger lift. All residents are in single occupancy bedrooms. The home was seen to have a good standard of hygiene and cleanliness throughout. As well as wash hand basins in bathrooms and toilets, alcohol disinfectant dispensers had been installed around the home to assist staff in maintaining a safe environment. The laundry was seen to be situated in an area which meant that soiled laundry did not have to be brought through areas where food is either prepared or eaten. The laundry itself was clean, had impermeable floor covering and easily cleanable walls. Residents also appreciated the clean environment with 12 of the 15 respondents to the pre inspection survey reporting that the home was always ‘fresh and clean’ and the remaining three saying that it was usually so. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the numbers of staff is sufficient to meet the needs of residents, the use of agency staff detracts from a continuity of care. The home operates an adequate induction programme. Residents are protected by the home’s robust recruitment policy. EVIDENCE: Since the last inspection there has been a considerable change over of staff. This was noted in several responses by residents to the pre-inspection survey and from some staff and also professionals who visit the home. The home has ensured that there are adequate numbers of staff by employing agency staff. The management of the home recognises that continuity of care is important and tends to use one agency and wherever possible the same staff to gain some level of continuity. The home has tried to resolve the situation by recruiting new staff, however, as not all the newly recruited staff stayed at the home, there still remains a situation of vacant shifts which are currently being filled by the use of agency staff. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 21 The home is currently advertising for new staff in order to resolve the situation. This reliance on agency staff combined by a high staff turnover can adversely affect the running of key worker system and continuity of care. The cleanliness of the home would demonstrate that domestic staff are employed in sufficient numbers. Whilst care staff do undertake some domestic duties, in discussion those spoken to said that this did not detract from the quality of care they were able to offer to their residents. From observation this would appear to be true as staff were at all times seen to be able to respond to residents’ requests for assistance within acceptable time scales. The home offers its staff NVQ training and also mandatory training such as Moving and Handling, Vulnerable Adults Training, Basic Food Hygiene. Some staff have received specialist training which probably related to their then residents, however, of late such training does not seem to have been available. Staff records showed that all staff were in receipt of two references and a police check before they were allowed to work unsupervised with residents. This protects residents. All new staff participate in an induction process which ensures that they have the basic knowledge required to offer undertake their roles as carers. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The annual Quality Audit allows for the views of residents to be incorporated into the running of the home. The system of financial recording protects residents Staff are appropriately supervised. Better communication could be promoted by more regular staff meetings. The health and safety of residents is protected and promoted. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager was not available at the time of the inspection as she was off work due to sickness. She has the appropriate qualifications and experience required by the National Minimum Standards of someone running a care home. In her absence the Social Services has seconded the manager of the day services which are run at Burrow House, to act in a ‘caretaker’ managerial capacity until the manager returns to work. This acting manager has substantial managerial experience running the day centre and previous to that, domiciliary care, complemented by having worked alongside the registered manager for a short time in the capacity of an assistant manager. She also has the Certificate in Management Studies. Her knowledge and experience is complemented by the fact that she knows many of the residents and staff at the home. Despite only having been acting manager for a short time she was aware of issues about the home, displayed a good knowledge of the individual residents and appeared to have a good rapport amongst those she was working with. During the course of the inspection, three assistant managers were on duty. One was new to the home and acting in a temporary capacity to fill a vacancy and another had only recently taken up her post. The latter demonstrated a good grasp of her managerial role, showing that staff supervision was well organised, although adversely affected by staff sickness. The home operates a Quality Assurance survey. This is conducted annually in April. It comprises questions regarding satisfaction with general level of care, satisfaction with food and beverages, helpfulness of staff, bedroom accommodation. The result of this was that residents expressed overall a general satisfaction with the level of care and the physical environment at the home. Previously this home has operated a good system of staff meetings. Often there have been meetings for specific groups of staff such as night staff or kitchen staff. Records showed that these meetings had not been held regularly, with the last two meetings for staff involved in respite care being on 1/11/04 and 27/4/05 and the last meeting for Residential Staff being during October 2004. The acting manager has scheduled two meetings for respite care and for residential staff on 11th. September and 31st August respectively and staff spoken to were aware of this and able to quote the dates without reference to diaries. The response by the registered manager to the pre-inspection questionnaire submitted by the CSCI shows that the home ensures the safety of its residents Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 24 by having electrical and gas installations serviced regularly and also hoists and lifting equipment. Records held on the premises also showed that there is a regular testing of the fire alarm system and that staff have received appropriate training regarding fire safety. Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 X 3 Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations In order to protect service users from date expired products being used it is recommended that a discard date is written onto all products with a reduced life on opening and that a record is also made of the opening date The home expands the activities available to residents in order to provide a more stimulating environment for them. Whilst the home maintains appropriate staffing levels the current reliance on agency staff will affect continuity of care and the effectiveness of key worker systems. 2 3 OP12 OP27 Burrow House DS0000033415.V295832.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burrow House DS0000033415.V295832.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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