Inspection on 09/02/06 for Burrows House

This inspection was carried out on 9th February 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

Burrows House 24/06/08

Burrows House 28/06/07

Burrows House 28/06/06

Burrows House 16/02/05

Burrows House 04/11/04

Burrows House 05/08/04

Burrows House 07/11/03

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 Burrows House 12 Derwent Road Penge London SE20 8SW Lead Inspector Lorraine Pumford Announced Inspection 9th February 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 Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burrows House Address 12 Derwent Road Penge London SE20 8SW 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) 020 8778 2625 020 8659 6240 Servite Houses Limited Ms Shelley Ratcliffe Care Home 54 Category(ies) of Dementia (23), Learning disability (2), Old age, registration, with number not falling within any other category (29) of places Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: This home is part of Servite Houses, which have a number of facilities throughout London and the southeast. The home is a 51-bedded facility for service user in the category of older persons and Dementia. The facility is purpose built over two floors. Individual bedrooms and communal space are provided on both floors. The main services i.e. kitchen and laundry are on the ground floor. The home is separated into seven units. Each wing, which comprises of two units, has its own kitchen, dining and sitting area. Staff are allocated to specific units and waking night staff are provided. All policies and procedures are generated centrally with amendments made to reflect the local situation. The head office deals with recruitment of new staff. The kitchen is operated through an external contract agreement. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken by one inspector who was in a home for approximately 7 hours. During that time the manager, area manager and some staff and service users were spoken with, also some documents and parts of the premises inspected. Although comment cards were provided for the manager to distribute to service users, their representatives and other stakeholders and stated these had been distributed prior to the inspection, at the time of writing this report no completed comment cards have been returned to the CSCI. A minimum of two inspections generally takes place within a 12 months period to all Registered Care Homes. As this inspection may not have covered all the “National Minimum Standards” on this occasion it is recommended that if further information is required a copy of the last inspection report also be obtained. What the service does well: What has improved since the last inspection? Since the last inspection all staff responsible for handling medication have received appropriate training and been assessed as competent to undertake the task. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 6 Staff have also received training regarding fire safety and weekly tests to the fire alarm system now take place. The home continues to benefit from the ongoing redecoration programme. The laundry has increased in size and additional domestic hours have been increased specifically to process laundry. Since the last inspection all service users living in the home had been provided with a copy of the Service User Guide. What they could do better: The provider must ensure that service users are not admitted to the home outside the homes current terms of registration. The provider must ensure that records required to be in the home and available for inspection by the CSCI are available, in this instance records regarding the assessment of service users and records pertaining to staff employment. Action must be taken to ensure service users dignity is not compromised by wearing inappropriately and badly labelled clothing. Handrails must be provided in all communal areas used by service users to reduce the risk of service users sustaining falls. All staff working in the home must be provided with written information regarding the providers whistleblowing policy and receive training in this and other adult protection issues on a regular basis. A room should be provided for service users to meet with visitors in private other than in their bedroom, this room should be appropriately furnished for the purpose. Action is required to minimise the risk of infection being spread within the home. The home must be able to provide written evidence that suitably qualified and competent staff are working in the home. Quality assurance mechanisms need to be developed further, to include a regular audit of the care and service provided by the manager of the home, Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 7 further the provider must undertake a monthly audit of the service and provide a copy of the findings to the CSCI. 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. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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 Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4 Action has been taken since the previous inspection to ensure that all service users are provided with a copy of the homes service user guide. Action is required by the registered provider to ensure that service users are not accommodated who are outside of the homes terms of registration. EVIDENCE: At the time of the inspection two service users were being accommodated outside of the homes current registration, staff do not have the qualifications and skills to meet service users who have additional needs. This was discussed with the manager and area manager and it was agreed that Servite Houses Ltd would apply to the CSCI for a variation of registration to enable these people to remain in the home. At the time of the previous inspection issues arose in relation to the assessment process of prospective service users to the home. The care plans Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 10 of three service users were examined specifically in relation to the assessment process. The manager stated that she had undertaken an assessment in relation to each person prior to their admission; on the day of the inspection only one assessment could be located. Servite Houses has developed a standard letter, this is sent to the service user or their representative following an assessment to indicate the home they have applied to can meet their needs prior to admission. The manager stated following the last inspection each service users has been provided with a copy of the homes Statement of Purpose and Service User Guide, copies of these were seen in service users bedrooms during the course of the inspection. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 Appropriate action has been taken by the provider to address the issues raised at the previous inspection in relation to medication, this ensures service users health and well-being are maintained. Service users clothing should be appropriately and discreetly labelled in order to promote their dignity. EVIDENCE: A rating of one was awarded in relation to standard 9 following the previous inspection, requiring action to be taken by the home with regards to medication procedures in the home. Since the last inspection all staff responsible for handling medication have received appropriate training and been assessed as competent to undertake the task. Medication procedures were reviewed on one unit, this indicated that action has been taken to address the errors found in the system previously. Medication was found to be securely stored, medication records were accurately completed. A minor requirement was made by the inspector that a record of all staff signatures responsible for administering medication should be held at the front of the medication records to provide for an effective audit. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 12 Discussion took place with the manager in relation to the labelling of service users personal clothing. A number of items seen in the laundry room had been marked with the service users bedroom number, which is inappropriate, as they should be marked with service users names. Further the type of print used for the purpose had permeated through the fabric and was clearly visible when the clothing was worn, clothing should be clearly but discreetly labelled, and both these issues compromise service users dignity. A shirt seen had been marked with a service users name, the service user was no longer in the home and the shirt had been given to another service user to wear without the name of the previous occupants being removed. An audit of all service users clothing should take place to ensure that items are appropriately named in a manner, which does not contravene the individuals dignity. Service users requiring assistance from staff were seen to be assisted in a calm unrushed manner. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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): 13,14,15 Service users are provided with a varied nutritional diet. The home must provide service users with a room for private conversation, other than their bedrooms, that is suitably furnished for the purpose. EVIDENCE: The manager stated that visitors are welcome at the home any time. At present the home does not have room available for service users to meet with visitors in private other than their bedroom. The manager stated that it would be possible to use a small office for this purpose, discussion took place around the need to make the room fit for the purpose including relocating a number of files containing confidential material to an alternative office. Service users the inspector spoke with in bedrooms had received help from relatives to individually personalise their room. Service users stated that they had been able to bring in small personal items of furniture, personal possessions and photographs. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 14 Menus seen indicated that service users are provided with a varied nutritional diet. Menus are well written giving service users clear information regarding the dishes being provided. Discussion took place with the chef and the manager regarding the recording of food to service users, the menu each meal time offers two alternatives, at present the home keeps a record of the options chosen by individual service users from this menu. A service user that the inspector spoke with stated she did not like either of the options available on the lunchtime menu, however when her meal arrived she had been provided with an alternative. Discussion took place with manager that the home keeps a written record of all food provided to service users, including any alternative meals, therefore providing evidence that all service users are receiving a varied, nutritional and well balanced diet. Staff stated that milk, tea coffee etc and basic food products are kept in each units kitchen to enable staff to provide snacks for service users wanting additional refreshments during the course of the day or night. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 15 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 Service users and their representatives are provided with information regarding the companys complaints procedure. Staff must have access to a clear whistle blowing process and adult protection training to ensure service users safety and well-being is protected. EVIDENCE: The manager stated that information regarding the companys complaints procedure is available in the service user guide provided to each resident. Since the last inspection two complaints made to the CSCI have been investigated, one of these was upheld and one was partially upheld. The manager stated that staff are no longer able to make a complaint to the company anonymously, however this information is not reflected in their whistle blowing policy. The inspector requested that the whistle blowing policy be amended to accurately reflect the current practice. The area manager stated this change of policy was due to a number of complaints the company had received which when investigated had been found to be malicious and unfounded, however he stated any issue brought to the companys attention which could result in the need to implement adult protection procedures would always be investigated regardless of if the allegation was made anonymously or not. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 16 Written information seen by the inspector, in relation to the companys whistle blowing policy was very limited and referred staff to obtain further information from the staff handbook. The manager stated that to date neither herself or to her knowledge any other member of staff have received a copy of the staff handbook, this issue needs to be addressed. Two of the three staff that the inspector met with privately, were not aware of the term whistle blowing, the manager stated that the issue would have been addressed with staff at the time of their induction. Discussion took place with the manager regarding the need for all staff to have both clear written information regarding the companys whistle blowing and adult protection policys and ongoing training to ensure its effective implementation. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Service users continue to benefit from the ongoing redecoration programme. Procedures relating to the handling of foul waste and materials needs to be reviewed to reduce the risk of the spread of infection. EVIDENCE: Since the last inspection a full time handyman has been employed and there was evidence of a sustained programme of redecoration taking place. Generally service users bedrooms and communal lounges were comfortable with appropriate furnishings. There was however a marked difference between bedrooms occupied by the physically frail and mentally frail service users, with the latest residents bedrooms showing signs of age, wear and tear, a number of these rooms would benefit from redecoration and refurbishment. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 18 Discussion took place regarding the need for service users without relatives who visit regularly to be supported by staff to personalise their rooms. The inspector observed a service user leaving her bedroom and making her way to the dining room, there are currently no hand rails, although the service user attempted to guide her self by the wall she became unsteady and a member of staff had to provide assistance. Handrails must be provided in all corridors and where appropriate communal areas to promote service users safety and independence. Suitable laundry equipment is provided to clean foul linen and reduce the risk of infection. Although attempts have been made to increase the size of the laundry by knocking down a wall to an adjacent room, the area remains small for the quantity of laundry being processed Discussion took place regarding the need to review the current laundry procedures to minimise soiled and clean linen being in the same area at the same time, and therefore reduce the potential risk of any cross infection being spread. This issue was also reviewed in relation to the removal of foul waste from toilet areas. At present disposable bags and protective clothing for staff are stored in sluice areas. Discussion took place regarding the need for these items to be easily accessible for staff in the toilets. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 The home must be able to evidence sound recruitment procedures are in place to protect service users living in the home. More staff are required to hold an NVQ 2 qualification, allowing service users to benefit from a suitably trained and competent work force. EVIDENCE: The manager stated that additional care staff would be employed when three beds recently registered by the CSCI are occupied. Since the last inspection additional domestic hours have been increased primarily to undertake laundry duties. At present the home does not employ a member of staff specifically to undertake activities with service users, the area manager stated this task would be allocated to care staff on a trial basis. If this arrangement takes place, it would be necessary for the manager to deduct the time staff spend undertaking activities with service users from the number of allocated care hours provided. The inspector spoke with three members of staff in private, further a random sample of three files were requested, one of these could not be located. Of the two staff files examined, there was evidence that staff had provided the names of referees and there was evidence of qualifications attained. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 20 Overall documentation did not comply with the Care Homes Regulations 2002, as there was no evidence in the home that staff had provided proof of identity, or information as to their health status. One file did not contain a photograph of the carer employed. Discussion also took place regarding CRB checks for staff, the inspector was provided with a staffing matrix, this did not provide information regarding all members of staffs CRB status, the manager stated that all staff working in the home had completed CRB checks in the past, although disclosure numbers had not been kept for everybody, therefore the human resources department had written to all staff requesting they bring in their CRB check for the manager to verify and record the appropriate information. Staff spoken with stated that they had completed a formal induction at the time they commenced employment with the company. The inspector requested written evidence that staff had been assessed as being competent to undertake specific care tasks; the manager stated that this information was not available. The area manager stated the company used workbooks that staff worked through supervised by a senior member of staff who regularly reviews their practice and signs the document when both parties are confident. Discussion took place that the home is required to provide written evidence that staff employed are competent to undertake necessary care tasks. Staff spoken with had not received copies of the GSCC code of good conduct and practice; the area manager stated that this issue would be addressed. At present a minority of staff hold an NVQ qualification, staff spoken with stated they were looking forward to undertaking further training, all spoke positively of training in general and thought their practice and knowledge had improved with training. The manager stated that the home had joined the care homes training Consortium in joint cooperation with Bromley Social Services Department. This would allow for staff to access 130 training slots between January and November 2006. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35, 38 The quality assurance mechanisms must be developed further and need to include a copy of the providers monthly audit being forwarded to the CSCI. There are sound procedures in place to ensure service users personal allowance is held safely EVIDENCE: Current quality assurance mechanisms were discussed with the manager and area manager, the home has recently had a full quality assurance survey undertaken by Laing and Boussion, the results of the survey will be made available to service users, their representatives and other interested parties including the CSCI. Discussion took place with the manager regarding the need for her to develop an internal system of auditing the care and services currently provided with a Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 22 view to improving the overall service. A copy of this audit needs to be available in the home for inspection. The company needs to ensure the responsible individual or a representative of Servite homes visits on a monthly basis to undertake the audit required of the provider. The CSCI have not received a copy of the providers audit since September 2005. Records in relation to service users personal allowance were examined; records indicated that a receipt is provided to service users relatives for personal allowance deposited with the home for safekeeping. A sample of money held on behalf of service users was checked against the records and these accounts tallied. Receipts are retained by the home for any items staff have purchased on behalf of service users. In one instance records indicated a service user had purchased air freshener for her bedroom, in the opinion of the inspector this was inappropriate use of the service user personal allowance as the resident would not been able to make this decision independently and the home should be purchasing these items out of the homes of cleaning budget. Money held for service users is held in individual named envelopes and remains the sole property of individual service users. Money is retained in an appropriate place for safekeeping. Individual amounts are kept in a named container for each resident, there is no security tag system in place for these containers, this has therefore led to a system developing of staff auditing the amount of money held on the changeover of each shift. General discussion took place regarding the possibility of finding a more secure system which would reduce the amount of time staff are required to audit small amounts of money held throughout the day. At the time of the previous inspection a requirement was made for staff to be trained in fire safety. Staff spoken with stated they had been provided with fire safety training, records seen indicated that staff are required to sign the fire book upon completion of training. Since the last inspection a system has been put in place to insure a weekly test to the fire alarm system. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 23 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 X 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 12 (1) (a) Requirement The registered person must ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. In this instance admitting service users outside of the homes category of registration. The registered person must make suitable arrangements to ensure that the care home is conducted in a manner, which respect the privacy and dignity of service users, in this instance by ensuring service users clothing is appropriately labelled. The registered person shall having regard to the number and needs of the service users insure that suitable facilities are provided for service users to meet visitors in communal accommodation, and in private accommodation which is separate from the service users own bedroom. The registered person must make adult protection training available to staff including clear DS0000006942.V276139.R01.S.doc Timescale for action 30/03/06 2 OP10 12 (4) (a) 30/03/06 3 OP13 23 (2) (i) 30/05/06 4 OP18 13 (6) 30/05/06 Burrows House Version 5.1 Page 25 5 OP26 13 (3) 6 OP19 23(2) (n) 7 OP29 7&9 sch2 8 OP33 24 9 OP33 26 guidelines on the companys whistle blowing policy. The registered person must 30/03/05 make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the care home The registered person must 30/06/06 having regard to the number and needs of the service users provide suitable adaptations and support for physically frail people, in this instance hand rails to all communal areas. Records regarding staff 30/06/06 employment are held in the home available for inspection and comply with scheduled 2. The registered person must 30/04/06 establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home The registered provider 30/03/06 undertakes a monthly audit of the care and services provided in the home and forward a copy of the report to the CSCI. 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 2 3 Refer to Standard OP15 OP9 OP19 Good Practice Recommendations The home needs to ensure a record of all food provided to service users is maintained. A record of staff signatures needs to be maintained for the purpose of auditing medication. Staff need to assist all service users to attain an individually personalised bedroom. DS0000006942.V276139.R01.S.doc Version 5.1 Page 26 Burrows House 4 5 OP29 OP28 All staff need to be provided with a copy of the GSCC code of conduct. The home needs to work toward 50 of the staff group attaining an NVQ2 qualification. Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Burrows House DS0000006942.V276139.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!