Inspection on 01/11/07 for Bursted Houses

This inspection was carried out on 1st November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bursted Houses 30/10/08

Bursted Houses 26/05/06

Bursted Houses 16/01/06

Bursted Houses 17/03/05

Bursted Houses 09/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Bursted Houses 227-235 Erith Road Bexleyheath Kent DA7 6HZ Lead Inspector Lorraine Pumford Unannounced Inspection 1st November 2007 09:30 Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 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 Bursted Houses DS0000038151.V350060.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 Adults 18-65. 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. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bursted Houses Address 227-235 Erith Road Bexleyheath Kent DA7 6HZ 020 8331 5196 020 8331 5196 bursted@mcch.org.uk www.mcch.co.uk MCCH Society Ltd 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) Samantha Torode Care Home 23 Category(ies) of Dementia (2), Learning disability (25), Learning registration, with number disability over 65 years of age (5) of places Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of service users accommodated at any one time should not exceed 25, of which 5 may be over 65 years of age.. 26th March 2007 Date of last inspection Brief Description of the Service: Bursted Houses is run by MCCH Society Ltd and offers accommodation for adult service users with a learning disability. It is made up of four selfcontained properties, three of which are bungalows and one a house with stairs. These properties are laid out within a quiet cul-de-sac facing each other. Each house has domestic style facilities, such as a kitchen, dining area, lounge, bathrooms and toilets. The management responsibility for Bursted Houses rests with the Registered Site Manager who has an office adjoining one of the houses on the site. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors who spent the day talking with residents and staff, examining policies and procedures and undertaking a tour of the premises. Staff assisted a number of residents to complete surveys, a number of relatives also completed surveys or spoke with the lead inspector and their comments have been included in this report. The manager has recently been registered by the CSCI and it is evident that staff have worked hard to improve standards since the last inspection. The fees are currently £1,139. What the service does well: Residents contracts are in a pictorial format. Prospective resident are able to test-drive the home prior to admission. It was apparent that staff endeavour to promote residents independence on a day-to-day basis. Residents are provided with relevant social and leisure activities. Residents are provided with a varied nutritional diet. Staff respect residents privacy and dignity. Staff enables residents to maintain links with family and friends. Residents receive good health care support. Residents and their advocates can be assured that any concerns brought to the providers attention will be appropriately managed. The provider has a comprehensive safeguarding adults policy which helps protect residents living in the home. Residents are provided with a clean comfortable home like environment. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Following the pre admission assessment the provider must confirm in writing to the prospective resident or their advocates the home is able to meet their needs. Care plans and risk assessments must be updated to protect residents and staff and enable then to meet residents changing needs. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 7 Some health and safety issues arose in relation to residents and the equipment they use. Medication procedures need to be developed further to safeguard residents. Recruitment procedures need to be devolved further. Where there is an assessed need staff must monitor and record residents weight on a regular basis. 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. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are given the opportunity to test drive the home before admission. The provider must provide written confirmation to prospective residents or where appropriate their advocate that following assessment the home is able to meet their needs prior to admission. EVIDENCE: While it is good to see that the provider has developed a comprehensive pictorial contract for residents it is recommended that an alternative symbol is found to convey to residents the terms under which they may be asked to leave the home as the current one may be misunderstood by residents. Since the last inspection one resident has been admitted. The care records for the resident included a comprehensive assessment completed by the Community Learning Disability Team. Although the manager stated that she had met with the prospective resident prior to admission and undertaken an assessment there was no written evidence that this had taken place. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 10 There was no evidence to show that the resident or the persons advocates had received written confirmation that based on assessment the home was suited to meeting their needs and action needs to be taken to address this. The manager stated that the prospective resident had visited the home on a number of occasions prior to being offered a place to enable her to meet with peers and staff members. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments must be updated to protect residents and staff and enable then to meet residents changing needs. EVIDENCE: At both the previous two inspections a requirement was made that care plans need to be reviewed on a regular basis and be fully reflective of residents needs. The following indicates some progress has been made towards this requirement. Residents care plans were examined in each of the houses, a sample of four care plans were examined in more detail. The care records seen in-house 235 for one resident included a care manager pre-admission assessment, an assessment of need competed by staff following admission and a risk assessment and a care plan. Although care plans were prepared these Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 12 provided very little information for staff on how assessed needs were to be met. Care records for one resident in house 231 were viewed. These included a care manager pre-admission assessment; a pre-admission assessment completed by the provider and a risk assessments. The in-house assessment of need for the resident was completed in January 2007 and did not reflect changes in their condition or their current care needs. Risk assessments and care plans for this resident were also out of date and not reflective of current care needs. For example in relation to nutrition the care plan said to ‘cut food up’ however the person required pureed foods due to swallowing difficulties. The moving & handling assessment and care plans did not show that the person needed a hoist for transfer. A Care plans was examined in relation to a resident in house 233. The Care plan was clear and comprehensive and included a risk assessment and there was evidence it had been reviewed. A Care plan was seen for a resident living in house 233a. . The Care plan was clear and comprehensive and included a risk assessment and there was evidence it had been reviewed, however this review had not been signed or dated so it was not possible to know when this had taken place. The resident in 233a has been diagnosed with dementia and is seen by a Psycho Geriatrician on a regular basis. Staff had recorded in their notes has become a little more confused. Discussion took place with the manager regarding the need for staff to provide more detailed information regarding this resident. This is required to accurately reflect the residents changing health needs, both to assist the Psycho Geriatrician in monitoring this residents condition and also to enable staff to monitor and ensure they are able to meet the residents increasing needs. In addition to care plans there are ‘guidelines’ in relation to care provision these provided adequate information as to how staff would meet the person’s assessed needs. Consideration should be given to reducing the amount of paperwork in care records and ensure care plans are easy to identify and implement. The majority of residents have limited ability to make decisions about their lives. Staff were seen interacting appropriately with residents in all houses, explaining what was happening and waiting for residents to respond before proceeding. In 235 a resident was receiving physiotherapy and with the support and explanations provided by staff the session was successfully completed. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 13 Staff said they became familiar with resident’s different ways of expressing their needs and did not rely solely on verbal communication. For example by reading body language, signs and sounds. Staff stated that all residents require some assistance with managing their personal allowance. Small amounts of money are retained for individually named residents. The sample examined indicated that residents personal allowance tallied with the house records. Relatives who were spoken with and completed questionnaires stated they were kept informed of important decisions and were invited to attend reviews concerning their relative. The majority of relatives stated that staff supported residents to live the life they choose. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It was apparent that staff endeavour to promote residents independence on a day-to-day basis. Residents are provided with relevant social and leisure activities and a varied nutritional diet. EVIDENCE: Each of the houses accommodates residents with varying levels of dependency. Most of the residents require assistance to participate in activities. One resident spoken with attended a day centre and indicated they enjoyed the time spent there. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 15 The manager stated that one of the care staff has taken the lead responsibility for co-ordinating activities and this appears to be working well. A recommendation was made at the time the last inspection that a more comprehensive record of activities provided to residents should be maintained. Action has been taken to address this. Records seen indicate residents have participated in various activities such as shopping, going to the gym, cinema and meals out at local restaurants, pubs and cafés. On the day of this visit staff had arranged a Halloween party for some of the residents. Relatives who completed questionnaires spoke positively of the support given to residents by staff. Staff enable residents to maintain links with family and friends, relatives stated they are always made to feel welcome when they visit. One relative voiced concern regarding the quality and quantity of food provided and felt this was variable depending on the experience of care staff on duty. In house 233A records seen indicated that one of the two residents living there prefers to have their main meal during the evening. Staff had prepared vegetables and these were seen in saucepans of water at 10:30 in the morning and discussion took place with the manager regarding this practice, as the nutritional value of the food would deteriorate during the course of the day. On the day of the visit one of the two staff working in house 233a was asked to undertake a task away from the home. This delayed the other resident who lives in this house from getting up and having breakfast. Although the person was provided with a drink, the cereal intended for breakfast was still in the kitchen at 11:45 am. Both these issues were discussed with the manager who stated that this was not general practice and that the matter would be discussed with staff. On the day of the visit lunch was observed in houses 231 and 235, meals were freshly cooked and looked very appetising and were well presented. One resident required food to be pureed and the foods were pureed separately to ensure they looked appetising. Staff keep a record of meals provided to the residents. In all houses adequate supplies of fresh, frozen and dried foods were seen and staff spoken with said they had received training in relation to food safety. Special crockery and cutlery is provided to help residents maintain their independence. Staff were seen to knock on resident bedroom doors before asking permission to enter. Residents are able to access all parts of the house and garden where they live. Good interaction was seen between residents and staff. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 16 Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive good health care support. Medication procedures need to be developed further to safeguard residents. People living in the home can be assured their privacy and dignity will be respected. EVIDENCE: All residents are registered with a GP, arrangements are made for dental, optical and chiropody care, access to other healthcare services are obtained through GP referral. Staff work with the Community Learning Disability Team to ensure resident’s specific needs are met, for example in relation to physiotherapy, psychologists and when necessary the Community Psychiatric Nurse. It was apparent from discussion with staff that one resident in particular has lost a considerable amount of weight, however there was no evidence to indicate that staff are monitoring and recording the persons weight on a Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 18 regular basis. Action should be taken to address this to ensure that appropriate health care is sought for this person. The system to store, order, dispose and record medicines are the same for each house. Medicines are stored in fixed cupboards. Medicines are supplied in blister packs and individual containers. Pre-printed medicine administration charts are also supplied. Records for receipt, administration and disposal of medicines were good. A requirement was made at the time of the last inspection regarding the need for the home to develop a safe system for storing, administering and recording medication and the need for staff to receive training and be assessed as competent to administer medication. It was evident that staff had worked hard to address these requirement particularly in house 227/229 where a number of issues had arisen at the time of the last inspection. The manager stated that staff responsible for administering medication had undergone additional training since the last inspection. A number of issues still need to be addressed with medication procedures. When staff add entries to the administration charts they must ensue the information recorded reflects what is written on the pharmacy label. Additional labels should not be used on administration charts as these can be removed and are not a permanent record. Medicines checked for two residents in house 231 were correct however medicine for two residents in house 235 showed some inaccuracies. It was good to see staff had developed protocols for the administration of PRN medication in houses 227/229, however this was not the case in house 233a and action should be taken to address this. Further discussion took place regarding the need for two members of staff to sign hand written entries to the MAR sheet to protect both residents and staff. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their advocates can be assured that any concerns brought to the providers attention will be appropriately managed. The provider has a comprehensive safeguarding adults policy which helps protect residents living in the home. EVIDENCE: Since the last inspection the manager has received one complaint. Records seen indicated that appropriate action was taken to investigate the matter. To date the CSCI had received no complaints regarding this service. There is a complaints procedure and additionally information is provided to residents regarding the complaints procedure in a pictorial format. A copy of the procedure is also displayed in the home. Relatives who completed surveys stated they were aware of the organisations complaints procedure, however to date had not felt the need to raise any concerns with them. The provider ensures that staff are provided with appropriate adult protection training including the organisations whistleblowing policy. Staff displayed a good awareness of safeguarding adults and knew what action to take if they had any concerns. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 20 Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean comfortable home like environment. EVIDENCE: A number of requirements were made at the time the last inspection in relation to the environment. Action was required to replace a broken lock to the bathroom door in a house 235 and make safe uneven flooring in house 231. Two residents share a bedroom and a requirement was made that appropriate privacy screening should be provided. Since the last inspection action has been taken to address all of these issues. All of the houses were clean and free from unpleasant odours. Each of the houses was appropriately decorated and furnished. Relatives and staff have assisted residents to individually personalise their bedrooms. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 22 Bath and shower rooms seen were clean and satisfactorily maintained. Hand washing facilities were provided and staff have access to protective clothing. Staff stated that the current laundry facilities meet the needs of the current resident group. The height of the fence to the rear of houses 227/229 has been increased which has improved the residents privacy and security. The home does not have a room available for residents to meet with visitors in private. A recomendation has been made that in the event of any change to the building this issues needs to be addressed. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitably trained and qualified staff are employed. Recruitment procedures need to be developed further. EVIDENCE: A recommendation was made at the time the last inspection that staffing levels should be reviewed to ensure that sufficient staff were employed to enable residents to participate in more activities. The manager stated that she has recently interviewed prospective staff with a view to filling staff vacancies and in addition the home has a designated group of bank staff. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 24 Personal files were examined for five people employed since the last inspection. Three were for staff that had commenced work and two were for staff waiting to commence. The files were well organised and contained most of the information required by regulation. All files had evidence that CRB and POVA checks had been completed. One file did not contain a recent photograph of the person, another file did not have an explanation for a gap in employment since 2005 and it was unclear that references received without a company stamp or compliment slip had been verified as genuine. The manager stated that these issues would be addressed. Individual staff training records were maintained. Five files were viewed and showed that training had been provided on a range of topics since the last inspection. Training provided included moving & handling, first aid, health & safety & diabetic care. One file showed that the person had attended four days training in the last year. The manager said that files were not up to date and that she had provided medicine management training for all staff but this was not recorded on the records viewed. Staff spoken with said they had access to adequate training and were supported by senior staff to carry out their roles. A recommendation was made at the time of the last inspection that the home should work towards 50 of the staff group obtaining an NVQ two qualification in care and the home has achieved this. There was evidence to show that staff received regular supervision and staff spoken with confirmed this. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider is currently introducing a comprehensive self-assessment format to monitor and improve the care and service provided. EVIDENCE: A requirement was made at the time of the last inspection that the person in charge of the home on a day-to-day basis should submit an application to the CSCI to be registered. Since then this has taken place and the home now has a registered manager. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 26 A recommendation was made that the person in charge of the home on a dayto-day basis should also work some evenings and weekends to monitor staff practice and be available to meet with relatives or friends who were more likely to visit during these times. The manager stated that she has taken action to ensure that some of her shifts take place outside office hours. Discussion took place with the manager and area manager regarding the providers quality assurance procedures. They are currently introducing a comprehensive policy which will meet the statutory requirements of regulation 24 and 26 which requires both the manager and the provider to have a system in place to monitor and improve the care and service provided. Staff complete weekly visual tests on moving & handling and bathing equipment. A resident in house 235 has bedrails fitted but a risk assessment has not been completed. Accident records were viewed and had been satisfactorily completed. One resident sustained injuries from a fall from a wheelchair even though a seat belt was fitted. This accident was not adequately investigated to ensure it did not happen again. A staff member was pushing a resident in a wheelchair into the dinning room the persons legs swung out and hit the doorframe. There were no footplates on the wheelchair and staff stated this was because it was potentially hazardous for this person. Records examined indicated that staff had completed a risk assessment in relation to this issue. Staff stated that a belt had been ordered in July to reduce the risk of the resident sustaining an injury from the chair. Staff stated this had been delivered in the last few days but not yet fitted to the chair. Action should be taken to address this matter urgently. A requirement was made at the time of the last inspection regarding the need for staff to receive suitable training in relation to fire prevention and to implement a system of fire drills and practices. From discussion with the manager and records seen it is apparent that this has been arranged and will also include night staff. Some doors had a considerable gap at the bottom and the manager was asked to consult with the local fire authority in relation to this matter. Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? 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 YA2 Regulation 14 Requirement The provider must confirm in writing to the resident or their advocate that following the assessment the home is able to meet the residents needs. The Registered Person must ensure that care plans are fully reflective of the individuals needs and reviewed on a regular basis. Previous timescale of 01/07/06. 02/07/07 not met. The Registered Person must ensure that there are safe systems in place for the administration and recording of prescribed medication. Previous timescale of 30/06/06. 02/07/07 not met The registered person must ensure that sound recruitment procedures are in place. In this instance ensure there is a photograph of all staff members working in the home and references are authenticated. The registered person must ensure that appropriate DS0000038151.V350060.R01.S.doc Timescale for action 04/01/08 1. YA6 15 31/03/08 2. YA20 13(2) 04/01/08 3 YA34 19 &Sch 2 04/01/08 4 YA42 13 04/01/08 Bursted Houses Version 5.2 Page 29 equipment is provided to reduce the risk of residents being harmed and action taken to prevent residents being harmed again. 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 YA5 Good Practice Recommendations It is recommended that an alternative symbol be found to convey to residents the terms under which they may be asked to leave the home as the current one may be misunderstood by residents. It is recommended that the care plan format be streamlined. Should the provider decides to change the use of rooms on site consideration needs to be given to increasing day space and adding a visitors room. Any gaps in staff employment history Should be explored as part of the recruitment process. 2 3 YA6 YA24 4 YA34 Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Bursted Houses DS0000038151.V350060.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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