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Inspection on 16/01/06 for Burton Closes Hall Nursing Home

Also see our care home review for Burton Closes Hall Nursing Home for more information

This inspection was carried out on 16th January 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a welcoming, friendly and homely atmosphere and service users gave positive feedback in terms of their relationships with staff, the way they are treated and their care and support. Given the high turnover of managers for the home within the last five years (and a change of ownership within that time period), staff have continued to demonstrate their commitment to the care and support of service users with whom good relationships are established.

What has improved since the last inspection?

A review of aspects of care systems has been undertaken, including the admissions process, assessment and care planning, aspects of medicines management and associated records and record keeping. This has resulted in a number of key improvements, with additional development identified and planned by the acting manager. A review of some aspects relating to infection control and health and safety in the home has also been undertaken, resulting in the provision of proper equipment for effective staff hand washing, improved waste disposal arrangements inside the home, proper storage of substances which may be hazardous to health and the provision of window restrictors to windows. Since coming into post during mid December, the acting manager has conducted a review of staffing systems, including that relating to staff cover, recruitment and staff training and has determined planned action to be taken in relation to matters arising.

What the care home could do better:

The registered persons need to ensure for the planned maintenance and necessary upgrading of equipment and systems in the home and to take effective action to ensure that where a timescale has been set for compliance with any standards relating to the physical environment, that a plan for achieving compliance is produced and followed and records kept. The registered persons must ensure that effective management systems are developed, including that relating to risk management, quality assurance and quality monitoring. It is also imperative that there is timely investment, action and support from the registered provider to ensure that the health, safety and best interests of service users is effectively promoted and protected.

CARE HOMES FOR OLDER PEOPLE Burton Closes Hall Nursing Home Haddon Road Bakewell Derbyshire DE4 1BG Lead Inspector Sue Richards Unannounced Inspection 16th January 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 Burton Closes Hall Nursing Home DS0000002048.V271994.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. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Burton Closes Hall Nursing Home Address Haddon Road Bakewell Derbyshire DE4 1BG 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) 01629 814076 01629 814078 carechcc.plus.com Hill Care Limited Vacant Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (5) of places Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Burton Closes Hall Nursing Home provides nursing and personal care and support for up to 47 older persons and 5 younger adults with physical disabilities. Accommodation is organised within three separate units in accordance with the category and needs of service users. Each unit has communal lounge and dining space, together with adequate bathing and toilet facilities. With the exception of four shared rooms, the care complex provides all single room accommodation, the majority of which have en suite toilets and wash hand basins or showers. Each unit also has a small kitchenette in which drinks and snacks can be prepared. There are centralised kitchen and laundry facilities. A range of equipment is provided to assist service users with mobility, both individual and environmental, although some areas do not have corridor handrails (see inspection report). A shaft lift is provided in the home and there is ramped access to an outdoor courtyard, with seating areas. There are also extensive gardens, which are generally well maintained. Service users receive care and support from a team of Registered Nurses, care and hotel services staff. The deployment of nurses and care staff is in accordance with the needs of three service user groups accommodated. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last planned unannounced inspection was carried out to the home in August 2005, which resulted in a total of 30 requirements being identified for action in the written report of that inspection. An additional unannounced inspection visit was also undertaken in November 2005 in order to monitor progress and compliance with a number of those key requirements and also to investigate matters arising from a complaint, which was initially investigated via Derbyshire’s joint agency adult protection procedures. The focus of this inspection has been largely concerned with the continued monitoring of compliance in respect of matters arising from the above inspection visits. This included extended case tracking in relation to specific service users in order to further assess matters arising from the additional visit carried out in November. A tour of the building was undertaken, which included the inspection of all communal areas and a selection of service users own rooms. Discussions were held with some of the nursing and care staff on duty and a number of service users and feedback taken into account from other professionals outside the home. The care plans and associated care records of identified service users were examined together with a range of records, which are required to be kept by the home. What the service does well: The home has a welcoming, friendly and homely atmosphere and service users gave positive feedback in terms of their relationships with staff, the way they are treated and their care and support. Given the high turnover of managers for the home within the last five years (and a change of ownership within that time period), staff have continued to demonstrate their commitment to the care and support of service users with whom good relationships are established. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The registered persons need to ensure for the planned maintenance and necessary upgrading of equipment and systems in the home and to take effective action to ensure that where a timescale has been set for compliance with any standards relating to the physical environment, that a plan for achieving compliance is produced and followed and records kept. The registered persons must ensure that effective management systems are developed, including that relating to risk management, quality assurance and quality monitoring. It is also imperative that there is timely investment, action and support from the registered provider to ensure that the health, safety and best interests of service users is effectively promoted and protected. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 7 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. Burton Closes Hall Nursing Home DS0000002048.V271994.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 Burton Closes Hall Nursing Home DS0000002048.V271994.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, 2, 3 & 5 There were satisfactory arrangements in place for service users admissions to the home. Key information was provided for those service users to assist them (or their representatives) in making a decision to live in the home. There were appropriate systems and arrangements in place to ensure that service users needs were fully assessed and also to determine that the care home is and continues to be suitable for the purposes of meeting their needs. EVIDENCE: The Statement of Purpose/Service User Guide for the home was examined. This had been reviewed and updated. Additional information about the home and its three units is provided by way of a brochure. The information provided therein in respect of the home’s registering body was incorrect. The admission records of service users case tracked were examined and the arrangements for their admission to the home were discussed with the manager and some of those service users. These were generally satisfactory, although separate written policy and procedural guidance for staff in respect of Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 10 the home’s admission criteria had not been revised, which was a specified requirement from the additional visit carried out in November. (See also Management Section of this report). The acting manager had produced a revised standard form of contract/terms and conditions, which gave more detailed information in accordance with requirements. Recorded needs assessment information was in place for the service users case tracked. These were comprehensive and detailed regular reviews. Individual lifestyle preferences and routines were also accounted for. Burton Closes Hall Nursing Home DS0000002048.V271994.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): 7, 8 & 9. I Service users health needs were properly promoted and their written care plans were reflective of recognised guidance concerned with the care of older persons. Medicines were properly stored and the medicines policy provided clear and comprehensive guidance in all aspects and was robust. EVIDENCE: At the additional inspection undertaken in November 2005, deficits were identified in the written care plans of service users case tracked in respect of the promotion of their health care needs and recorded care interventions, which were not always reflective of recognised guidance for the care of older persons. During this inspection, the care records of those service users were examined again, together with additional ones. Comprehensive care plans were recorded, which detailed care interventions in accordance with recognised guidance concerned with the care of older persons, including that relating to falls. Care records were being maintained in accordance with recognised standards for records and record keeping. (See also management section of this report). The manager advised of her proposals to review and promote Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 12 improved arrangements for consultation with service users/representatives about their care plans. The Inspector will assess progress in this area at the next inspection for this service. The health care needs of those service users were discussed including access to outside health care service and professionals and associated records examined. The arrangements for the management and administration of medicines in the home were inspected at the inspection for this service carried out in August 2005, when a number of requirements were identified in respect of the storage of medicines and also written policy and procedural guidance for staff. These were assessed as being met during this inspection. Burton Closes Hall Nursing Home DS0000002048.V271994.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): The standards in this section were not assessed on this occasion. EVIDENCE: Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Key information is provided for service users and their representatives to enable them to raise concerns, and to make a complaint. The revision of some of the key policy guidance in place in the home, together with a review of individual’s documented care planning interventions has ensured they are reflective of recognised guidance concerned with the care of older person better and assists in promoting the protection of service users from abuse. However, the review of additional key policy guidance and the delivery of outstanding staff training will further empower and enable staff to further act in the best interests of service users. EVIDENCE: Information regarding how to complain was provided in the service user guide/statement of purpose for the home and had been revised and updated. The inspection carried out in August 2005 identified areas of key staff training and updates to be organised in relation to the delivery of care and clinical practise. This resulted from matters arising out of a previous complaint investigated via Derbyshire’s joint agency adult protection procedures. Not all areas had been achieved. (See also staffing section of this report). This was discussed with the acting manager during this inspection (who came into post on 12 December 2005). The above inspection also identified the need for a review of the home’s policy guidance in respect of dealing with and managing violence and aggression. This was discussed with the manager and existing policy guidance examined. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 15 This had not been achieved, however, the acting manager, who came into post during December 2005 planned to carry out a review of all policies. Recognised policy and procedural guidance was in place in relation to adult protection and recognising and responding to abuse and staff were familiar with their existence. The acting manager had undertaken staff training needs analysis and developed a training plan, although the ongoing arrangements for staff training and/or instruction in relation to adult protection were not confirmed. An additional inspection visit was carried out to the home on 04 November 2005. One of the reasons for this visit was to further investigate matters arising from an additional complaint, which was initially investigated via Derbyshire’s joint agency adult protection procedures. Following this additional visit a letter was forwarded to the registered provider detailing requirements of particular concern about a number of areas affecting the safety and consistency of the service, including that relating to the care of service users. Matters arising are referred to under the relevant sections of this report together with the outcome of areas inspected during this visit. The arrangements for the management and handling of service users monies were examined. These had recently been reviewed and were satisfactory. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 16 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, 25 & 26 The registered provider is not ensuring for the planned maintenance and necessary upgrading of equipment and systems in the home, which potentially compromises the health and safety of service users and staff. The registered provider is not taking effective action to ensure that where a timescale has been set for compliance with any standards relating to the physical environment of the home, a plan for achieving compliance is produced and followed and records kept. EVIDENCE: At a previous inspection for this service carried out in August 2005, a number of health and safety issues were identified, in relation to the environment, equipment provided and maintenance of the same. This included a number of recommendations made by the Fire Officer. These were referred to in the inspection report of that visit, with requirements detailed. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 17 During the additional inspection visit carried out in November 2005 the Inspector assessed compliance with some of the requirements as detailed above in accordance with timescales given, which were in relation to the required maintenance of equipment in the home. One item was reported as achieved, with a certificate to be provided. Extended timescales were agreed to and set out in writing to the registered provider, for the completion of two other areas of maintenance. Evidence of completion of the work has not been provided within given timescales. These issues have been raised separately in writing with the registered provider following this inspection requiring immediate action to be taken. Written notification has been received from the Fire Officer, who had carried out a follow up visit to the home on 11/01/06 and granted an extended timescale for the complete achievement of works previously identified by him. During this inspection further monitoring of compliance with other requirements previously made (see report August 2005) in respect of the building was undertaken, including that relating to health and safety and repair and renewal. Although a number of items had been achieved, there continued to be no written programme for the maintenance, repair and renewal of the home and a significant number items remain outstanding. No work had been undertaken to ensure the safety of service users in relation to radiators around the home, which was identified as a requirement in the previous inspection report. This issue has been raised separately in writing with the registered provider following this inspection, detailing immediate action to be taken. There was no mechanical sluice provided to the identified area on the first floor of the unit for older persons requiring nursing care. A number of other The Environmental Health Officer (HSE) visited the home in August 2005. There was no report of his visit available in the home. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 18 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 The acting manager, who had only recently commenced her employment in the home had taken reasonable steps to undertake a review of staffing arrangements in the home, including that relating to staff training and development with a satisfactory management plan provided in relation to these. EVIDENCE: Details of staff employed were provided and examined, together with staff duty rotas and the arrangements for their recruitment, training and deployment in the home were discussed. The acting manager had undertaken a review of night staffing levels and was in the process of securing additional staff to ensure effective staffing arrangements at night. The Inspector will continue monitor progress with this. At the previous inspection for this service (August 2005) serious concerns were raised regarding staff recruitment records. These have since been confirmed as satisfactory. Since coming into post in December 2005 the acting manager had undertaken a training needs analysis and developed a staff training plan accordingly. This was largely satisfactory, although the ongoing arrangements for staff training/instruction in relation to adult protection was not confirmed. The Inspector also discussed two areas of staff training, which had previously been Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 19 identified as being required following a complaints investigation and which was still outstanding, the manager agreed to address these items. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 20 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, 36, 37 & 38 The acting manager, who recently came into post, has begun to take reasonable steps to review management systems and arrangements in the home and to formulate a management plan. However, investment and support from the registered provider is essential to ensure that the health safety and best interests of service users is effectively promoted and protected. EVIDENCE: The acting manager came into post during December 2005 and was in the process of carrying out a management assessment of all systems in the home, in accordance with priority. The Inspector will therefore assess progress and compliance with previous requirements made in respect of the management of the home at the next inspection for this service, as many remain outstanding. (There is no formal system of quality assurance monitoring in place). Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 21 The arrangements for the management and handling of service users monies were examined and were satisfactory. A number of records, which are required to be kept, were examined during the inspection process. These were satisfactory and securely stored. The arrangements for ensuring safe working practises in the home were discussed with the manager and staff. The manager had begun to address areas of health and safety training outstanding by the completion of a staff training needs analysis and a training plan had been put into place. At the previous inspection for this service evidence was not provided in relation to a number of areas, which would indicate that all systems and equipment were being properly maintained in accordance with legislation requirements. These areas of serious concern have now been raised separately in writing with the registered provider requiring immediate action to be taken. (See also environment section of this report). The systems and arrangements for the reporting and recording of accidents in the home were examined and were satisfactory. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X 1 2 STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 1 3 1 Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13 & 23 Requirement (YA 24 applies here also). The registered person must ensure that where a timescale has been set for compliance with any standard relating to the physical environment of the home, a plan and programme for achieving compliance is produced and followed and records kept. NB Original timescale 30.09.05). Recommendations made by the Fire Officer must be fully complied with in accordance with the timescale he has set – adequate precaution must be taken to prevent, detect, contain and extinguish fire. (YA 24 applies here also). (YA 30 applies here also). Radiators in all areas to which service users have access must be guaranteed low surface temperatures or be suitably guarded. Written programme detailing action plan to be forwarded to the Commission – as per immediate requirement letter. NB Original timescale 30.09.05). DS0000002048.V271994.R01.S.doc Timescale for action 28/02/06 2 OP19 23(4) 11/02/06 3 OP26 13(3) 28/02/06 Burton Closes Hall Nursing Home Version 5.1 Page 24 4 OP24 16(2)(c) (YA 26 applies here also). Suitable locks and door handles or push plates must be provided to all service users bedroom doors, together with lockable storage space for those bedrooms which have none provided. (NB Original timescale 30.09.05 request for maintenance plan). (YA 24 applies here also). The registered person must undertaken appropriate consultation with the authority responsible for environmental health and safety for the area,which the care home is situated. (In this instance HSE who visited the home in 08/05 in order to obtain feedback/report of that visit). A mechanical sluicing disinfector must be provided in the nursing unit. (YA 24 applies here also). Carpet replacement must be undertaken as necessary, with details to be included the maintenance and renewal plan as referred to under Point 1. above. (YA 29 applies here also). Appropriate signing/aids to orientation must be provided for key areas of the home. Grab rails must be provided to corridor areas in the residential unit). (YA 33 applies here also). The registered person must ensure that sufficient numbers of staff are provided at all times - with suitable experience and training (in accordance with the manager’s review proposals). The arrangements for staff training and updates in relation DS0000002048.V271994.R01.S.doc 30/11/05 5 OP19 23(5) 28/02/06 6 7 OP26 OP19 13(3) 23(2) 31/07/06 31/07/06 8 OP22 23 30/04/06 9 10 OP22 OP27 23(2) 18(1) 30/04/06 28/02/06 11 OP30 18(1) 28/02/06 Page 25 Burton Closes Hall Nursing Home Version 5.1 12 OP33 24(1) 13 OP36 18 14 OP38 13 to tissue viability/pressure ulcer prevention, pain management and adult protection must be reviewed and included in the training plan for the home as necessary. (YA 39 applies here also). The registered person must establish and maintain a system for reviewing at appropriate intervals, and improving the quality of care provided at the home (including the quality of nursing care. (Formal quality monitoring system). (From 04.11.05 additional inspection). (YA 36 applies here also). The registered persons must ensure that care staff receive formal supervision at least 6 times a year - which includes suitable arrangements for the clinical supervision of registered nurses in the home. (From 04.11.05 inspection). (YA 42 applies here also). The health and safety of service users (and staff) must be ensured at all times – evidence of the safe maintenance of the electrical hardwiring system and portable appliance testing must be provided – original timescale 31.10.05 (see also immediate requirement letter dated 19.01.06). 31/03/06 31/01/05 31/03/06 Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 26 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 (YA 20 applies here also). (As the weather becomes warmer later in the year) The acting manager should monitor the temperatures of the medicines storage room in the hall and ensure temperatures appropriate for the requirements of medicines storage. Burton Closes Hall Nursing Home DS0000002048.V271994.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Burton Closes Hall Nursing Home DS0000002048.V271994.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. 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