Inspection on 02/08/05 for Burton Closes Hall Nursing Home

This inspection was carried out on 2nd August 2005.

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

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

Other inspections for this house

Burton Closes Hall Nursing Home 17/04/07

Burton Closes Hall Nursing Home 23/05/06

Burton Closes Hall Nursing Home 16/01/06

Burton Closes Hall Nursing Home 08/02/05

Burton Closes Hall Nursing Home 26/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Burton Closes Hall Nursing Home Haddon Road Bakewell Derbyshire DE4 1BG Lead Inspector Susan Richards Unannounced 02 August 2005 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 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 C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 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 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 Mr John Andrew Hill Anita Smith-Acting Manager Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (5) with nursing. of places Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Completion of kitchen re-organisation and provision of a covered walk-way/link from the Hall to the House. - now complied with. The condition relating to the private accommodation of a former named service user does not now apply as that service user no longer resides in the home. Date of last inspection 8th February 2005 Brief Description of the Service: Burton Closes Hall Care Home provides nursing and personal care and support for 47 older persons and 5 younger adults with physical disabilities. The home is organised into three separate units. Burton Closes Hall accommodates those older persons receiving nursing care over two floors, with 5 physically disabled younger adults located within the Orangery, which is at ground floor level, being a dedicated and separate living area. Older persons receiving personal care only are accommodated in Burton Closes House, which is over three floors. All areas of the home can be accessed by shaft lifts. Each area has its own communal lounge and dining space and bathroom and toilet provision, which are generally suitably equipped. 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. There are central catering and laundry facilities, although each service user area has a small kitchenette facility. Ramped access is provided to a courtyard, with seating areas organised. There are separate garden areas which are generally well maintained. There has been a change of Manager since the previous inspection. The Acting Manager is supported by a team of Registered Nurses, care and hotel services staff. Staffing is organised in accordance with the three service users groups accommodated, with named nurse and key worker systems in operation. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? Work in relation to the relocation of the main kitchen has been completed, including the development of satellite kitchens in the younger adults unit (Orangery) and the house, which accommodates service users receiving personal care only. Work has also been undertaken in the laundry and a proper floor coating is now provided. Photographs of service users are in place and care plans inspected were up to date and evidenced regular reviews. Detailed inventories of service users belongings were also properly recorded. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 4 There were satisfactory systems and arrangements in place to ensure that service users individual needs were full and properly assessed. The Inspector was unable to properly determine as to whether staff individually and collectively had the skills and experience to ensure that service users care needs could be fully met, given the lack of information and records in relation to staff training and recruitment. EVIDENCE: The Statement of Purpose for the home and Service User Guides were not examined on this occasion. This has been evidenced as being provided at previous inspections for this service, although with no details of room sizes provided therein. Recorded individual needs assessments were examined of those service users case tracked. These were in accordance with a recognised needs assessment model and were well recorded and were up to date. Person centred daily living Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 9 plans were also recorded, which included details of individual’s lifestyle preferences. Copies of the single assessment and care plan summary were provided for those service users whose admissions to the home had been arranged by way of care management (social services) arrangements. Discussions with staff and service users and their representatives indicated that staff were conversant with the overall care needs of service users accommodated. However, significant deficits in staff training and recruitment were identified (see Complaints and Protection and Staffing sections of this report). Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. Overall there were satisfactory systems and arrangements in place to facilitate the meeting of service users health care needs, although attention is required to some aspects of medicines storage and administration and the provision of up to date written policy guidance for medicines. EVIDENCE: Written care plans were recorded for each service user case tracked. These were in accordance with identified needs assessments and formulated within a framework of risk management. They were reflective of relevant clinical and professional guidelines and were reviewed monthly. Individual person centred daily living plans were in place, which reflected service users lifestyle preferences and likes and dislikes. However, these were not signed by the service user themselves or a representative where they were unable to do so. There were satisfactory arrangements in place to enable service users to access outside healthcare professionals, including that for the purposes of routine health care screening. Records of inputs from outside health care professionals were kept for each service user. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 11 The arrangements for the management and administration of medicines in both the house and hall were examined. A number of requirements were identified in relation to policy guidance and the administration and storage of medicines. Staff was observed to be respectful in their interactions with service users and mindful of their needs. Discussions with staff and service users and their representatives were reflective of this. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 12 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 standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16, 17 & 18 There were satisfactory systems in place to enable service users and their representatives to complain. Staff was not fully conversant with recognised procedural guidance in relation to adult protection. The arrangements for staff training and updates in tissue viability/pressure ulcer prevention and pain management were not confirmed. There was no clear guidance for staff in relation to dealing with violence and aggression in the workplace. EVIDENCE: There is a satisfactory complaints procedure in place, which is openly displayed. Three complaints had been received since the previous inspection, which were recorded in accordance with the home’s complaints policy, including details of action taken and outcomes. Since the previous inspection there has been an investigation under Derbyshire’s joint agency adult protection procedures in relation to the alleged neglect of a service user in the home. Details of the investigations together with outcomes and action taken/agreed by the registered provider as a result of these have been provided. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 14 Recommendations were made via the adult protection group in relation to the above, which were agreed by the representatives of the registered provider. These included the need to arrange for staff training and updates on tissue viability/pressure ulcer prevention and also pain management. Details of the arrangements for staff training as provided in the pre-inspection questionnaire completed by the Acting Manager did not include these arrangements. Internal policy and procedural guidance was in place in the home in relation to adult protection. The Inspector spoke with some staff about the action they would take in response to any allegation or witnessing of the abuse of any service user. Their responses demonstrated a ‘common sense’ approach, but they were not familiar with Derbyshire’s joint agency adult protection procedures. The Inspector also spoke with staff about dealing with violence and aggression. They were not aware of any policy guidance being in place in relation to this. The arrangements for service users monies were not inspected on this occasion. These will be inspected at the next inspection for this service later in this inspection year 2005-06. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26. Whilst the registered person has clearly focused on some aspects of the upgrading of the premises, which has included the provision of increased single room/en suited accommodation for service users, there are a significant number of areas where the health and safety of service users is not being adequately promoted and where health and safety requirements are not met. EVIDENCE: A full tour of both buildings was conducted, including the Orangery. All communal areas accessed by service users were inspected and some bedrooms, including those of service users case tracked. Areas of the home were generally clean and odour free. A number of health and safety issues were identified, which included missing window restrictors to windows first floor and above, radiators, which did not have low surface temperatures, including those located in service users own rooms, having no suitable guarding/covers, inadequate hand washing facilities and waste receptacles in some areas and unsafe storage of some substances Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 16 potentially hazardous to health. (The arrangements for external clinical waste storage and disposal were not examined on this occasion – these will be assessed at the next inspection for this service during 2005-06). There was no written programme in place for the redecoration and renewal of the home. A number of corridor areas required redecoration and replacement of carpets, which were heavily worn and stretched. Woodwork to doors, doorjambs and skirting boards were heavily damaged in these areas. There was no signing in the home for key areas such as bathrooms and toilets to aid orientation for service users and many bedroom doors did not have handles or push plates on the outside of the door. Some corridor areas did not have handrails provided. The exterior paintwork/windows were also in need of repair and attention as was some garden furniture. Details of the Fire Officer’s most recent inspection of the home (June 2005) were provided. This was a follow up visit from 02nd February 2005 when a number of recommendations were made in respect of fire precaution. The Fire Officer identified some items, which remained outstanding and gave an extended timescale for compliance with these. The Inspector observed and pointed out to the Manager, a number of fire doors, which were held open with door wedges. There were a number of areas of deficit in relation to required maintenance, which are also referred to in the Management and Administration section of this report. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30. Whilst there were sufficient numbers of staff provided, there were deficits in relation to some areas of staff training. Record keeping in relation to staff recruitment was poor and service users were not protected by the home’s recruitment practises. EVIDENCE: The details of staff employed, including recruitment details, together with four weeks duty/staffing rotas were provided. Rotas indicated sufficient numbers of staff on duty and discussions with care staff reflected this. Discussions were also held with the manager and staff about the arrangements for staff recruitment and the organisation of staff on duty in the home. Serious concerns were raised separately in writing during the inspection regarding the lack of proper recruitment practises for some 12 staff employed by way of failure to ensure that criminal records and POVA checks were consistently and properly undertaken for these staff. The files of two staff more recently employed were examined – one of these did not contain written references. Details of staff training undertaken in the previous 12 months were and also training planned was provided by way of the inspection questionnaire, which indicated provision of a variety of staff training. However, there was little in the way of staff training records kept in the home. The Acting Manager, who is Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 18 new in post, advised that she had identified this and had recently undertaken a training-needs analysis, although this was not available for inspection or any written plan. The Inspector will assess progress in this area at the next inspection for this service. Comments are also made under the Complaints and Protection section of this report in relation to some areas of staff training. Staff spoken with advised of core training they had undertaken, which was satisfactory and also NVQ training. The Inspector was advised that 42 of care staff have achieved at least NVQ level 2. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37, & 38. A review of management systems is required to ensure that the health, safety and welfare of service users and staff are consistently promoted and fully protected. EVIDENCE: There has been a change of Manager since the previous inspection. The Acting Manager now in post is currently undertaking the fit persons process in relation to their application to the Commission as Registered Manager for the home, although not all information requested has been received in relation to this application. Discussions with the Manager and staff indicated that there are proper systems in place for the continuous supervision of staff on a day-to-day basis. However, there was no formal system in place for the individual supervision of staff. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 20 A number of records, which are required by law to be kept in the home, were examined and the arrangements for the storage of service users records examined. Deficits were identified in relation to staff recruitment and training records. Service users care records were not stored safely and securely. Details of staff training were provided by way of the pre-inspection questionnaire, although as previously identified individual staff training records were poor. Information provided included core training arrangements for fire safety, first aid, moving and handling and food hygiene and handling, although actual numbers of staff who had attended or who were due to attend was not clear. Arrangements for staff training in relation to infection control were not provided. Details of the required maintenance of equipment in the home were provided. There were a number of areas where there was no up to date evidence of required annual servicing/maintenance. The arrangements for ensuring that risk assessments are carried out for all safe-working practices were discussed with the manager. A number of potential/significant environmental risks were observed and pointed out during the inspection to the Manager. There were no recorded environmental risk assessments recorded in relation to the premises and safe working practises therein. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 3 3 2 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 2 2 1 Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 22 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 OP24 & YA26 Regulation 16(2)(c Requirement Timescale for action 30.11.05 2. OP7 & YA7 3. OP25 & YA24 4. OP1 & YA5 5. OP1 & YA1 Suitable locks must be provided to service users bedroom doors and lockable storage facilities provided in those bedrooms without. Original timescale 31.07.04. 15(2)(a)(c The registered persons must ) & (d) ensure that (unless impracticable) service users are consulted about their plan or any revisions of it and that it is available to them. Original timescale 30.04.05 13(4)(a) Systems must be in place to & (c) ensure that hazards to the health and safety of service users are highlighted and so far as practicable eliminated. Original timescale 30.04.05. 5 (5A Individual written terms and amended conditions must be provided 2003) between the home and each service user, which provide information in accordance with this standard(s) and regulation. (Original timescale not given on previous report). NB THIS STANDARD WAS NOT INSPECTED ON THIS OCCASION. 4, Details of individual room sizes Schedule must be included in the C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc 31.09.05 01.10.05 30.09.05 30.09.05 Page 23 Burton Closes Hall Nursing Home Version 1.30 1 6. OP9 & YA20 OP9 & YA20 13(2) 7. 13(2) 8. OP9 & YA20 13(2) 9. OP9 & YA20 OP9 & YA20 13(2) 10. 13(2) 11. OP9 & YA20 13(2) 12. OP30 & YA35 18(1)(a) & (c) 13. OP18 & YA23 OP18 & YA23 18(1)(a) & (c) 13(6) & 18(1)(a) 14. statement of purpose for the home. (Original timescale not given in previous report). A detailed medicines policy must be provided for Burton Closes House in accordance with recognised guidance. Creams and lotions must be properly stored at all times in accordance with recognised guidance for the storage of medicines. Medicines/creams must not be administered to any other service user than that person for whom they are prescribed and whose name is identified on the container label. The medicines storage room in the Hall requires review and upgrade with provision of a work surface. A minimum and maximum thermometer must be provided for the daily measurement of the temperature of the medicine refrigerator. Staff must be conversant with the action to take if the temperature is outside the normal range. A review of the temperature of the medicines storage room in the Hall must be undertaken - it must be ensured that room temperatures must be appropriate for medicines storage. Details of the arrangements for staff training and updates in tissue viability/pressure ulcer prevention and pain management must be confirmed. Clear policy guidance must be provided for staff in relation to dealing with violence and aggression. Registered persons must ensure that staff have access to and are 30.09.05 30.09.05 31.08.05 30.11.05 30.09.05 30.09.05 30.09.05 31.10.05 30.09.05 Page 24 Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 & (c) 15. OP19 & 25 & YA24 13(4)(a) & (c) 16. OP38 & YA42 13(4)(a) & (c) 17. OP25 & YA42 13(4)(a) & (c) 18. OP26 & YA30 13(3) 19. OP26 & YA30 OP38 & YA42 13(3) 20. 13(4)(a) & (c) 21. OP19 & YA24 23(2)(b) 22. OP19 & YA24 23(4) conversant with Derbyshires joint agency adult protection procedures. Environmental risk assessments must be undertaken of all areas of the building and recorded together with details of action taken. This must include an process for review. The registered person must ensure the provision and maintenance of window restrictors based on assessment of risk to service users. Radiators in service users private and communal accommodation must be suitably guarded or have guaranteed low suface temperatures. Dispensible soap and paper hand towels must be provided to sinks in accordance with the assessment of risk to staff and service users and the principles of infection control. Waste receptacles in toilets and bathrooms (including service users en suites) must be occlusive. The registered persons must ensure compliance with COSSH Regulations 1988 - cleaning materials must not be left out openly around the home. They must be properly and safely stored. A written programme of maintenance, repair and renewal must be provided, which includes all items detailed under the Environment section of this report. A copy must be forwarded to the Commission detailing timescales for action. Recommendations made by the Fire Officer must be fully complied with. Adequate precautions must be maintained 31.10.05 31.08.05 30.09.05 31.10.05 31.10.05 30.09.05 30.09.05 immediate attention. Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 25 23. OP38 & YA42 13(4)(a) & (c) & 23(2)(b) 24. 25. OP28 & YA32 OP29 & YA34 18(1)(a) & (c) 19 26. OP29 & 37 & YA34 & 41 OP31 & YA37 OP36 & YA36 27. 17, Schedule 4 & 19 Schedule 2 9(1) & (2) 28. 18(1)(a) 29. 30. OP37 & YA41 OP30 &YA35 17(1)(b) 17(2) & 18(1)(c and door wedges must not be used to prop open fire doors. The registered person must ensure the safety of service users and staff and provide evidence of proper maintenance of the following - Gas Safety Certificate (Landlords), electrical hardwiring certificate and portable appliance certification. Copies of these must be forwarded to the Commission. A minimum ratio of 50 of care staff must have at least NVQ level 2 by end December 2005. Evidence of satisfactory CRB/POVA checks must be confirmed for all staff working in the home. New staff must only be confirmed in post following completion of satisfactory checks. NB IMMEDIATE REQUIREMENT MADE DURING INSPECTION. Records must be kept in the home in respect of each staff member working there in accordance with regulatory requirements. The Acting Manager must provide the necessary information required to complete the fit persons process. There must be a formal system in place for the individual supervision of care staff and the clinical supervision of nurses working in the home Service users records must be kept securely. Individual staff training records must be kept and a training plan maintained. 31.10.05 31.12.05 02.09.05 30.09.05 30.09.05 31.10.05 30.09.05 31.10.05 Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 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 Good Practice Recommendations Burton Closes Hall Nursing Home C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection South Point 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 C52 C02 S2048 Burton Closes V234352 020805 Stage 4.doc Version 1.30 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!