Care Home: Burgh House

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What the care home does well What has improved since the last inspection? Some parts of the building have been improved since the last inspection with bedrooms made larger and redecorated and new radiators with low surface temperature installed. Loose flooring identified at the last inspection has been replaced. The registered person is now carrying out monthly quality review reports which help to keep up the standards of the home. What the care home could do better: There are some areas where choice needs to be increased. Some residents would like daily showers instead of a weekly bath and some would like to be taken out more. The food is generally appreciated but there is no choice on the menu. These areas need to be reviewed. The process for recruiting staff needs to be much more rigorous to ensure that residents are kept safe. Checks and references have been gathered but not in a methodical way before the person is taken on. This needs to be tightened up to comply with the regulations. Policies on safeguarding adults and on wills/bequests need to be clearer so that residents are kept safe. The home could increase the facilities in residents` bedrooms to allow them more independence and privacy. A locked drawer would enable residents to look after their own money and documents. CARE HOMES FOR OLDER PEOPLE Burgh House High Road Burgh Castle Great Yarmouth Norfolk NR31 9QL Lead Inspector Mrs Dorothy Binns Unannounced Inspection 29th October 2008 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 Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burgh House Address High Road Burgh Castle Great Yarmouth Norfolk NR31 9QL 01493 780366 01493 789250 greiner@hotmail.co.uk 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) Burgh House Residential Care Home Ltd Mr Joseph Greiner Mrs Helen Harris Care Home 33 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (33) of places Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-three (33) Older People may be accommodated. Date of last inspection 9th November 2006 Brief Description of the Service: Burgh House is a care home providing personal care and accommodation for 33 older people and is owned by a limited company – Burgh House Residential Care Home Limited - with Mrs Julie Church-Greiner registered as the responsible individual. The home is situated within the village of Burgh Castle on the outskirts of Great Yarmouth. The home was opened in 1987 and consists of a two-storey building. It has 29 single and two shared bedrooms with en suite facilities. One of the single bedrooms is used for respite accommodation. Access to the first floor is via a shaft lift. The premises consist of a two-storey building situated in large attractive grounds with ample parking at the front of the building. The current range of fees for living at the home are from £346.50 - £387.50 per week with additional costs for hairdressing, chiropody, toiletries, newspapers and magazines. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. Care services are judged against outcome groups, which assess how well a provider delivers the service. This report gives a brief overview and current judgements for each outcome group. For the inspection, the manager completed a lengthy questionnaire about the service which told us what was happening in the home, what improvements had been made and where the manager thought further changes could be made. Records held by the Commission and previous inspection reports were also checked. This information was valuable in helping the Commission reach a judgement about how well the home was faring. This key inspection also comprised an unannounced visit to the home that lasted seven hours. Records and policies were examined and discussions took place with the manager and staff in the home. In addition five people living in the home were interviewed in private to see what they thought of the home. Survey forms were also sent to a sample of residents for their views. Five replied. Two staff also answered a survey form. All of these views have been incorporated into the report. Overall residents were happy in this home and felt treated well. We have identified some areas for improvement and review but are confident that the manager will look positively on the report and take things forward. What the service does well: The service makes its residents feel comfortable and well looked after. Residents are very positive about the home and like the staff. The daily routine is flexible and this gives them a sense of being able to please themselves. There are also a lot of in house activities. Some of their comments included “Life is very nice here” “If I left here tomorrow, I’d give them a good report” “Life is brilliant – it’s a very good place” “It’s pretty good here”” The service is good at ensuring that residents have access to community medical facilities and that their health care needs are monitored. They look after and administer medication safely with only trained staff doing that task. The service is good at providing training for staff and has embarked on a new induction programme that will comply with national standards. Other training Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 6 opportunities are also good providing competent and satisfied staff which benefits the residents. The home has also approximately half of its staff trained in a national care qualification (NVQ2) and another six staff are currently studying for it. This again can give confidence to the residents that staff are trained for the job and able to meet standards of care. The residents described the carers as “very helpful”, They “do anything for you”, “the girls are excellent” were some of the comments. The manager is accessible and residents feel they will be listened to. What has improved since the last inspection? 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 Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 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 Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are all fully assessed before coming into the home to make sure their needs can be met and that the care will be individual. EVIDENCE: Three care files were examined to see what information the home had received about the residents. All contained information from outside assessors, such as social services or from a hospital giving details of the care required. The Home also carries out its own assessment, the manager confirming that everyone is visited first before they come to the home and where possible come for a visit to see the home. The home assessments are full giving details of routine and social care as well as the physical aspects of the care required. This information forms the basis for the care plan and the information is reviewed regularly. The home also carries out a holistic risk assessment to ensure safety issues are covered. Residents thought they were well cared for in the home indicating that the care was appropriate and individual. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents do feel well treated in this home and find the staff kind and considerate of their needs. Their health is also monitored closely and they can be confident that the home’s procedures on medication ensure that it is given out safely. EVIDENCE: All residents have detailed information in their files about what care is required and what they are able to do themselves. Care files also contain information about routines and social activities. Staff have full access to these files and write daily notes on how the resident is progressing in the home or about any difficulties experienced. Reviews of care were seen to be in place though one resident told the inspector that he had not had a review of his care. There was some duplication of information in the files and when talking to residents some aspects of their care were not being carried out, for instance a person preferring showers but not having them. Some refocusing of these reports could be carried out though in general, residents experienced the care as good Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 11 saying things like “the staff are all helpful” and “ the staff are excellent”, indicating that they felt well looked after. Of the five people returning the survey form sent to them by the Commission, four said they “always” received the care and support they needed, and one said they “usually” did. Files showed that residents did have access to community medical facilities and doctors, district nurses, chiropodists all attended the home. Information from the manager confirmed that opticians and dentists pay regular visits to the home. A fitness instructor also comes in weekly to provide exercise to those who want it. When asked about access to medical services, the residents seen at the inspection said there was no problem getting to see the doctor. They gave examples of contact with community services, for example over wound care and diabetes. One district nurse returned a survey form to the Commission and confirmed that she liaised with the home on particular issues. Five residents completing the survey form said they “always” received the medical support they needed. Staff also confirmed that they will accompany residents to a healthcare appointment if a relative cannot take them. Staff also monitor how well people are eating and it was noticed that all residents have drinks in their room to ensure their fluid intake is satisfactory. How the home looks after residents’ medication was checked. All medication is kept in a locked room and a locked trolley is used to take medication round to people. A monitored dosage system is used where the medication is pre packed by the pharmacist. Only senior staff give out medication and they have been trained to do so. Two people’s medication was checked against the records and the supply, and found to be administered and recorded satisfactorily. Controlled drugs are kept in a special cupboard and given out by two staff together who sign the record. Residents had no complaints about the way medication was given out and felt they were receiving their medication correctly. Residents overall feel well treated by staff. “Life is very nice here”, “I have a good laugh with them” and “It’s pretty good here” were some of the comments. One person said she wouldn’t stand for any indignities when asked about her treatment. Another said that “as soon as I ring the bell those girls are here” meaning that she wasn’t left waiting for staff to help her. Personal care is provided in private and visitors can be seen in their bedrooms. The district nurse replying to the Commission’s survey confirmed that she sees her clients in private at all times. In general staff seen spoke positively and respectfully about the residents. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some aspects of daily life suit the residents very much and they feel comfortable in the home. There are areas where improvements and changes should be made to enhance their quality of life. EVIDENCE: All the residents seen at this visit said they could please themselves about their daily routine and get up and go to bed when they liked. Several mentioned quite late bedtimes and one person said she got up herself. “If I’m not downstairs by 9:30am they come and find me” (to make sure she is alright) Another said she pressed the bell once she was ready and the staff came to help her downstairs. Staff said that a few were up early and that residents found their own routines. One routine that was more rigid was the bathing regime which residents said was once a week. This suited one person spoken to but two of the people seen said they had been used to showers several times a week when in their own home but that they did not have the facilities here. One resident said “the bathing arrangements are awful” and went on to say he had waited a long time to have a bath when he first arrived. He also did not like being woken up Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 13 to have a bath at 7:30am. There are also no evening baths as the home has a special member of staff on duty in the mornings to help with bathing. With regard to activities, residents said there were a number of activities offered and you could choose whether to participate or not. An entertainer comes in once a week and a fitness instructor. The home organises bingo every week and there is a scrabble and card group. The home has parties regularly, the hairdresser comes weekly and the vicar comes in once a month. Of the five people returning the survey form, three said there were “always” activities arranged by the home and two said there “usually” were. Of the residents seen, three said that the home did provide in house activities though one person said there was nothing to do except watch television. Three out of five said they would like to be taken out more and were never taken out for a walk. One person said “They don’t let us” (go out). One said I have lost my independence because I can’t even post a letter. The home does not hold formal residents meetings and the key worker system is not fully developed which may be hampering the ability of the home to provide individual stimulation. Residents were able to see their relatives and enjoyed their visits and outings. They relied on them to go out. There is little going on in the local community though the manager said that he had on occasion taken someone to the pub. The home has recently sponsored a local girls football team who now have links with the home and the volunteers coming into the home are local people. Residents are able to exercise choice over their daily routines, whether to participate in activities and in having a say over bringing their possessions into the home. As mentioned earlier, the bathing routine is not offering enough choice and residents are not taken out and rely on staff doing their shopping when they might prefer to be taken out to do it themselves although the home does organise a clothes show four times a year where residents can see the clothes and purchase items. Too many residents have their finances looked after by the home when they could look after their money themselves if provided with a locked facility. Autonomy could be further encouraged. The menus of the home showed a four weekly rotating menu which looked varied and nutritious. However there was no choice offered and residents confirmed that was the case. One person said they “enjoyed their food”, another that “the dinner was good but there was no choice”, another that “the standard of food was good but I don’t like all the menu” and another that “ the food was pretty good”. The five people answering the survey were varied in their replies with two saying they “always” enjoyed the food, two saying they “usually” did and one saying they “sometimes” did. Teas and breakfasts were generally satisfactory for the residents though one said there were too many sandwiches for tea. Drinks are offered throughout the day and in the evening. One resident confirmed he had drinks during the night. The manager is supporting the cook in training for an NVQ certificate and agreed that a review of the menus could be carried out to see if a more active choice could be Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 14 offered. Diets are catered for and one person with diabetes confirmed she had special desserts. However there was no record of any diets catered for. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents feel able to speak up in this home and feel protected by staff though some procedures could be more robust. EVIDENCE: The home has a complaints procedure which is welcoming in tone asking residents to speak up so that things can be rectified. Residents seen felt they could speak up to the management and they would be listened to. All five answering the survey said they knew how to make a complaint. There have been no formal complaints and none has reached the Commission. The home has a policy for safeguarding residents from abuse though some amendments are needed to bring it up to date. It stated that referrals would only be made if consent was given which is no longer best practice, and there was no procedure for notifying the Commission. However it was clear about suspending any staff where required and liaising with the police. The home did have policies on whistle blowing, on dealing with racial harassment, and aggression towards staff. The home also had a policy on the receipt of gratuities but not on the need to preclude involvement in assisting in the making of or benefiting from a resident’s will. There had recently been a question raised by the provider about such a matter. The training plan showed that most staff had received outside training on adult abuse and of the two staff interviewed one confirmed she had attended a training course. The Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 16 manager said there had been no cases of abuse so no referrals had been made to the Adult Protection Unit nor to the Protection of Vulnerable Adults register. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. This is a pleasant home for residents to live in but some extra facilities like locked cupboards and showers should be provided to allow for more choice and independence. EVIDENCE: The home is spacious and attractive with good communal space and pleasant bedrooms, all with ensuite facilities. Some bedrooms have been enlarged this year and the home is well maintained. Residents have been encouraged to make their rooms personal and individual and radiators are low surface or covered to ensure the safety of residents. Some of the doors have locks on them though residents did not seem to use them. No one had a locked facility in their room either which may contribute to the residents not feeling able to have money in their own rooms. Neither were there any additional chairs for visitors in people’s rooms. These facilities would increase the residents’ sense Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 18 of privacy and independence and should be reassessed by the manager to bring them in line with standards. The garden is a nice size with plenty of room to sit outside and residents confirmed they sat outside in the summer or had a walk around the garden. The home complies with the requirements of the fire and environmental health officers. The home has some adaptations to make it easier for people with mobility problems. There was a shaft lift and grab rails to hang on to in corridors and in toilets, and callbells in each bedroom. Three people have hoists in their rooms. The main bathroom is adapted but there is no adapted shower facility which for a home of this size restricts choice, though seven of the bedrooms have showers and there is a standard shower in one of the bathrooms. Several residents spoken to said that they had been used to having daily showers at home but were not able to have that choice here. The laundry was a separate facility and contained two washing machines with a hot wash facility and two tumble driers. The home had appropriate facilities for dealing with soiled laundry and staff are trained in infection control. Residents had no complaints about the laundry and felt their clothes were dealt with satisfactorily. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents feel that staff are very helpful and kind and that they are in safe hands, and this is borne out by the amount of staff training provided. But flaws in the recruitment process are unsatisfactory and need to be dealt with. The numbers of staff on duty should be reassessed. EVIDENCE: The staff rota was seen showing that three care staff are on duty throughout the day until 8pm and that in addition there is a bath person on duty from 6am to 1pm, a cook on from 8-2pm, two domestics on duty in the mornings and a manager. Two waking night staff are on duty between 8pm and 8am. Residents did say they found the staff helpful indicating that they did not feel rushed. However they did have things to say about the frequency of bathing and their wish for more outings which could be an indicator that more staff hours are needed. The lack of a teatime cook in such a big home also has implications for staff time as the care staff are having to make the tea. When staff hours were more clearly indicated in the past by inspectors, this current rota would have shown a shortage of about 30 hours. The manager will have to consider how best to meet the needs of his residents and ensure that the numbers of staff are sufficient. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 20 NVQ training is on course with the training plan showing seven out of fifteen carers already qualified to NVQ2 level. A further six are undergoing training enabling the home to exceed the standard once they have completed their training. Four staff files were examined to see what the recruitment process was. Some checks and references are obtained but there were flaws in the process. Three files showed that no checks had been made against the Protection of Vulnerable Adults register (of people who should not be working with vulnerable adults). Two subsequently received a satisfactory criminal records check but these came in three months later. One new staff still did not have her criminal records check though the manager said she was under supervision. Two files showed that only one reference had been obtained and there was no reference from the previous employer on one. Evidence of identity had been provided and job descriptions and contracts were in place. A code of practice had also been given out to staff. Overall recruitment processes are not rigorous enough. There was evidence of induction training on the staff records and the manager showed workbooks from a new induction scheme that will comply with the Common Induction Standards. One new staff was half way through her training and two staff interviewed said they felt there were good opportunities for training in the home. A training plan showed what courses staff had completed and showed that training was ongoing. Staff files also showed training certificates and what each staff had achieved. Residents felt staff were competent and did their jobs well indicating that they were trained for the job. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents live in a home which is managed well and where their safety is taken seriously. Residents’ views are taken into account and their financial interests safeguarded. EVIDENCE: The manager is qualified and of good character and has been running the home for some years. He is related to the owners of the home. He has an open approach, and residents spoke well of the management team and felt them to be easily approachable. The manager cooperates well with the Commission and welcomed discussions about the home during the inspection process. He was able to take on board criticisms about the home and think about how to improve matters. An assistant manager is also in place who Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 22 shares some of the responsibilities. Some budget control still rests with the provider who takes an active interest in the home and completes regular audits of the home. Two staff returning the survey and two seen at the visit confirmed that the manager was approachable and that communication was good. The home has a quality assurance system where the residents are asked for their views about the home on a regular basis. Staff also complete surveys. A summary of conclusions was seen following the last round of surveys. The annual quality assurance assessment was produced for the Commission and listed where the home hoped to make improvements. An action plan would take this system further by focussing on what needed to be done. The home also takes action to meet the requirements identified in inspection reports and the provider makes regular reports on the home. The home helps several residents with their money and keeps it safely on their behalf. Records were seen showing all the accounts of residents’ money and what amounts were held in cash on their behalf. This was seen to be administered satisfactorily but the practice was felt to be reducing the independence of some residents. The manager was advised to relook at why residents were not looking after their own money and what could be done to help them. The home has a comprehensive health and safety policy outlining its responsibilities for safe working practices. The training plan showed that most staff had completed moving and handling training, fire training and other training sessions on health and safety. Most also had food hygiene training and infection control. The fire record was seen and confirmed that equipment was checked regularly and alarms tested. The manager said that staff have a fire drill once a year though this was not recorded. The lift is regularly serviced and an accident book is kept. Water temperatures are tested though seen to be much higher than the recommended 43 degrees. Risk assessments were seen on residents’ files and equipment to help people move more easily was in place. Overall the safety of residents was taken seriously. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x 2 x x x x 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 12(3) Requirement Timescale for action 31/01/09 2. OP18 13(6) 3. OP29 19 4. OP38 13 The registered person must take into account the wishes and feelings of the residents regarding their welfare. In this instance there should be more choice regarding outings and a more flexible routine on bathing. The registered person must 31/12/08 make arrangements to prevent residents from being abused by having appropriate procedures in place. In this instance the safeguarding procedure needs to be updated and there needs to be a policy on bequests/wills. The registered person must not 31/12/08 employ a person to work in the care home unless he has obtained all the information and documents specified in paragraphs 1-7 of Schedule 2. The registered person must 31/12/08 ensure that unnecessary risks to the health and safety of the residents are identified and as far as possible eliminated. In this instance water temperatures were well beyond the safety level of 43 degrees. DS0000027440.V372985.R01.S.doc Version 5.2 Burgh House Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP7 OP15 OP19 OP27 OP35 Good Practice Recommendations It is recommended that the care plans are reviewed to ensure they reflect what the residents want. It is recommended that a choice of menu is provided. It is recommended that the facilities in residents’ bedrooms are reviewed in line with standards. It is recommended that the staff rota is reviewed and if necessary increased to enable staff to accommodate more of the residents’ choices. It is recommended that residents are encouraged to, and given facilities for, looking after their own money. Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Burgh House DS0000027440.V372985.R01.S.doc Version 5.2 Page 27 - 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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