Care Home: Burroughs, The

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What the care home does well The home has comprehensive documentation to provide to prospective new residents and their relatives. Comprehensive assessments of need are undertaken before a new resident moves into the home. Clear contract terms and condition statements are issued to new residents. Good standards of care are provided. Computerised care planning systems are in place and working well. Health and medication procedures are good. A full programme of activities is offered on weekdays. Food is of a good standard and is served in attractive surroundings. The home is in a pleasant area and is well designed. Security within the building has been enhanced by the installation of key-pad locking systems. The premises have been risk assessed. Administrative record keeping is generally of a high standard. A substantial amount of staff training is provided, and good training records are maintained. Formal professional supervision of staff members has commenced and its planned frequency exceeds the NMS. The home is well managed. Residents and relatives told us they were pleased with the care provided at The Burroughs. What has improved since the last inspection? Hard copies of the assessments and care plans of every resident are available for relatives to see. The assessment process documentation is excellent. The medication aspects of the care plans are now kept up to date. A section of the care plans now considers general health needs. Redecoration has taken place in ground floor communal areas. Some improvements have been made to kitchenettes. Tablemats have been replaced. The access to one toilet has been improved, and ventilation systems have been checked. No mal-odours were noted on the day of the inspection. Improvements to the hot water supply are underway. A recruitment drive for more permanent staff has taken place, and 15 additional care staff members are working towards obtaining NVQ awards in care. Formal supervision of staff has been increased and the system now includes annual staff appraisals. Quality control systems concerning health and safety matters have been strengthened. An independent system of assessing customer satisfaction levels has been introduced. What the care home could do better: The home`s Statement of Purpose must accurately reflect the current services available, and the current staffing levels. Whenever a period of respite care finishes, the care home should complete a report summarising the outcomes of the stay, and keep the report on the resident`s care file in order to assist the home`s staff to provide the best possible care, if and when the resident returns for a further period of respite care, or moves in as a long-term resident. Whenever a resident suffers a fall, a risk assessment must be undertaken or updated concerning the possibility of further falls and how to avoid them occurring. This is a restated requirement. When any risk assessment form is being filled in, the process must be completed by scoring the risk in order to ascertain the likelihood and severity of a resident suffering an injury if action is not taken to reduce the risk. Fire escape doors that are in a poor state of repair must be replaced urgently in order to offer better protection to residents and staff. Advice must be taken from the Fire Authority concerning evacuation of the premises via the back garden as one of the gates is currently locked. The institutional looking waste bins in the kitchenette areas, some of which have unhygienic rusting lids, must be replaced in order to improve the living environment for residents. The damaged chair in the foyer should be removed, the soiled wall by the entrance to the home should be washed down, and dining room chairs should be moved between units so that matching sets can be re-established where possible to create a more attractive home for residents and their visitors. Full and satisfactory recruitment checks and information must be obtained and be available for inspection on every person employed in the care home to ensure that residents are adequately protected. CARE HOMES FOR OLDER PEOPLE Burroughs, The Mill Road West Drayton Middlesex UB7 7EQ Lead Inspector Robert Bond Key Unannounced Inspection 22nd April 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 Burroughs, The DS0000027126.V360665.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. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burroughs, The Address Mill Road West Drayton Middlesex UB7 7EQ 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) 01895 435 610 01895 435611 manager.burroughs@careuk.com www.careuk.com Care UK Community Partnerships Ltd Matthew Stephen Bowden Care Home 75 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (39) of places Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 2nd October 2007 Brief Description of the Service: The Burroughs is a care home for 75 older people situated in a pleasant residential area, not very far from West Drayton High Street and associated shops, facilities and public transport. The home was originally built and operated by the London Borough of Hillingdon but is now operated by Care UK Community Partnerships Ltd. The London Borough of Hillingdon remain the sole purchaser of all the places, hence referrals have to be via the Council. The home is divided into six residential units, three of which are for ‘elderly frail’ and three are for people with dementia. The latter are on the ground floor. There are 67 single bedrooms and 4 double rooms. The home was extended in 2001 and all of the bedrooms in the new extension have an en-suite toilet. There is a large enclosed garden to the rear of the building and a large car park to the front. Burroughs, The DS0000027126.V360665.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 Star. This means the people who use the service experience good quality outcomes. This inspection was a ‘key inspection’ that considered the performance of the home against the anticipated outcomes of the key National Minimum Standards (NMS) for care homes for older people, as published by the Department of Health. During the inspection, we spent 6 hours on the premises during which time he toured the home, interviewed the Registered Manager, met other staff members, talked to residents and relatives, and examined a range of documents. Care UK’s Regional Director was present for part of the inspection. The Registered Manager, hereafter referred to as The Manager, completed an Annual Quality Assurance Assessment (AQAA) for the CSCI in advance of the inspection. The home was also supplied with CSCI survey forms for residents and their relatives to complete and send to us. However none were returned to us in time to be considered within this report. Equalities and diversity were considered throughout the inspection and no issues of concern came to light. The home is able to provide ethnic meals and is able to meet the needs of residents with physical disabilities or with dementia. Cultural and religious needs are considered during the assessment and care planning process. In total the Inspector assessed 23 of the NMS and found that the anticipated outcomes of 3 were exceeded, 15 were fully met, whereas 5 outcomes were only partially met. This led the Inspector to make 7 requirements, one of which is restated from the last inspection having not been achieved within the time scale set. The Inspector also made 2 recommendations. On the day of the inspection, the home had 10 vacancies, mostly within the elderly frail section of the home. However the dementia care section of the home is not exclusively occupied by residents with a diagnosis of dementia. This is because the number of places for people with dementia was increased in March 2007, but the anticipated level of demand has not yet been reached, and some residents in the dementia care units who do not have dementia have declined to move into other parts of the home. As the number of residents with dementia is not as high as anticipated (24 as opposed to a registration level of 36), the care staffing levels have not yet been fully increased. Two bedrooms are generally occupied by respite care residents on a temporary basis. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 6 The home still relies quite heavily on relief agency staff travelling from East London. On the day of the inspection, 240 care hours per week were vacant, but permanent employees had been found for 180 of these hours. A relief care bank of Care UK staff is also being set up. On the day of the inspection the carpeting of the upstairs corridors were being replaced by non-slip vinyl. A great deal of refurbishment work to the building, its decoration and furnishings is planned over the next three years What the service does well: What has improved since the last inspection? Hard copies of the assessments and care plans of every resident are available for relatives to see. The assessment process documentation is excellent. The medication aspects of the care plans are now kept up to date. A section of the care plans now considers general health needs. Redecoration has taken place in ground floor communal areas. Some improvements have been made to kitchenettes. Tablemats have been replaced. The access to one toilet has been improved, and ventilation systems have been checked. No mal-odours were noted on the day of the inspection. Improvements to the hot water supply are underway. A recruitment drive for more permanent staff has taken place, and 15 additional care staff members are working towards obtaining NVQ awards in care. Formal supervision of staff has been increased and the system now Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 7 includes annual staff appraisals. Quality control systems concerning health and safety matters have been strengthened. An independent system of assessing customer satisfaction levels has been introduced. 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. The summary of this inspection report can be made available in other formats on request. Burroughs, The DS0000027126.V360665.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 Burroughs, The DS0000027126.V360665.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): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the production standard of the information documents supplied to prospective residents and their relatives is good, the contents are not wholly accurate or complete. Excellent detailed assessments of prospective and actual residents are undertaken and kept up to date. EVIDENCE: We examined the home’s Statement of Purpose and found that it did not refer to the provision of respite care that is a feature of the home. The staffing figures quoted in the current Statement of Purpose relate to when the staffing levels have been increased in the future to meet the needs of an increased number of residents with dementia. The actual current staffing figures must also be quoted. We examined three residents’ care files in detail and found that all contained detailed assessments of need prepared by Hillingdon Council which were confirmed by assessments undertaken by staff from The Burroughs. A wide range of types of assessments were undertaken by the home, such as the Bartel, Broden and Waterlow assessments, plus care assessments, night time assessments, nutritional assessments, and continence assessments. All Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 10 assessments were seen to be kept under review, and to be used as a means to create detailed individualised care plans for each resident. The needs assessment process at The Burroughs is commended. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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. 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’ health, personal and social care needs are well set out in individualised care plans, but risk assessments are not always properly completed. Medication records are generally well maintained, and residents are treated with respect and their dignity and privacy are maintained appropriately. EVIDENCE: Three care files were chosen at random that reflected the three categories of care available at The Burroughs; dementia care, elderly frail care, and respite care. A hard copy is now kept in addition to computer records so that relatives can more easily view the care records. The quality of the care plans was uniformly good in terms of content, presentation and continuing review. Personal care needs, health needs, social needs and cultural/religious needs were all covered in the care plans. Night-time care needs and individual wishes about whether or not to be observed at night were also detailed, which is commended. Each care plan contained a recent photograph of the resident. Care plans were summarised from time to time, and the contents entered into a care plan report. However the respite care file did not contain an summary of how the period of respite care had gone, which was a recommendation made following a previous CSCI inspection, and agreed by the management of The Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 12 Burroughs. Neither of the long-stay care files contained any documentation of reviews undertaken by the London Borough of Hillingdon as the placing and funding authority for those places. The Manager checked the computer record and found that one had been last reviewed on 11/07/06 and the other had had a review scheduled for 10/05/07 that had been cancelled by the Hillingdon care manager without a new date being set. Health needs are now subject to a dedicated section of the individual care plans, which also detail preventative actions to be taken in order to help maintain good health. Whenever an ‘intervention’ by a health professional takes place, a ‘multi-disciplinary report’ is written and placed on file. The work of the in-house physiotherapist is appreciated by the Manager as documented in the AQAA, and the employment of a physiotherapist is commended. Unfortunately the risk assessment process is not yet completely satisfactory. We examined 4 risk assessment documents and 2 did not have the scoring system completed. In other instance, a ‘falls’ risk assessment had not been completed following a fall by a resident, despite this being a requirement at the last inspection. We examined the home’s medication records and storage facilities. One error in recording a refusal to take medication was noted. We were told that the GP had been made aware that the resident quite often refused this particular medication due to the size of the tablet. In all other respects everything concerning medication was in order. We observed good relationships between staff and residents who were being treated with dignity and respect. The following comments by residents were recorded, “Quite alright here”, “Great home”, “Staff are lovely”, and “Everybody is well looked after.” A relative we spoke to confirmed that in her view there were ‘no problems’. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activity provision is improving, the promotion of independence is improving, community links are good, and the food is appreciated. EVIDENCE: The Manager reported that a second social activities worker had recently been recruited who would work every second weekend in addition to weekdays. The second social activities worker is currently on maternity leave but it is hoped when she returns that she will cover the other weekends so that all seven days are covered in the future. The Manager reported that care staff are more involved in activities than before, with activities such as board games, and colouring books. Two workers are registered to drive the Community Bus and hence outings to The London Eye, the coast, and local pubs for lunch have all taken place in recent times. Workers have been trained in dementia care and appropriate activities for people with dementia such as reminiscence therapy. A new development just being introduced is known as ABC, that is Activities Based Care. This involves the residents being encouraged to help themselves more by for example buttering their own toast at breakfast time. Promotion of independence in this way is commended. Relatives are encouraged to visit the home, as we observed. The Manager makes a point of inviting them to attend social events. A survey of their views Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 14 is currently being undertaken. A Church of England service is held at the home every three weeks, and a Roman Catholic priest visits the home regularly. We observed residents eating their lunch in pleasant surroundings. Table cloths were clean and ironed, and new place mats had been purchased. The food appeared to be nutritious and appetising, and portions were good. Residents told us they enjoyed the food served at The Burroughs. Burroughs, The DS0000027126.V360665.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. Complaints are fully investigated and acted upon but the complaints recording system was not completely satisfactory. Good systems, with adequate staff training mechanisms, are in place to protect residents from abuse. EVIDENCE: We examined the home’s complaints record. One complaint had been received since the last inspection. The complaint had been appropriately investigated and responded to, but the record in the complaints’ file was not complete as it did not contain details of the outcome of the complaint. This was that the complainant had received a refund of the fees charged to her for a period of respite care. No requirement is made as the Manager corrected the omission there and then. The home’s complaints procedure is advertised throughout the home. However the version that was seen in the two residents’ bedrooms visited did not refer to the role of the CSCI. No requirement is made as the home’s Administrator made sure that the new revised complaints procedure was displayed in every resident’s room, whilst the Inspector was still on the premises. None of the residents or relatives spoken to made any complaints to us. No Safeguarding Adults referrals were made by the home in the period since the last CSCI inspection. Staff continue to receive Protection of Vulnerable Adults training using the L Box (self-directed training) but the Manager reported that the London Borough of Hillingdon are to be requested to provide additional POVA training. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment of the home is not well-maintained in all respects, and two fire safety issues and one hygiene issue cause concern. The home does not fully meet the required standard in terms of it being clean and pleasant throughout. EVIDENCE: The Inspector and the Manager walked around the building and grounds. The ground floor has been redecorated since the last CSCI inspection and some improvements have been made to the kitchenette areas. Some bedroom doors have been personalised to assist residents with dementia to locate their rooms, which is commended. First floor corridors were being re-floored on the day of the inspection, and the existing carpet is being replaced by non-slip vinyl. No malodours were noted at any point, and the home was seen to be generally clean and hygienic throughout, with some exceptions reported below. Nevertheless, there remains a substantial amount of work to do to bring the environment of the home up to the required standard. The management of the Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 17 home accepts this view, and is currently prioritising a three-year improvement plan to achieve it. Specific aspects mentioned in the draft plan include replacing carpets in the lounges and foyer, replacing damaged ceilings, replacing furniture that does not match, and replacing the conservatories. In the meantime, some specific actions are required or recommended by the CSCI to improve the environment and make it safer in the short-term. These include replacing the present institutional waste bins in the kitchenette areas some of which have rusty lids that cannot be kept hygienic and clean, replacing the rotting exterior fire escape doors from lounges, changing the locking system on one of the back garden gates, cleaning soiled walls, and making changes to the communal furniture allocation. One bathroom is currently out of use. Another bathroom was seen to be somewhat cluttered by items that need not be in there. Bathrooms and toilets were clean and their ventilation systems were working. The call bell system was tested and found to work. The kitchen and food storage areas were observed to be tidy and clean. All the equipment in the laundry was seen to be in working order. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are looked after by sufficient numbers of staff who are well trained and are competent. To ensure that residents are always fully protected, better management oversight of the staff recruitment process is necessary. EVIDENCE: The home’s current staffing rota was examined. The Manager explained that 9 care staff are rostered to be on duty during the day, with 6 on duty at night. He added that the numbers will be increased when the number of residents with dementia has increased. At the time of this inspection that home has 240 care hours vacancies (per week) but 180 hours have been offered to new recruits who are currently having recruitment checks undertaken. Recruitment to a ‘care-bank’ of staff is also taking place with the intention of removing the need to use temporary agency staff. In the meantime the Manager reports that every effort is made to use the same temporary staff so that residents do not suffer by having frequent changes of staff looking after them. At the current time, 40.5 of the permanent care staff have NVQ level 2 or higher awards in care. The AQAA completed by the Manager states that a further 15 care staff are undertaking the award, which will potentially produce a figure of 81 qualified staff. The national target is 50 . The Inspector asked to see the recruitment records for any two staff members. Both files produced contained application forms, identification checks, medical disclosures, references and Criminal Record Bureau disclosures. However one recruitment file raised certain concerns. The applicant said on her application Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 19 form that she had not received a job description for the post she was applying for. The reference from her previous employer did not provide any information about the applicant’s abilities but did make a statement that warranted further investigation. The applicant’s health declaration contained a statement that warranted contact with her General Practitioner for further information. The applicant had been interviewed by two managers but the interview notes of only one had been kept on the recruitment file, and these were incomplete. Therefore a requirement is made in line with Regulation 19, ‘Fitness of Workers’. Training records were examined that demonstrated an improvement over previous training records seen. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration systems are generally very good and operate to provide good outcomes for the residents. EVIDENCE: The Manager is now the Registered Manager having been approved by the CSCI as being a ‘fit person’ to manage a care home. He reports that he is undertaking the Registered Managers Award. His success in improving standards at The Burroughs is evidenced by the reduction in requirements from 15 in the last inspection report to 7 in this report, and the increase in the CSCI grading of the home from 1 star to 2 star. Quality Assurance at The Burroughs is now being undertaken independently of the home. Care UK’s Customer Experience Manager is currently undertaking a survey of residents and their relatives. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 21 We sampled the records of residents’ money held for them by the home. The records are excellently maintained and show that residents’ money is appropriately spent only on ‘luxury’ items that the home itself is not expected to provide. The cash balances held tallied with the records kept. The Manager reported that regular staff supervision is now fully underway and produced a spreadsheet to demonstrate the fact. Rather than the National Minimum Standard of formal supervision being at least 6 times per year, The Burroughs is aiming for monthly supervision, which is commended. Annual appraisals are to be included within the system. In order to check health and safety matters, we inspected hot water temperatures, fridge and freezer temperatures, and the call bell system. There is still a problem with the hot water supply to part of the home, but we were shown evidence that a new water heater was on order. As reported above, there are some fire and hygiene safety issues for which requirements have been made in the Environment section of the report. Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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 2 x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 4 x 3 Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 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 OP1 Regulation 4 Requirement The home’s Statement of Purpose must accurately reflect the current services available, and the current staffing levels. Whenever a resident suffers a fall, a risk assessment must be undertaken or updated concerning the possibility of further falls and how to avoid them occurring. This is restated as the requirement has not been fully met. When any risk assessment form is being filled in, the process must be completed by scoring the risk in order to ascertain the likelihood and severity of a resident suffering an injury if action is not taken to reduce the risk. Fire escape doors that are in a poor state of repair must be replaced urgently in order to offer better protection to residents and staff. Advice must be taken from the Fire Authority concerning evacuation of the premises via the back garden as one of the DS0000027126.V360665.R01.S.doc Timescale for action 01/06/08 2. OP8 14(2) 01/06/08 3. OP8 14(2) 01/06/08 4 OP19 23(2)(b) 01/07/08 5 OP19 23(4)(a) 01/06/08 Burroughs, The Version 5.2 Page 24 6 OP26 16(2)(k) 7 OP29 19(5)(d), Sch. 2. gates is currently locked. The waste bins in the kitchenette areas must be replaced in order to improve the living environment for residents. Full and satisfactory recruitment checks and information must be obtained and be available for inspection on every person employed in the care home to ensure that residents are adequately protected. 01/07/08 01/06/08 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 OP7 Good Practice Recommendations Whenever a period of respite care finishes, the care home should complete a report summarising the outcomes of the stay, and keep the report on the resident’s care file in order to assist the home’s staff to provide the best possible care if and when the resident returns for a further period of respite care, or moves in as a long-term resident. The damaged chair in the foyer should be removed, the soiled wall by the entrance to the home should be washed down, and dining room chairs should be moved between units so that matching sets can be re-established where possible to create a more attractive home for residents and their visitors. 2. OP26 Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Burroughs, The DS0000027126.V360665.R01.S.doc Version 5.2 Page 26 - 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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