Inspection on 19/11/07 for Blackbrook House

This inspection was carried out on 19th November 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Blackbrook House Gun Hill Dedham Colchester Essex CO7 6HP Lead Inspector Francesca Halliday Unannounced Inspection 19th November 2007 09:20 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 Blackbrook House DS0000070084.V355122.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. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackbrook House Address Gun Hill Dedham Colchester Essex CO7 6HP 01206 323496 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) martin.murphy2@btconnect.com Carefore Homes Limited Mr Martin Andrew Murphy Care Home 38 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (20), Physical disability (2) of places Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: 2. Either The maximum number of service users who can be accommodated is: 38 Date of last inspection Brief Description of the Service: Blackbrook House is owned by Carefore Homes Ltd. It is a purpose built home set in its own grounds and was first registered in June 2007. The home is set in a rural location on the outskirts of the village of Dedham. The home is near to the A12 and approximately five miles from Colchester. There is a limited bus route between Colchester and Ipswich, which passes in front of the home. There is ample car parking on the site. The home can accommodate up to 38 older people in two separate units. The dementia care unit is on the ground floor and is for up to 18 residents. The general care unit is on two floors and is for up to 20 residents over the age of 65 year who require personal care. The home can also accommodate up to 2 people with a physical disability. The fees at the time of inspection in November 2007 were £695 per week. Additional charges were made for hairdressing, private chiropody, private physiotherapy, manicures and pedicures, dry cleaning, toiletries and newspapers. For the most up to date information on fees please contact the home directly. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on 19th and 27th November 2007. An expert by experience accompanied the inspector on 27th November and their comments are included within the report. An “expert by experience” is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The term resident is used throughout the report to refer to people who live in the home. The registered manager and operations manager were present throughout the inspections. At the time of inspection the home the home was about half full as occupancy was still developing following the opening in June 2007. The majority of residents were spoken with during the inspection, by either the inspector or the expert by experience, although advanced dementia made communication difficult with some residents, particularly on the dementia care unit. A number of relatives were also spoken with during the inspection. Four surveys were received from residents, five from relatives and six from staff. Parts of the premises and a sample of records were inspected. An additional twelve-bedded unit was in the process of being built to the side of the current home. The proposal was for the new unit to provide care for residents with advanced dementia. What the service does well: What has improved since the last inspection? Not applicable. This is the first inspection since the home was registered. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3, standard 6 not applicable Quality in this outcome area is good. Prospective residents can be assured that the home will assess their needs prior to an admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a range of information for prospective residents and their representatives. On some occasions the information had been sent to relatives and had not been shared with prospective residents. The manager said that a copy of the residents’ brochure would be placed in each resident’s room. The manager confirmed that all prospective residents had an assessment of their needs prior to being offered a place at the home. He said that he made every effort to be in the home on the day of admission so that he was there to welcome the resident. A sample of preadmission assessments was seen. They were generally of a good quality but the manager was advised to expand the assessment form to cover all aspects of standard 3 and to develop a mental Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 9 health assessment form for prospective residents with short-term memory loss and dementia. Blackbrook House DS0000070084.V355122.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): Standards 7, 8, 9, 10 Quality in this outcome area is good. Residents are confident that their health and care needs are met and that they are treated in a dignified and respectful manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents and relatives spoken with considered that the standard of care in the home was very good. One relative said “the care and support goes beyond anything we could have wished for. It’s taken a huge burden from us – to be honest it’s like she’s staying with family”. There was evidence that residents, and relatives where appropriate, had been involved in the assessment of needs and drawing up of care plans. Monthly audits of care plans are undertaken as part of the company’s monthly Regulation 26 visit. The care plans would have benefited from being separated from the assessments and having an evaluation of care and care needs rather than just a review of the care plan. Staff were in the process of identifying residents’ specific needs and preferences by completing “all about me” life histories and “my daily routine” Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 11 with residents. This should enhance their involvement and provide more personalised details for the care plans. The operations manager said that a key worker system would be introduced when the occupancy of the home had increased. Relatives said that communication with them about health concerns was very good. Daily care records generally contained a good range of detail about residents’ care, health needs and how they had spent their day. The assessments for moving and handling contained specific guidance for carers for moving and handling in different circumstances and detailed the equipment required. There was a form for recording falls but this was not always completed when falls had taken place. The manager confirmed that residents had been referred to the falls prevention service when appropriate. The home was introducing assessments for nutrition and continence and residents’ weight was being regularly monitored. There was some evidence of monitoring of psychological health within the daily records. However, a systematic tool for assessing ongoing psychological health, mood and response to medication was needed for residents with short-term memory loss and dementia. There was evidence, from care documentation and from relatives surveyed, that some residents had been rehabilitated following admission so that they were able to regain a greater degree of independence. The manager confirmed that the home had access to physiotherapy and occupational therapy services if needed. Residents had the choice of two local GP practices. Staff reported that they had good support, particularly from one of the practices. Staff said that arrangements could be made for residents to attend the local surgery if they wished. Residents confirmed that they could see the GP when they needed to. The home also received good support from community nurses and community psychiatric nurses when needed. A continence nurse also visited on a regular basis. A chiropodist visited the home every eight weeks and a dentist and optometrist visited when required. The Medicine Administration Records (MAR) were generally well completed. However on some occasions greater clarity was needed when using codes and recording as required medication. Staff said that the system on the MAR for ongoing audit of tablets would be extended to all as required medicines. On a number of occasions some residents were not receiving their last dose of medicine for the day, as they were asleep. Advice was being sought from the GP. However, person centred medication administration should mean that residents receive their medication at a time that suits them, if the routine medication rounds are not meeting their needs. Staff were advised to get the prescriptions for laxatives changed to “as required”. None of the residents were self-medicating but staff confirmed that a risk assessment would be carried out for any residents wishing to take their own medicines. The Controlled Drugs (CDs) stock balance was checked and was correct but staff were advised not to record the return of CDs until they had left the Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 12 premises. CDs were being held in a locked cupboard until a CD cupboard could be installed (this was on order). Staff were advised to ask the pharmacist to label the medicine containers (for eye drops and creams), as well as or instead of the outer carton, in order to reduce the possibility of cross infection. Medicines with a limited shelf life on opening were not being dated when first used. Staff had a reference guide for information on medicines. Staff administering medicines had received training in administration, however this did not involve an assessment of competence. The manager confirmed that this would be carried out following the inspection. Residents that staff respected their privacy and treated them in a respectful manner and relatives confirmed this. One relative said “she has been treated with discretion, dignity, professionally – yet in a flexible, caring manner”. The expert by experience said that one resident, whose catheter bag seemed to have leaked during lunch, was promptly and sensitively assisted by a member of staff. He said that residents were complimentary about the attitude of staff, confirming that staff listened to them and heeded their wishes and preferences. Blackbrook House DS0000070084.V355122.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): Standards 12, 13, 14, 15 Quality in this outcome area is good. Residents are encouraged to maintain independence and have the lifestyle they choose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some relatives were happy with the social activities and stimulation in the home, but one relative said “I feel there should be games, more activities and also the opportunity to go out. Up to today Mum has not been outside Blackbrook House”. There was evidence of some activities and outings in the home but staff were aware that this was an area that needed to be developed further. Residents had been accompanied on walks and had visited the local teashop in Dedham. The manager said he was hoping to arrange a visit to Maldon in the near future. Residents said that they had enjoyed the recent Halloween party in the home. A number of activities had been planned for the Christmas period. Staff said that they had not been able to arrange for a mobile library to visit, but said that the local library had agreed to provide a stock of books for the home, which they would change every eight weeks. The manager said that he would be investigating the possibility of setting up internet access for residents who wished to keep in touch with family and Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 14 friends by email and access the internet. Staff were aware of residents’ hobbies and were encouraging them to pursue them when possible in the home. The manager confirmed that residents might be able to bring pets into the home if they were suitable, did not cause a risk to others and they were able to continue to care for the pet whilst in the home. The home was in the process of developing links with the local community. A communion service was held once a month in the home and one resident attended the local church. Staff were hoping to develop links to the local school. The manager said that they were trying to arrange for a PAT dog to visit the home. Residents were also offered the services of a manicurist and pedicurist who visited the home every six weeks. The manager was investigating whether any residents might like to have aromatherapy massage or Indian head massage. A member of staff was due to attend a training session on providing exercises for older people. There were some records of activities but this was an area that needed to be developed. Staff said that the home did not have any set visiting hours and relatives confirmed that they were made welcome whenever they visited. They said that it was particularly important that residents could invite relatives and friends to eat with them, as the majority of residents would find it difficult to attend a restaurant. Relatives said that they appreciated the fact that they could use the kitchens attached to each unit to make drinks and snacks with the resident. Residents said that they were able to get up and go to bed at times that suited them and confirmed that they chose where and how they spent their day. Staff were able to give examples of how they encouraged residents’ independence and promoted choices in the home. The expert by experience said, “Everything I saw and heard indicated to me that residents’ personal freedom and wishes, which are among the most important aspects from a resident’s perspective, were respected by the manager and staff, and I commend the management and staff of the home for this”. The home had enrolled on an “expert patient” course, which was to be held once a week for six weeks. The aim of the course was to empower residents to be in control of their condition and the symptoms of their condition. Experts in various conditions will be working with residents, who wish to participate, on an individual basis. This is an excellent initiative. Residents spoken with and surveyed were generally very satisfied with the menu and meals on offer. They confirmed that choices were available at every meal. A number of residents described the food as “good” and one resident described it as “excellent” and said that they were particularly pleased that the food was served hot. Residents said that they enjoyed the glass of sherry before lunch and glass of wine with their meals. The expert by experience said that staff, some of whom ate their own meals with the residents, were patient and thoughtful with those who needed help or encouragement to eat. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 15 Following consultation with residents the start of supper had been delayed by 15-20 minutes to 17.45-18.00, as a number of residents had felt that the previous time was too early. The catering manager had completed a course in nutrition for the elderly. A member of the catering staff visited residents every day to discuss their meal choices for the day. The kitchen was clean and looked well organised. Kitchen staff had information on residents’ likes and dislikes, any dietary needs and any allergies. There were regular deliveries of fresh produce and systems in place to monitor the safe temperature of food, for both storage and cooking. There were no fly screens in the kitchen but these were on order. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 16 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): Standards 16, 18 Quality in this outcome area is good. Residents’ concerns are addressed promptly and they feel safe in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure, which was in the residents’ brochure and was displayed within the home. Residents and relatives surveyed said that they knew how to make a complaint in the home if this became necessary. Residents spoken with confirmed that they saw the manager very regularly and could raise any concerns with him and felt safe in the home. The home had received one complaint since they opened. The allegation related to the injury of a resident and lack of referral to a GP and had not been resolved at the time of inspection. Staff were not documenting verbal concerns and a discussion was held about the benefit of documenting concerns as part of the quality assurance programme. A system for documenting verbal concerns was put in place following the inspection. The home had procedures for safeguarding vulnerable adults and a whistle blowing policy. The operations manager confirmed that great emphasis was put on safeguarding training in the home. She said that this was fully discussed at induction and said that safeguarding training was due to be held shortly after the inspection for all staff who were due an update. Staff spoken Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 17 with had an understanding of the different types of abuse that could occur and the actions to take if they suspected any abuse or poor care practices. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 18 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): Standards 19, 26 Quality in this outcome area is good. Residents live in safe, comfortable and pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Blackbrook House opened in June 2007 and was in excellent decorative condition. The home had a wide range of communal areas to suit residents’ differing needs and chairs of different heights were available. There was a sensory room on the dementia care unit. Each unit had a self contained kitchen with a dining table and chairs for residents’ and relatives’ use. The dining rooms were very attractive with fresh flowers on the tables and mats at each place setting. The operations manager was in the process of ordering improved signs for rooms and facilities within the home and confirmed that they would include pictograms for the dementia care unit. There were no grab Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 19 rails in the home and the operations manager said that this would be addressed following the inspection. Residents had been encouraged to personalise their rooms by bring in their own furniture, pictures, soft furnishings, beds, bedside tables and bedding if they wished. Additional shelving has been put up at their request. All residents’ rooms had an en-suite toilet and handbasin and eleven had a walkin shower. The operations manager said that footstools at the same height as the chair seat would be ordered as this had been identified as a need. There was a well equiped hairdressing salon. The home had enclosed courtyards with a water feature and raised beds, tables, chairs and parasols. The garden area for the dementia care unit was secure. All accommodation was in single rooms with en-suite toilets and washbasins and ten bedrooms had a walk-in shower. The home had a good range of assisted baths as well as ordinary baths and showers. One toilet did not have an emergency call bell. The operations manager confirmed that all rooms would be checked to ensure that they had call bells and that this would be rectified following the inspection. Residents said that staff generally responded promptly to call bells. The call bell system had an automatic log of calls and response times in order that staff response times could be monitored. The home had monitors on all residents’ doors, which allerted night staff if residents left their room at night and needed assistance. The home was very clean on the days of the unannounced inspections. A minor odour in one area of the dementia care unit was resolved following a carpet shampoo. The home had a suitable laundry and the manager said that additional washing and drying machines would be installed as resident numbers increased. All residents spoken with said that the laundry service was very good. A number of areas did not have soap or paper towel dispensers installed but the manager said that this was in the process of being addressed. The manager was advised to remove the bars of soap and terry towels from communal areas in the interests of good infection control. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29, 30 Quality in this outcome area is good. Residents are cared for by competent staff. Recruitment procedures provide protection for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that at the time of inspection, when the home was half full, care staff levels were one senior carer and four carers in the morning, one senior carer and three carers in the evening and two carers at night. Additional care and support staff were being recruited as occupancy of the home increased. One relative said that they appreciated the fact that residents on the dementia care unit were well supervised in the communal areas. A sample of staff records was inspected and they provided evidence of good recruitment practices. Staff had provided two references and all had been checked with the Criminal Records Bureau and with the Protection of Vulnerable Adults list. All staff received an induction and the home was working towards introducing the Skills for Care common induction standards. Approximately 50 of care staff had National Vocational Qualification at level 2 or above, or were working towards the qualification. Staff had identified that they needed more training to enable them to provide good support to residents with palliative care needs and their relatives. The manager, who held a diploma in palliative care, was Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 21 planning to provide an in-house palliative care course for all staff who needed it. The operation manager said that staff would be attending training on Parkinson’s disease. Approximately half of the care staff had received some dementia care training and the operations manager said that further dementia care course was being set up in order to ensure that all staff received the training. The operations manager also confirmed that staff would be given training on the Mental Capacity Act and the changes to Power of Attorney that had recently been brought in. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 22 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): Standards 31, 32, 33, 35, 38 Quality in this outcome area is good. The home is well managed and run in the best interests of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had a background in nursing, had management experience and had completed a diploma in palliative care. He had commenced a diploma in dementia care. The manager said that he had excellent support from the senior management team. A discussion was held about the benefit of appointing a deputy manager and reviewing the on-call rota as the manager was on call at all times apart from when he was on holiday. The operations manager visited the home very regularly to carry out Regulation 26 visits and to assist with staff training. The Regulation 26 reports contained detailed Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 23 audits and clear guidance to staff if any improvements were needed. The manager started his day by visiting residents and so was able to get regular feedback from residents and to address any minor concerns very promptly. The manager said that he hoped that surveys would be sent out to residents and relatives in the near future, in order to get more formal feedback on services and care in the home. One relative described the excellent support they had received from the manager and operations manager and described them as “exemplary”. There were good systems in place to manage residents’ personal monies. Only a small amount of cash was kept on the premises. Receipts were kept for all purchases and double signatures were used for all transactions. The home had a qualified bookkeeper to oversee the systems in place. Staff confirmed that they had very regular informal supervision, that the manager had an open door policy and that they had very good support from the management team. Formal supervision systems had been set up prior to the inspection. Staff were reminded that all chemicals must be kept locked up as some were seen on the side in the dementia care unit kitchen. The manager was aware that the cords for the call bell could on occasions be a potential trip hazard, and pendant call bells were being ordered so that residents could call from anywhere in the home. A number of the emergency call bells had been tied up near the ceilings and were not within reach. The manager said that this would be rectified following the inspection. An accident record had been completed for all accidents noted in the care records. The manager said that he would be bringing in a system for systematically reviewing all accidents, in order that preventative measures could be taken when necessary. The manager confirmed that valves were in place to prevent water temperatures getting too hot and that systems were being put in place to regularly monitor the temperatures of water outlets used by residents. The majority of equipment in the home was new and under guarantee, and there were systems in place for servicing and maintenance. The home ensured that equipment brought in to the home by residents was checked for electrical safety. There were systems in place to ensure that staff received training in safe working practices. There was a rolling programme for training in health and safety, infection control, food hygiene, moving and handling, first aid and fire safety. The operations manager was the moving and handling trainer for the home. She confirmed that the training included an assessment of competence for each member of staff. She also confirmed that sufficient staff would be trained in first aid so that there was always a member of staff with a first aid certificate on duty. Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 X X 2 Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard 1. OP9 Regulation 13(2) Requirement The times residents are given their medication must be reviewed in order to ensure that they receive all doses of their prescribed medicines. Medicines, which have a limited shelf life on opening, must be dated when first used so that staff know when to dispose of them. Staff must have a regular assessment of their knowledge and understanding in order to ensure that they are competent to administer medicines. Chemicals for cleaning must be locked up at all times in order to reduce the risk to residents with dementia. Risk assessments must be carried out of the toiletries on the dementia care unit in order to assess and manage the potential risk to residents. Informed at the time of inspection. Timescale for action 17/12/07 2. OP38 13(4) 19/11/07 Blackbrook House DS0000070084.V355122.R01.S.doc Version 5.2 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 OP3 OP8 Good Practice Recommendations A mental health assessment tool should be developed in order to improve the assessment of prospective residents and to monitor the psychological health of residents with dementia in the home. The management team should consider appointing a deputy manager for the home and reviewing the on call arrangements so that the manager has sufficient breaks from work. 2. 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