Inspection on 10/11/05 for Blackmore House

This inspection was carried out on 10th November 2005.

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

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

Other inspections for this house

Blackmore House 08/09/09

Blackmore House 07/11/08

Blackmore House 06/06/07

Blackmore House 12/09/06

Blackmore House 29/07/05

Blackmore House 06/12/04

Blackmore House 29/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Blackmore House School Drive Bromsgrove Worcestershire B60 1AY Lead Inspector Andrew Spearing-Brown Unannounced Inspection 10th November 2005 08:50 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 Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 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. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Blackmore House Address School Drive Bromsgrove Worcestershire B60 1AY 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) 01527 575222 01527 575222 Broadening Choices for Older People Mrs Paula Georgina George Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (28) Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: Blackmore House was built in 1989 as a care home for older people. The home is single storey and accommodates a day centre that helps to maintain links with the local community. The home provides single bedroom accommodation for a total of 28 residents who are accommodated in 5 “bungalows”. Each bungalow represents a virtually self-contained living environment with a lounge/dining space, toilets and bathrooms, bedroom accommodation and a kitchenette. Three of the bungalows each accommodate 4 residents, while two bungalows accommodate 8 residents. Emphasis is placed on creating a “homely” living environment. Blackmore House provides a care service for older people with or without a physical disability and for older people with dementia. Broadening Choices for Older People (BCOP) is the registered provider however, the building is owned by, and leased from Worcestershire County Council. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by a regulation inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The inspection took place over a period lasting 5 ¾ hours commencing early morning. The last inspection at Blackmore House took place during July 2005 making this inspection the second statutory visit during the 2005 – 2006 inspection year. Part of this inspection was to assess the progress made in relation to the requirements from the previous inspection. Shortly prior to this inspection the CSCI received a formal complaint therefore a range of issues raised were investigated as part of this inspection. Throughout the inspection the registered manager was on duty. Some other members of the senior team were also on duty and assisted with certain parts of the inspection process. Consultation with a number of residents took place. Many parts of the home were seen. These areas included communal areas as well as a high percentage of bedrooms. Staff areas seen included the laundry and the kitchen. The care records regarding a sample number of residents were viewed. Other documents seen included medication records, fire records, and some training records. What the service does well: The design and layout of the home is well suited to older people with mobility difficulties. The relative smallness of the bungalows can assist residents with memory loss to orientate themselves to the toilets and their bedroom from the lounge / dining area, however this could be improved by using visual aids. The kitchenettes within each of the five separate bungalows have newly fitting units, a dishwasher and a fridge. Information regarding advocacy services was available. Residents are able to join in with the activities available within the day centre. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 6 An emphasis is placed on staff training. 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 contacting your local CSCI office. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 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 Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Blackmore House. EVIDENCE: Although Blackmore House currently accommodates a number of long stay residents, the home is currently only admitting persons on a respite (short stay) arrangement; many individuals receive respite on a regular rotational basis. On the morning of this inspection one respite resident was admitted. A care plan from a previous respite stay in August was available. The daily notes from that stay and an earlier stay were not on file. These were found along with other care notes waiting to be filed. There was no recorded evidence that the possibility of a change in care needs was explored since the last respite stay. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Although improvement in medication management was seen these are not sufficient to fully safeguard residents. Care plans are sufficiently detailed however progress in ensuring that they are reviewed and up dated remains limited. Systems for filing care notes are weak and leave residents at potential risk. EVIDENCE: Individual plans of care are available and those seen covered a range of heath, personal and social care needs. Care plans are held on computer with a hard (paper) copy held on file. A number of shortfalls were found. Firstly it was apparent that care plans are not reviewed and up dated as required on at least a monthly basis to reflect the changing care needs of an individual. Furthermore the most up to date care plan was not always printed out from the computer and therefore unavailable to care staff. One care plan stated that a resident was to be showered twice weekly. Activity sheets and bathing records showed that this is not happening. No reason as to why the care plan is not taking place was recorded. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 10 Information on risk assessments was lacking in areas such as nutritional screening. The terminology used on the daily notes by carers was greatly improved since the last inspection. The registered manager must continue to ensure that terms used cannot be misinterpreted as opinionated or judgemental. The current sheets for recording daily events are held collectively. These are then filed within individual residents own files. A backlog in filing was apparent. One residents file contained daily notes finishing in April 2005, all sheets from that date onwards were waiting to be filed and were in a state of disorder. Recent inspections have noted improvement in the overall management of medication. Medication is now stored centrally rather than on individual units. Only senior staff and night carers are now involved in medication administration. A suitable medication trolley is now in place, this was secured to the wall. In addition a suitable cabinet for the safe storage of controlled medication is also now in place. At the time of this inspection no controlled medication was in use. A bound book is available to record controlled medication give and the balance held. The current month’s MAR (Medication Administration Record) sheets were viewed. These appeared to be signed appropriately in line with procedures, however one shortfall gave cause for concern. It was noted that one resident had one drug for which nobody had signed as given for a period of 3 ½ weeks. It was evident that nobody had noticed this error and therefore suggests that staff fail to check the MAR sheets against medication administered. Despite this concern some good practice was noted especially the recording of the actual dose given when a variable dosage was prescribed. A list of medication held on a residents file was checked against the MAR sheet and found to differ. MAR sheets were recorded satisfactorily regarding the receipt of drugs and they also indicated any known allergies or stated ‘none known’ when this is the case. Hand written amendments to the MAR sheets did not have any signatures in place to demonstrate who had recorded the change; a second member of staff who also must sign the MAR sheet must witness these changes. Blackmore House offers respite care. It was pleasing to hear that staff always check the medication they receive with the residents own doctor upon admission. Furthermore staff now request confirmation via fax of any verbal changes to medication given by doctors or their surgeries. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 11 Part of this inspection was to investigate a number of concerns raised within a recent complaint. A number of the allegations centred around staff attitudes and the lack of privacy and dignity for residents. The registered manager stated that she was not aware of any such incidents and was confident that staff would of reported such practice to a senior member of staff and that appropriate action would be taken. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Activities provided within the day centre are creative and stimulating. Residents living in the home can be involved in these activities. EVIDENCE: Blackmore House has a day centre within the same building, this service is not required to be registered and therefore does not form part of this inspection. As a number of individuals who receive a respite service at Blackmore attend the day centre they continue to attend day care while at the home for their short stay. The day centre can be used as a resource for the residential home during evenings and weekends. Residents are able to bring personal possessions into the home if desired. Information regarding the availability of an advocacy services was displayed on a notice board within the home for residents and their representatives. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The complaints procedure needs amending to ensure that residents rights are fully maintained. EVIDENCE: The complaints log was viewed. Correspondence regarding one complaint received since the last inspection was seen. The Commission for Social Care Inspection received a formal complaint in relation to this home shortly before this inspection. A copy of the complaints procedure was on display. This procedure needs to be amended in order to meet the National Minimal Standard for older people. The procedure makes no reference to a timescale, this need to be added. The head office of BCOP has recently moved and also needs amending of the procedure. Finally although the address for the local CSCI office is given it does not give the name of the commission but simply says ‘the government body who monitors standards of care’. The homes policies and procedures regarding adult protection could not be found on this occasion and will therefore be re assessed as part of a future inspection. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Improvements have taken place to the environment. Further improvements are necessary to ensure that residents have a safe and comfortable place to reside. EVIDENCE: The home consists of five family-sized “bungalows” of which, three bungalows accommodate four service users each, and two “bungalows” accommodate eight service users each. Every “bungalow” contains single occupation bedrooms, a lounge/diner and a kitchenette. The bungalow style design promotes homeliness and helps to facilitate a family-living approach and culture. In addition to the communal space cited, each bungalow has a communal bathroom and communal toilet facilities. None of the bedrooms have en-suite facilities. As the building is located on a single level, residents who have mobility difficulties can freely access all areas. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 15 The majority of bedrooms fall below the 10m² usable floor space; this is compensated by additional communal space. The furniture within bedrooms is in a satisfactory condition. The registered manager was requested to undertake an audit regarding the safe usage of the brakes on residents beds. The baths on the two larger units have recently had an electric overhead hoist fitted. Although commissioned not all staff have received the necessary training to operate this equipment. The showers within these bathrooms were still available to residents. A new shower was seen on Wyrelea unit, which was very pleasant. The bath in Brocklands is stained. One bathroom contained a wheelchair without any footrests in place. Toilets throughout the home were satisfactory, although it was unclear whether the extractor fans were working. The registered manager undertook to assess the effectiveness of the extractors. The seal between the floor and wall had come away in a couple of place in one bathroom and a toilet. No offensive odours were noted within communal areas although some bedrooms had an aroma. Two sluices are provided, one on each of the larger units. These sluices are however situation beyond one of the toilets and can therefore can only be accessed via the toilet. The hot water tap was checked in a majority of bedrooms. All were found to be working. The registered manager confirmed that Blackmore House has experienced some difficulties with water supply recently due to air locks. A book listing invoices passed for payment confirmed that contractors had visited on a number of occasions. The registered manager stated that the problem did not exist at the time of this inspection. The kitchenettes in all 5 units were replaced recently. The hairdressing room could only be briefly seen due to residents having their hair done, however it was noted that a new ‘hairdressing style’ basin is now in place. The bedrooms belonging to permanent residents were personalised. Although the design of the bungalows makes them compact and self-contained the décor along the corridors does not provide a visual aid to residents with memory impairment. Paintwork is peeling at the entrance of Kuling unit and needs attending to. The woodwork in the lounge within Kuling had splash stains on it. Two wheelchairs on one unit were practically dirty and stained. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Sufficient staff are not always on duty to ensure the different units are suitable covered. EVIDENCE: On the morning of this inspection 3 carers plus a ‘floater’ were on duty in addition to 2 senior carers. Care staff are required to undertake laundry tasks. The only domestic on duty was from an employment agency. A sample number of rotas covering the last 2 months were viewed. On two occasions it was found that for between 1 and 2 hours the staffing level was reduced by 1 carer, therefore 3 people on duty covering 5 bungalows. During the previous inspection staff consulted felt that sufficient staff are on duty, this was not however the experience of a number of residents who spoke of staff shortages. The layout of the home must be taken into account when preparing staff rotas as well as the number of residents within the home to ensure that care needs can be met. The home was holding an interview for a domestic member of staff on the day of this inspection. Other staff vacancies were for a weekend floater and a night carer for 3 nights per week. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37 and 38 Systems for filing care records are weak and need improving. A range of health and safety shortfalls were identified which could place both residents and staff at potential risk. EVIDENCE: A notice was on display stating that an announced inspection by the Commission for Social Care Inspection is to take place on ’22 November’. No inspection is planned for this date, however an announced visit is planned for this date. This notice may refer to previous years and therefore needs removing to avoid confusion. Another notice gives the name of a former inspector and the former area manager, these also should be removed and replaced with up to date information. The security of care records was not assessed. The current daily record sheets are held collectively. Residents files viewed as part of this inspection did not Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 18 contain documents decanted from the collective file. These records were awaiting filing and therefore out of date order making it difficult to assess recent care events. The handyperson carried out the weekly testing of the fire alarm during the inspection. This was well organised, residents and staff were altered prior to the alarm sounding and doorways were checked due to the risk of fire doors closing on to people. The records regarding the weekly testing were well maintained. Some other records within the fire log are however in need of improving. No records could be sought regarding the monthly visual checking of the fire extinguishers and emergency lighting. Staff training records were not viewed however one carer confirmed that she has attended training in fire awareness, food hygiene and moving and handling. She was due to attend a first aid refresher in the foreseeable future. Temperature records of hot food and fridges and freezers within the kitchen were viewed. These are not always filled out on a daily bases although the gaps were regularly on the cooks day off when either agency or other staff cover. The record regarding one of the freezers gave cause for some concern as it is regularly reading very high. Freezers must maintain a temperature of -18° C or lower, the records showed temperatures as high as – 9 ° C. A cleaning schedule is in place, however no records exist of cleaning undertaken. The cleaning schedule includes duties to be performed on the cooks days off. No kitchen domestic is employed. Some areas within the kitchen required some cleaning including the top of fridges and behind fridges. The over was not clean. A small cupboard leading off the bathroom on the Brocklands unit containing a water tank and pipes was unlocked. Accident records were held on individual residents files. The registered manager is aware of the requirement to inform the CSCI of certain events. The registered manager needs to review the current practice within Blackmore House regarding staff members wearing jewellery to work. Items such as rings with stones or bracelets and necklaces can be hazardous to both residents and staff members in certain circumstances. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 2 X X 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 1 Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 (1) (2) Requirement The registered manager must ensure that care plans are reviewed on a monthly basis or more frequently when necessary to take into account changing care needs and significant events. The date of the review must be recorded. (Previous timescale of 31/03/05 and 29/07/05 not met). 2 OP7 14(2) 17(1)(a) S3(o) The registered manager must ensure that residents’ care plans contain information regarding nutritional care needs and that residents weights are recorded. (Part met) 3 OP9 13 (2) The registered manager must ensure that any handwritten amendments to the medication administration record (MAR) sheets are checked, dated and counter signed by a second member of staff. (Previous timescale of immediate and on going not met). Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 21 Timescale for action 10/11/05 10/11/05 10/11/05 4 OP9 13 (2) The registered manager must ensure that items such as eye drops have the date of opening recorded. The registered manager must ensure that Medication Administration Record (MAR) sheets are signed at the time that medication is administered. The registered manager must ensure that a record is kept of meaningful and purposeful activities, which take place within the home. (Part met – extended timescale given) 10/11/05 5 OP9 13 (2) 10/11/05 6 OP12 16 (2) (n) 31/12/05 7 OP18 13 (6) The registered provider must ensure a review of the corporative document regarding adult protection takes place to comply with local guidance issued by Worcestershire Social Services. (This standard was not able to be assessed as part of the inspection carried out on 10th November 2005. The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection). 30/09/05 8 23 (2) (b) The registered provider must 31/01/06 ensure that all areas of the home are well maintained. (Timescale of 30/11/05 not reached at the time of this inspection. This timescale however extended). Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 22 9 OP22 23 (2) (n) Opportunity must be taken to provide appropriate visual signage for service users to assist in the location of areas and rooms within the building. Opportunity must also be taken to use colour and décor for orientation purposes. This should be undertaken from the viewpoint of service users who may possess a form of visual impairment and/or possess short-term memory loss. (Timescale of 30/11/05 not reached at the time of this inspection. This timescale however extended). 31/01/06 10 OP26 13 (3) The registered manager must ensure that items of equipment within the home including wheelchairs are kept clean and hygienic. The registered manager must ensure that sufficent staff are on duty at all times to meet identified care needs of residents as well as the layout and purpose of the care home. Quality assurance and monitoring systems must be developed to comply with NMS 33. Specifically;· Effective quality assurance and quality monitoring systems, based on seeking the views of service users must be in place to measure success in meeting the aims, objectives and statement of purpose of the home.· There must be an annual 10/11/05 11 OP27 18 (1) (a) 10/11/05 12 OP33 24 31/01/06 Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 23 development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users and· Feedback must be sought from service users about services provided. (Previous timescale of 30/04/05 and 30/09/05 not met). 13 OP35 17 (2) Schedule 4 (9) The registered provider must develop suitable policies and procedures in relation to items held in safe keeping which are unclaimed by the rightful owner. (Previous timescale of 31/03/05 and 30/09/05 not met – extention given). 14 OP37 17 (1) The registered manager must ensure that care records are appropriately stored. The registered manager must ensure that the use of jewellery amongst staff is in line with the health, safety and welfare of residents. The registered manager must ensure that the cupboard housing hot pipes and a hot water tank remains locked at all times to prevent unauthorised access. The registered manager must ensure that all areas of the kitchen are kept in a clean and hygienic state and that suitable records are maintained. 10/11/05 31/12/05 15 OP38 13 (4) (c) 31/12/05 16 OP38 13 (4) 10/11/05 17 OP38 13 (3) 16 (2) (j) 10/11/05 Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 24 18 OP38 13 (3) 16 (2) (j) The registered manager must ensure that suitable action is taken regarding the freezer with consistently high temperature readings. The registered manager must ensure that the required fire safety test records are up to date and maintained. 10/11/05 19 OP38 23 (4) (c) 10/11/05 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 OP19 Good Practice Recommendations The registered manager should carry out an audit upon the brakes fitted to bed legs to ensure they are suitable. Blackmore House DS0000018462.V265099.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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