Inspection on 29/07/05 for Blackmore House

This inspection was carried out on 29th July 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 10/11/05

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 29 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Blackmore House Address School Drive Bromsgrove B60 1AY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01527 575222 01527 575222 Broadening Choices for Older People Mrs Paula Georgina George CRH 28 Dementia -over 65 Old age Physical disability - over 65 28 28 28 Category(ies) of DE(E) registration, with number OP of places PD(E) BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no other conditions of registration other than those refered to on the previous page of this report. Date of last inspection 6 December 2004 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. Each bungalow has staff members assigned to it. 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 E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted just under five hours. The last inspection took place during December 2004 and January 2005. As a result of a number of serious concerns raised during this inspection a follow up inspection took place during April 2005, no additional requirements were made during the follow up inspection however some requirements were assessed as unmet. The main focus of this inspection was therefore to assess the progress made in relation to the requirements from the previous inspection. On the day of this inspection the registered manager was on a day off prior to commencing some annual leave. The assistant manager and a senior carer were on duty in addition to other members of staff. Both senior members of staff as well as two care assistants and a small number of residents were consulted as part of this inspection. Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, fire records, accident records, service records and some policies and procedures. What the service does well: The home was clean, tidy and reasonably furnished although some chairs may not meet the required fire regulations. The design and layout of the building 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 toilets and bedroom from the lounge / dining area, however this could be improved by using visual aids. Blackmore House no longer admits permanent (long stay) residents, therefore the home is currently only admitting on a respite (short stay) basis. It was evident that the home encourages potential residents to visit or get to know the home prior to their stay. This is good practice. Residents voiced no concerns during this inspection. Residents consulted spoke favourably about both the food provided and staff employed. Confidence in the manager was also expressed. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 6 Recruitment procedures and the obtaining of suitable pre-employment checks were assessed as good and in line with the required standard. 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 E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5. Standard 6 is not applicable to Blackmore House. Relevant information was available for staff to develop an appropriate initial care plan for residents at the point of admission into the home. These care plans need to be reviewed, up dated and built upon in respect of residents who receive regular respite care to both determine and ensure that identified care needs can be effectively met. EVIDENCE: The latest Statement of Purpose and Service Users Guide were reported as being on the manager’s computer. As the manager was on a day off it was not possible to view these on this occasion. These documents will therefore be assessed as part of a future inspection to ensure that the necessary amendments are now in place. These documents are to provide prospective residents with details upon the service enabling an informed decision prior to admission. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 9 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. A pre-admission assessment was seen in relation to an individual due to be admitted for respite care later that day. The information upon the assessment was collected as part of a day visit undertaken by the potential resident to the home. No Community Care Assessment was initially available although staff had attempted to contact the social worker during the last week. This information was faxed over to the home from Social Services prior to the admission but was not viewed as part of the inspection. It is therefore envisaged that an initial care plan can be drawn up. These initial care plans do however need to be developed and built upon, as the resident becomes better known and care needs become more evident. The reviewing of one initial care plan of a resident who had received respite a number of times had not taken place and did not reflect current care needs as gleaned from other records. Failure to up date care plans could lead to serious repercussions such as care needs being overlooked. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 10 Significant progress has been made with regard to the administering and recording of medication to fully safeguard residents, however systems to up date care plans in this home are weak and failed to ensure that the health care needs of all residents are appropriately identified and met. EVIDENCE: Individual plans of care are available and those seen covered all aspects of heath, personal and social care needs highlighted under standard 3.3 of the National Minimum Standards. Care plans are however not reviewed as required on at least a monthly basis or to reflect the changing care needs of an individual. One care plan was dated the 29th April 2005 prior to that was a care plan dated November 2004 these care plans were the same with no changes recorded. However it was evident that considerable changes had taken place. All the care plans seen were found to be lacking current information gleaned from daily notes in relation to continence, dietary needs and moving and handling needs. From the information upon care plans it would be difficult to BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 11 fulfil the current care needs of residents and therefore an over reliance on staff knowledge and memory. Sit on scales are available. The care plan of one resident stated ‘weigh weekly’ due to weight loss in the past. The last recorded weight was taken in January 2005. No nutritional screening is taking place. Risk assessments regarding the prevention of falls were in need of developing to fulfil the required standard. Care plans were out of date regarding falls sustained. The daily notes of one resident showed a number of serious falls within a short timeframe, however no up to date risk assessment or associated plan was in place to prevent future occurrences. The terminology used on the daily notes was not always appropriate, terms used included ‘unhelpful’ ‘ miserable’ ‘constantly buzzing every 15 minutes wearing me out in the heat’. The daily records did not include details of meaningful activities undertaken by residents. An immediate notice of concern was issued due to the shortfalls noted with care plans. Concern was expressed to the senior on duty regarding an incident overheard by the inspector whereby a carer was heard rebuking a resident. While accepting that the expression may be intended to be jovial the implications of such comments, which can be perceived as derogatory or abusive, should not be dismissed. There was a significant improvement in the overall management of medication since the last inspection. Medication is now stored centrally rather than on individual units. The current month’s MAR (Medication Administration Record) sheets were viewed and were signed appropriately in line with procedures. The administering of the lunchtime medication was appropriately carried out. Some areas need to be improved further to fully comply with the required standard. The trolley used to transport medication around the home is totally unsuitable as it cannot be locked while in use and must therefore be replaced as soon as possible. Although no controlled drugs were reported as held within the home, the storage cupboard is not suitable, this was highlighted in the last inspection report. It was noted that secondary dispensing is taking place; this is potentially dangerous practice and must cease immediately. 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 E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 While the social activities undertaken by residents needs to be improved to demonstrate how quality of life is maintained and enhanced, the meals provided are balanced and well received by the residents. 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 and therefore continue to attend 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 consulted were content with the limited activities and opportunities that are otherwise available, however the recording of activities was not sufficient upon daily notes to demonstrate that needs are suitably met. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 13 The walls along the main passageway are brightened up by means of some large pieces of artwork. These items were painted by a school and formed part of the Community Enterprise Project 2005. A plaque displayed near the entrance states that the project is ‘bringing together different sections of the community in an inclusive and mutually beneficial way.’ A number of residents living in the home were spoken with. All those who commented on the food said it was generally good and plentiful, special reference was made regarding the soup, which is served as a starter at lunchtime. Care staff consulted also said that they believed the food to be good. Other comments included ones that the tea menu was now better than in was in the past. One resident was seen to be receiving assistance from a member of staff; this was carried out in an unhurried manner. The layout of the home and the number of staff on duty could make having to attend to residents in each of the units at the same time problematic. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure needs a minor amendment however information obtained showed that residents feel that any concerns or complaints would be listened to. The vulnerable adults procedure needs to be reviewed to ensure that it is consistent with local procedures to fully safeguard residents. EVIDENCE: The requirement to review the complaints procedure within the last two inspection reports has taken place. The procedure is now in line with the National Minimum Standards. However it was noted that it stated that it was the complaints procedure for nursing homes managed by BCOP, Blackmore House is not registered to provide nursing care and therefore this needs to be amended to ‘care home providing personal care’. The home’s adult protection procedure was viewed briefly, however it was noted that it was a corporative document and therefore not specific to Blackmore House. Although it contained instruction which would be expected to take place it did not make direct reference to the Adult Protection Coordinator employed by Worcestershire Social Services or her telephone number. Reference to the former National Care Standards Commission needs to be changed to the Commission for Social Care Inspection. The majority of staff have attended training upon the recognition of abuse and of reporting such matters BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 25 and 26 Improvements have taken place in the standard of the environment with further improvements taking place to ensure that residents have a safe and comfortable place to live. 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 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 E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 16 The majority of bedrooms fall below the 10m² usable floor space; this is compensated by additional communal space. The baths on the two larger units were out of use while the arrival and commissioning of electric overhead hoists are awaited. The showers within these bathrooms were still available to residents. A new shower was seen on Wyrelea unit, which was very pleasant. Toilets throughout the home were satisfactory, they all contained antibacterial soap and paper towels in line with infection control procedures. Residents consulted confirmed that the home is kept clean and tidy; no offensive odours were noted throughout the visit. All 5 units have new kitchenettes in place, which were a significant improvement since the last inspection. The fridges checked were clean and suitably organised. 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. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Procedures for the recruitment of staff are sufficiently robust to ensure the protection of residents. EVIDENCE: The staff files for two newer members of staff were viewed these demonstrated that all the necessary recruitment checks to ensure the protection of residents had taken place. No other staffing records could be viewed on this occasion, as the lock on the filing cabinet was jammed and awaiting attention. A copy of the rota was on display in the staffroom; this however was not checked on this occasion. 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 and having to wait for staff such as when they were bringing meals up from the kitchen in the heated trolleys. The layout of the home must be taken into account when reviewing staffing levels and ensuring that care needs can be met. At the time of this inspection vacancies existed for night care staff and a ‘floating’ member of care staff for weekends. The cook on duty was from an agency. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 and 38 The procedures for seeking feedback by means of quality assurance and protection of residents’ money and valuables are not sufficient to ensure protection of residents. Incomplete documents regarding fire prevention and other health and safety shortfalls such as having no footrests on wheelchairs can also place all those within the home at risk. EVIDENCE: No quality assurance programmes are in place although a system is currently being piloted elsewhere within the company. Due to the number of respite residents residing at the home regularity and consistency of residents meetings could be difficult. Despite this the need to seek feedback from residents as part of continual planning, evaluating and reviewing of the service provided is important and needed. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 19 Regulation 26 of the Care Homes Regulations 2001 requires the registered provider to visit at least once per month and write a report. This requirement was highlighted within earlier inspection reports but has not yet commenced. A template for these visits was seen, these visits must now commence in order to comply with the above regulation. Blackmore House has a safe for the safekeeping of small amounts of money and other valuables deposited by either residents or their representatives. A random number of residents’ money was checked and found to balance with the exception of 1p for one resident. The records seen gave a brief description of the item purchased or service provided such as hairdressing. A separate sheet is used for the hairdresser to sign; this ensures that the hairdresser does not have sight of any resident’s actual cash balance. It was evident during the previous two inspections that BCOP did not have a policy upon the eventual disposal of items held in safe keeping for a considerable period of time whereby the rightful owner was not known. This policy has not yet been finalised. Wheelchairs were stowed in a number of different locations including a bathroom, entrances to the bungalows and a corridor, without footrests in place. Although no transferring of residents was seen it was noted that a resident was sat at the dining table in a wheelchair with no evidence of any footrests. This practice can be potentially hazardous to both residents and staff. An immediate concern notice was given in relation to this matter. A member of staff with face piercing did not have these areas covered at the start of the inspection. These items need to be cover to comply with health and safety requirements. The fire log indicated that the necessary testing of the fire alarm is not always carried out on a weekly basis. The location of the break glass used was not recorded. Visual inspections of the emergency lighting and fire extinguishers were not recorded. No record was seen in relation to the action after three fire blankets failed their annual test. Records existed of fire drills and staff who took part however no details of what the drill involved or any learning experience was recorded. An immediate concern notice was given in relation to this matter. Furniture within public areas especially the corridors may not meet the required fire safety requirements. The anticipated new fire risk assessment mentioned in the previous report was not available. It was of some concern to note that the door to a small cupboard containing a hot water tank and hot pipes was open. The cupboard containing cleaning materials was locked. Although data sheets are available for cleaning materials suitable risk assessments remain outstanding on some items used. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 20 Some work was ongoing to improve the environment, this included improvements to some bathrooms and increasing the size of a bedroom. The safety of residents has to remain paramount while work is taking place. The bedroom was left unattended and contained a range of tools. Of serious concern was finding a Stanley knife within a communal bathroom. Service records were viewed for the portable hoist, gas equipment and portable electrical equipment and found to be in order. A certificate showing that the required level of public liability insurance is in place was noted. BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 2 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 1 x 2 2 x 1 BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 (1) Requirement The Statement of Purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1. (This standard was not assessed as part of the inspection carried out on 29th July 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 2. 1 5 (1) A Service User’s Guide, which includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users. (This standard was not assessed as part of the inspection carried out on 29th July 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/04/05 Timescale for action 30/04/05 BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 23 3. 7 17 (3) (a) 15 (1) (2) The registered manager must ensure that care records are kept up-to-date for easy reference. (Previous timescale of 28/02/05 not met). immediate and on going 4. 7 15 (1) (2) The registered manager must ensure that care plan monthly reviews take into account changing care needs and significant events. The date of the review must be recorded. (Previous timescale of 31/03/05 not met). immediate and on going 5. 7 13 (4) 15 (2) Service users must be assessed in regard to their risk of falling and the outcome included in their plan of care with details of appropriate interventions in relation to the prevention of falls. The registered manager must ensure that residents’ care plans contain information regarding nutritional care needs and that residents weights are recorded. The registered manager must ensure that medication is held securley at all times by means of the provision of a suitable drugs trolley for transporting medication around the home. Timescale given to allow time for suitable trolley to be obtained. In the meantime a risk assessment to be carried out. immediate and on going 6. 8 14 (2) 17 (1) (a) Schedule 3 (o) immediate and on going 7. 9 13 (2) 31/08/05 BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 24 8. 9 13 (2) The registered person must ensure that controlled medication is held and stored in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973. (Previous timescale of 31/03/05 not met). 30/09/05 9. 9 13 (2) The registered manager must ensure that any handwritten amendments to the mediaction administration record (MAR) sheets are checked, dated and counter signed by a second member of staff. immediate and on going 10. 10 12 (4) (a) The registered persons must immediate ensure that residents dignity is and on maintained at all times by means going of appropriate written records and verbal communiaction. The registered manager must ensure that a record is kept of meaninful and purposeful activities which take place within the home. The registered provider must ensure a review of the corporative document regarding adult protection takes place to comply with local guidence issued by Worcestershire Social Services. 31/08/05 11. 12 16 (2) (n) 12. 18 13 (6) 30/09/05 13. 19 23 (2) (b) 30/11/05 The registered provider must ensure that all areas of the home are well maintained. (Previous timescale of 31/05/05 not met). BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 25 14. 21 23 Bathing facilities must be reviewed with a view to the provision of assisted baths (given the changing needs and dependencies of service users over time). (Previous timescale of 31/05/05 not met). 30/11/05 15. 22 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. (Previous timescale of 31/05/05 not met). 30/11/05 16. 30 12 (1) 18 (1) All members of staff must receive induction training to National Training Organisation (NTO) specification within six weeks of appointment to their posts. (This standard was not assessed as part of the inspection carried out on 29th July 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/04/05 BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 26 17. 30 12 (1) 18 (1) All members of staff must receive foundation training to NTO specification within six months of appointment to their posts. (This standard was not assessed as part of the inspection carried out on 29th July 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 30/04/05 18. 33 24 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 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 not met). 30/09/05 19. 35 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 not met). 30/09/05 BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 27 20. 36 26 The registered provider must ensure that monthly visits are undertaken and reports are generated and distributed to the registered manager and the Commission for Social Care Inspection. (Previous timescale of 31/03/05 not met). 30/09/05 21. 38 23 (4) The registered manager must ensure an audit of chairs within the home takes place against The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). (Previous timescale of 31/03/05 not met). 30/09/05 22. 38 13 (4) The registered manager must 30/09/05 ensure that all potentially hazardous materials / chemicals are appropriately stored / maintained. In addition all items where Control of Substances Hazardous to Health data sheets are available from manufacturers a copy must be held within the care home. (Previous timescale of immediate and on going part met - risk assessments remain outstanding). 23. 38 13 The registered manager must ensure that footrests are in place upon wheelchairs at all times. immediate and on going BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 28 24. 38 13 (4) (c) 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 fire records are maintained as required including weekly testing of the alarm and monthly visual checks of equipments. 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. immediate and on going 25. 38 23 (4) immediate and on going 26. 38 13 immediate and on going 27. 38 13 The registered manager must immediate ensure that all workmen/women/ and on going contractors work in line with health and safety regulations to safeguard the welfare of residents and staff. 28. 29. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI BLACKMORE HOUSE E52 S18462 Blackmore House V239158 280705.doc Version 1.40 Page 30 - 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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