CARE HOMES FOR OLDER PEOPLE
Blackwell Vale Nursing Home Rear 61 Durdar Road Carlisle Cumbria CA2 4SE Lead Inspector
Marian Whittam Unannounced Inspection 30th August 2007 10:30 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 Blackwell Vale Nursing Home DS0000010111.V342044.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. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Blackwell Vale Nursing Home Address Rear 61 Durdar Road Carlisle Cumbria CA2 4SE 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) 01228 512456 01228 810994 www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Helen Joyce Smallbone Care Home 60 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (28) of places Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 60 service users to include: up to 28 service users in the category of OP (Older people not falling within any other category) up to 32 service users in the category of DE(E) (Dementia over 65 years of age) Date of last inspection 30th January 2007 Brief Description of the Service: Blackwell Vale Care Home is owned by Four Seasons Health Care Limited and is located on the outskirts of Carlisle near to the racecourse. There is a bus stop nearby and ample car parking is provided. The home is divided into three areas with the ground floor providing nursing care for service users within the category of registration of Older People. The second floor accommodates and provides nursing care for people with Dementia. The home was purpose built and each unit has its own lounge and dining room. There is a conservatory and two other lounge areas on the ground floor. Fees payable at the home are from £387.00 a week up to £550. 00 a week as at the time of the inspection. There are additional charges for hairdressing, private chiropody, personal newspapers and magazines, toiletries and taxis for personal travel. The home makes information about its services available through its own brochures, its service user guide and statement of purpose. These are available within the home. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit, that forms part of a key inspection, took place over five and a half hours. The pharmacist inspector assessed the handling of medicines during the visit through inspection of relevant documents, storage and meeting with the staff and residents. The pharmacy inspection took four and a half hours. Time was spent looking around the home observing routines and staff interaction, talking with residents in the lounges and in their own bedrooms, speaking to the staff, observing any activities in progress and looking at care plans. Policies and procedures, systems for recording complaints, financial records and personnel and training records were looked at in the afternoon as well as other records required by regulation. Before the visit information was also gathered on the service from records of previous visits, notifications and other regulatory activities including any concerns and comments made by people coming into contact with the service. Questionnaires about the service from people and other agencies, provided by CSCI, were returned before the inspection took place. What the service does well:
The home provides a safe, warm and homely environment where residents feel relaxed and comfortable. Feedback from residents about this service was very positive. Residents spoken to liked living in the home and spoke highly of the staff and the care and support they received from them. One person said “ I like the way my family are welcomed into the home when they come to visit me and that afternoon tea is always laid on for them after their journey to get here”. A relative of a person living there commented that their relative had “plenty of help, was well fed, always smartly dressed with clothes always clean and kept hung up in the wardrobe, regular checks on them and plenty of tea and biscuits”. Relatives also commented on how welcome they were made to feel and how well the manager and staff kept them up to date on matters that affected their relatives. All residents are fully assessed prior to admission to ensure all needs can be identified and met. Family members are invited to be part of the assessment process providing the resident is in agreement and it is appropriate. Medication is handled safely and this protects the health of residents. Good records are kept and show that medicines are given as prescribed by the doctor. The manager makes sure there are robust recruitment procedures for staff and the thoroughness of pre employment checks means people living there can feel confident their welfare is promoted. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 6 The home maintains a good standard of catering that residents found acceptable with the majority of food home made, reflecting residents preferences and choice. What has improved since the last inspection? What they could do better:
The home has a complaints procedure and encourages resident’s and relative’s opinions however, concerns, even verbal and apparently minor, raised by residents and visitors should be recorded showing what action was taken and the outcome so people can be sure their concerns are taken seriously and further improve good practice. Although call bells are in all areas used by resident’s staff should make sure that they are always within reach of people where their mobility is limited so they can easily summon assistance.
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 7 The service has maintained the improvements it has made in medication handling and recording but should make sure that medicines that have been refused by residents are always recorded for disposal so that they can be accounted for. The nursing staff should also make sure they always accurately record the date and time of administration of controlled drugs in the register to reduce the risk to residents from missed or doubled-up doses. The nursing staff should ensure that the reasons for giving “when required” medicines such as sedatives are recorded to justify their use and to reduce the risk to residents from unnecessary medication. 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. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is made available about the home. Assessments are completed before people move in to make sure that their individual needs are identified and can be met. EVIDENCE: There is a statement of purpose and user guide that has been updated and is available as part of a pack prepared for people visiting this service to look for accommodation. These are also available in different formats to meet different needs. All residents are given the information pack when they come to the home. The home also has an informative colour brochure that is part of its information pack for new and prospective residents. The home’s admission process includes a pre admission assessment of individual needs for residents before admission to the home. There is an
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 10 admission checklist to ensure that all relevant information is gathered and put into a care plan. There is a six week trial period for new residents, during which time the homes assessment is continued to see that resident’s needs are being met and that they want to stay in the home. Information is gathered from other agencies on care and health needs before people come to live in the home and where appropriate a social services management plan is obtained and held on file. Where possible families, other specialised care agencies and professionals are being involved in providing information and background on the health and personal needs to be met for residents. It was observed during the visit that family members were very involved in their relative’s care and the daily life of the home where they wanted to be. The manager made herself easily available to relatives who wanted to talk about their relatives and care. All prospective residents and their families are invited and encouraged to visit the home prior to admission. This gives them an opportunity to assess the quality and suitability of the home. One relative commented on how “very friendly and welcoming” the staff and manager are to both relatives and residents coming to the home. Another relative said, “when I arrive they always offer me a cup of tea or some food, which makes you feel welcome and nothing is a bother”. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and assessment system in place and the health and personal care that people receive is based on their individual needs. EVIDENCE: Each resident has an individual plan of care and four of these were looked at in detail. The information provided covered areas such as levels of dependency, mobility, diet and health, social and personal care needs. Appropriate equipment to prevent pressure sores is in use, mental health is monitored and effective nutritional screening is being done and weights recorded. This information ensures the staff are aware of the level of care required to meet people’s different needs. Care plans show that they have been reviewed at least monthly and any identified changes in conditions and assessments have been consistently incorporated into them. It was evident from examining the plans that any identified changes in the care needs are noted promptly and the plans updated to make sure they reflect their current situation. This is
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 12 supported by an audit system to make sure the care plans are fully reviewed and evaluated so any gaps in care planning can be quickly identified and updated. In this respect the care plans are used as working documents reflecting people’s condition and needs. This was evident for one person whose condition had deteriorated and a thorough reassessment of care needs had been done to reflect their changed needs and appropriate care investigations done promptly. Medicines were well managed and the service showed good practice in a number of areas. The service does regular checks to make sure that medicines are handled in accordance with procedures. Records were good for receipt of medicines into the home and administration to residents. Records for the disposal of medicines were mostly good but the service should make sure that medicines that have been refused by residents are also recorded for disposal so that they can be accounted for. The service should take care to accurately maintain the controlled drugs to reduce the risk to residents from missed or doubled-up doses. Some residents with dementia type illnesses were prescribed sedating medicines “when required” for agitation. Sedatives were given only very occasionally but when they were given the reasons were not always recorded. The service should ensure that the reasons for giving “when required” medicines are recorded to justify their use and to reduce the risk to residents from unnecessary medication such as over-sedation and increased risk of falls. Good records were kept for more complex administration of medicines such as through tubes into the stomach and checks were made with pharmacists and doctors to make sure this was safe. Good practice was shown in the way the service responded to possible side effects in a resident from a blood thinning medicine. Observation during the inspection, records of care planning, survey responses and conversations with residents indicate that residents are treated very much as individuals with their dignity, independence and choice promoted by staff. One resident said, “I get on well with all the staff, we chat about families and going out, they are all very kind.” A relative commented that staff understood their relatives needs and “treat him with the respect he deserves”. Blackwell Vale Nursing Home DS0000010111.V342044.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): NMS 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are supported to make choices about their lifestyle and to maintain their independence. EVIDENCE: The home encourages relatives and friends to visit and residents say there are no restrictions on when people can visit them. Care plans show information is gathered about people’s preferred social and religious activities and some useful personal profiles indicating, important events, people and interests are in place. This is valuable information that can be used in promoting a person centred focus on opportunities for recreation particularly for those who have difficulty communicating their thoughts and feelings. The manager is aware of the need to make activities suited to the individual as well as for groups and is trying to incorporate this as they continue the development of their activities programmes. The home has an activities organiser and a list of all the planned activities is on display in the home. Activities include gardening projects, pamper
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 14 mornings, trips out and musical entertainments. The home also has a monthly newsletter that gives information on events and meetings as well as general information about what is going on with staff and residents. The home has use of a minibus and several trips out have taken place and more are planned to take place. There are ‘ladies’ and ‘gentlemen’s’ days out where the male residents selected an aircraft museum for a day out and the ladies chose to visit a garden centre. One to one activities are supported and efforts are made to make sure all people who want to be are involved in the activities. This was evident for one person whose physical condition has deteriorated so limiting what they could do and enjoy. This person had a face and head massage and a manicure and pedicure. They had responded positively to this interaction and contact. One resident said they had been out shopping with a carer and had enjoyed that and another said how much she enjoyed it when the “girl comes and helps me with my letters and cards”. The organiser keeps records of what people have taken part in and their enjoyment and what they got from the experience. The home makes information on advocacy services available and on paying for care and how to contact the Citizen’s advice Bureau for advice and support if they want it. The home produces all its own meals on site and offers a range of nutritious food. The home has a main menu with the main meal for the day and this is run on a four-week rota. There is also a menu of alternatives to the main meal; this included such things such as pasties, sandwiches and salads. Residents spoken with said they were happy with the choice and quality of the meals. One resident said, “The meals are always enjoyable and are all homemade”. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns knowing they will be listened to and acted upon. EVIDENCE: Since the last inspection the home has logged two complaints and has made one safeguarding adults referral to Social Services. This has been investigated and addressed by the home manager with other relevant agencies including appropriate referrals to protect residents. No concerns have been raised with CSCI since the last inspection. The home has a complaints procedure and a system for logging complaints for investigation. The procedure is displayed and is also available in the Statement of Purpose and in large print version. Records of written complaints and investigations are kept. We did discuss what should be recorded as “ a complaint” and it was recommended that in future all concerns, even verbal, raised by residents and visitors should be recorded showing what action was taken and the outcome. This good practice recommendation could help quality monitoring of the service and further ensure people can see that their concerns, even apparently minor ones, will be treated seriously and acted upon. Residents spoken with said they knew who to make a complaint to and
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 16 relatives and residents surveys supported this view. One resident said the manager “is usually available to listen to any anxieties I have”. The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the Local Authority’s Multi Agency Guidance was also seen to be available. The staff handbook also contains information on adult protection. Staff training records indicate that training in this subject is being given. Nursing staff spoken with confirmed they had training on this and felt they understood their responsibilities for this and that the manager would support them if they did raise concerns. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 20, 21, 22, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a comfortable and homely living environment. The premises are reasonably well maintained and kept to a good standard of cleanliness. EVIDENCE: The home now has a maintenance person to take care of daily maintenance and safety checks. There is also a housekeeper in post to supervise the domestic team and the home was clean and tidy. Problems regarding odours in some rooms in the home are being addressed and alternative flooring is to be used to help relieve this and make the environment more pleasant for the residents using the rooms. It was evident looking around the home that since the last inspection that work has been done to improve the environment for residents and this work is still
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 18 going on. The manager has reduced the number of shared rooms in the home and currently only one room is being shared. The corridors have already been redecorated and painted giving a lighter and more spacious feel and new carpets are due to be fitted shortly. Rooms that have been refurbished so far are of a good standard and residents can personalise them as they want to. Plans are also in hand to improve shower rooms and bathrooms and to provide new furniture in the rooms as they are redecorated. One resident said that they liked their room and it had been redecorated and “all done ready when I came in”. On the day of the visit work was underway in the gardens to improve access for residents and enable them to use them more. Plants and shrubs were being delivered and residents were involved in deciding on plants and where they should be. Overall the grounds are much tidier and more pleasant for residents but this work needs to continue with suitable seating and safe recreational areas. The manager has a clear vision of how they are going to develop the garden and facilities for residents and is keen to do this so all residents can safely use the grounds. Call bells are available in bedrooms and communal areas. It was noted that in two bedrooms visited to speak with residents who were in bed the call bells were not in reach. Staff need to make sure these are always placed to hand when people’s mobility is limited. There are some adaptations inside the home to help resident’s mobility including adjustable nursing beds and moving and handling equipment to keep people safe and promote their independence. There is sufficient communal space in the lounge dining areas on each floor for people to relax, see visitors or join in an activity. There is a small laundry on site employing full time laundry staff and sluices with disinfection facilities on each floor. The problem with the temperature on the top floor being too hot at times is being addressed to improve the environment for residents and a range of options being considered to provide a long term solution. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of care staff on duty are meeting the personal and health care needs of people living in the home and people using this service are protected by appropriate recruiting procedures. EVIDENCE: Staff rotas and observation during the visit indicate that the home had a stable and experienced staff group providing continuity of care for residents. The staff uses a key worker system and duty rotas show there are enough staff with appropriate skills on the shifts to provide nursing and personal care during the day and night. There were two registered nurses on duty on the unit caring for people with dementia all day during the visit and four care staff. On the nursing unit there was a registered nurse on duty all day and three carers including a senior. There is a registered nurse on duty on each floor at night with two carers on the EMI floor and one on the nursing floor. The home uses its own dependency tool when it does assessments to help monitor people’s needs and if more staff might be needed for changing dependency. There is also a staffing grid in the statement of purpose to indicate how the home arrives at staff levels.
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 20 There are sufficient ancillary and domestic staff on the duty rota over 7 days to keep the home safe and clean. Residents said that the home is kept clean and tidy. The home has administrative staff and reception staff also. People spoken with and survey comments indicate that there are staff usually available when they want them and give them a good level of care and attention. One relative commented on the nursing and care staff saying, “I would like to praise all the staff at Blackwell Vale as they have made my father’s standard of life so much better”. Staff records show that thorough recruitment procedures are being followed and staff have had appropriate Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks before starting work. Periodic checks are carried out on nurse’s registration status and two references are taken up. Training is considered very important by the management and staff confirmed they are given opportunities to train and develop their skills. The manager has a staff training programme in place for the year to make sure all mandatory training is done and up to date. Staff have individual training files recording their training. NVQ training is well established and needs to continue for staff. The home is working on a project with the Primary Care trust (PCT) around dementia mapping to identify areas where practices can be improved. An action plan is being developed with community staff working with the nursing staff and additional training planned as a result. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 31, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a home that is safe, well managed and run in their best interests. EVIDENCE: The registered manager is appropriately qualified and has experience of working with older people and is being well supported in her role. During the visit it was clear that the manager operated an ‘open door’ policy for staff, residents and relatives and communicated a clear focus on care and support to staff relatives and residents. Staff spoken with said that the manager was approachable and flexible and they had staff meetings where they could look at
Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 22 practice issues. Relatives and residents comments also indicate the management style is open and inclusive and that they are kept informed of what is happening in the home. Resident’s relatives and friends are asked for their views and opinions using customer surveys, and the home organises residents and relatives meetings to allow people to raise issues and ideas. This is also a social occasion where refreshments are provided and a guest speaker from the Primary Care Trust came to the last one to talk about continuing nursing care provision. Policies and procedures are being reviewed and the provider and manager are updating these where needed and the standard of record keeping is generally good. The home has a comprehensive range of audits taking place across all areas of the home to support its quality monitoring and sets timescales for action. The audits have been very effective in identifying areas where improvement has been needed and all staff are involved in the audit process. It is clear that reviews of facilities are going on and that development of the services generally is underway and a lot of planning is going into developing the service for residents. Staff are being given regular recorded supervision and annual appraisals to support their practice. There are procedures in place to safe guard the residents finances with records kept within the home. Records and servicing contracts indicate that the home has systems in operation and training to promote resident health and safety. Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 3 2 X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP16 Good Practice Recommendations All concerns, even verbal, raised by residents and visitors should be recorded showing what action was taken and the outcome so people can be sure their concerns are taken seriously. Staff should make sure that call bells are within reach of people where their mobility is limited so they can easily summon assistance. The service should make sure that medicines that have been refused by residents are recorded for disposal so that they can be accounted for. The service should accurately record the date and time of administration of controlled drugs in the register to reduce the risk to residents from missed or doubled-up doses. The service should ensure that the reasons for giving “when required” medicines such as sedatives are recorded to justify their use and to reduce the risk to residents from unnecessary medication.
DS0000010111.V342044.R01.S.doc Version 5.2 Page 25 2. 3. 4. 5. OP22 OP9 OP9 OP9 Blackwell Vale Nursing Home Blackwell Vale Nursing Home DS0000010111.V342044.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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