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Inspection on 13/06/07 for Blakenhall Community Resource Centre

Also see our care home review for Blakenhall Community Resource Centre for more information

This inspection was carried out on 13th June 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This is a home that has a sustained track record of delivering good performance and managing improvement to ensure that people living at the home receive quality care, delivered by a highly skilled staff group. Staff have a wide range of qualifications and skills in the field of dementia care and older person`s mental health and these skills are applied to every day practice to achieve positive outcomes for people living at the home. Admissions to the home are well managed and an effective assessment procedure takes into account people`s needs including those regarding equality and diversity-care is then planned to take account of these needs, individual likes/dislikes and preferences. Staff working at the home have a good understanding of people`s different needs and capabilities and enable people to make choices as part of their daily lives. The home is continually monitoring the service it provides, employing specific techniques such as dementia care mapping which enables evaluation of the quality of care provided to people who, because of their illness are unable to provide accurate written or verbal feedback.Blakenhall Community Resource CentreDS0000036769.V343030.R01.S.docVersion 5.2

What has improved since the last inspection?

The last inspection required the home to finalise the home`s medication policies and procedures-observation of this document confirmed that this has been achieved. There were no other requirements made at the last inspection.

What the care home could do better:

Shortfalls within this home are few; one requirement and one recommendation were made as a result of this inspection. Although the home now has a comprehensive medication policy, it was seen that on occasions the temperature of the medication fridge had been recorded by staff as being outside of the temperature range, with no evidence to suggest that any action was taken to address this deficit. The home is required to ensure that all staff are made aware of the home`s medication policy so as to ensure that medication needing refrigeration is consistently stored according to manufacturer`s instructions. One person had bed rails in place on their bed-the bed rails had been fitted by staff working for the community moving and handling team and were observed to be fitted correctly. To enhance safe use of bed rails a recommendation from this inspection is for individualised risk assessments to be completed. It is also strongly recommended that all staff are made aware of MHRA/HSE guidance in the Safe Use of bed rails-this is to ensure that staff are able to monitor bed rails to ensure their continued safe use.

CARE HOMES FOR OLDER PEOPLE Blakenhall Community Resource Centre Haggar Street Blakenhall Wolverhampton West Midlands WV2 3ET Lead Inspector Rosalind Dennis Draft Unannounced Inspection 13th June 2007 10:00 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 Blakenhall Community Resource Centre DS0000036769.V343030.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. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blakenhall Community Resource Centre Address Haggar Street Blakenhall Wolverhampton West Midlands WV2 3ET 01902-553547 01902 553549 Julie.Criag@wolverhampton.gov.uk www.wolverhampton.gov.uk Wolverhampton City Council 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) Post Vacant Care Home 29 Category(ies) of Dementia (29), Mental disorder, excluding registration, with number learning disability or dementia (29) of places Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age 50 and above No number division between the categories Date of last inspection 1st June 2006 Brief Description of the Service: Blakenhall Resource Centre provides residential care and respite care for 29 adults over the age of 50 with mental health needs-the majority of people admitted to the home have a diagnosis of dementia, but the home is also able to provide care to people with other mental health needs. There are two residential units, Warwick and Windsor which offer long-term care for twenty two older people no longer able to live at home-all of the bedrooms on these units are single and have en-suite facilities. Ludlow Unit provides respite/short term and seven single bedrooms are located on this unit-these rooms do not have en-suite facilities but toilets and bathroom are located nearby. The home has a range of lounges and dining areas and a sensory garden is an excellent resource and enables people to access outside areas safely. The Resource Centre is managed as a joint project between the city council’s Social Services Department and the Care trust and all people living at the home are funded by the local authority-the home is not aware of individual fees. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around 5 hours. The inspection involved observing interactions between staff and people living at the home, speaking with staff, and looking at records. All ‘key’ standards were assessed during the day- that is those areas of service delivery that are considered essential to the running of a care home. Since the last inspection a new manager has been appointed, Julie Craig who has a wide range of supportive qualifications as well as previous experience in managing the home in the capacity of deputy manager- Julie was present at the time of this inspection, which found the home functioning well. Although many people living at the home are unable, because of their illness, to provide accurate feedback on their views of the home and care they receive, all people living at the home appeared content, well cared for and staff attentive in meeting their needs. What the service does well: This is a home that has a sustained track record of delivering good performance and managing improvement to ensure that people living at the home receive quality care, delivered by a highly skilled staff group. Staff have a wide range of qualifications and skills in the field of dementia care and older person’s mental health and these skills are applied to every day practice to achieve positive outcomes for people living at the home. Admissions to the home are well managed and an effective assessment procedure takes into account people’s needs including those regarding equality and diversity-care is then planned to take account of these needs, individual likes/dislikes and preferences. Staff working at the home have a good understanding of people’s different needs and capabilities and enable people to make choices as part of their daily lives. The home is continually monitoring the service it provides, employing specific techniques such as dementia care mapping which enables evaluation of the quality of care provided to people who, because of their illness are unable to provide accurate written or verbal feedback. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. The home has a good assessment and admission procedure, which ensures that the home is able to meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preparation for a planned pre-admission assessment taking place during the afternoon of the inspection showed that people are offered the opportunity to come to the home for a ‘trial visit’ and that the home seeks to obtain as much information as possible prior to an admission to the home. This includes information obtained during the referral process on the person’s religion, ethnicity, language and any barriers to communication. Person-centred Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 9 assessment forms, have pictures and symbols to assist people with communication difficulties to make choices and specify their likes and dislikes and a staff member explained how they are continually updated depending on changing needs and preferences. Each care file contained a ‘life history’ of the person based on information provided by the person and/or their significant other and this provides staff with an insight about the person prior to and during their illness –it was seen that this information had been incorporated into care plans to enable individualised care to be promoted. All care files contained information on funding agreements. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is excellent. There is clear and consistent care planning in place, which focuses on the individual needs of people living at the home and provides staff with the information they require to meet people’s needs. Evidence of regular review and good multi-disciplinary working ensures that the health and personal needs of people living at the home are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Time was spent observing staff interactions with people living at the home, and this showed that staff are skilled in their approaches with people, showing patience, empathy and appropriate use of humour. Some people living at the home were able to provide comments, which indicated that they felt satisfied with their care –these included ‘staff are kind’ ‘staff are very good’. All people Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 11 seen during the inspection appeared well-looked after and showed signs of well-being. Observation of three people’s care files shows that the home assesses and plans care effectively. Care plans were seen to be clear, up to date and reviewed regularly, providing information to staff on how to meet each persons needs including mental health, personal care, mobility, safety, and social care needs. A range of risk assessments provides additional information on any recognised or potential risks to the individual. Regular ‘Dementia Care Mapping’ is carried out by the home as a way of observing and examining the quality of care from the perspective of the person with dementia–and information on the results of this process was contained within care files and any action for improvement noted. Comprehensive recording within care files confirms that people receive regular input from health and social care professionals including regular ‘formal’ reviews involving the person, their social worker, family representative and link worker from the home. Care files also contained detailed information on caring for the person should their condition deteriorate, recognising religious and cultural needs through illness and in the event of the person’s death. Staff were seen to promote people’s dignity, any personal care interventions were carried out away from communal areas and during meals staff provided sensitive assistance to people who needed help with eating. Observation of medication administration record (MAR) sheets showed that the home has good recording processes in place, all medication was recorded accurately and if medication was not given, the reasons were recorded clearly. A newly updated administration of medications policy provides guidance for staff and during the inspection an assessment of staff competence in administering medication took place, showing that the home regularly monitors practice-records show that all staff involved in administering medication undertake suitable training. The medication room was seen to be wellorganised and the manager aware that the temperature should be maintained below 25°C. Records showing the temperature of the medication storage fridge showed that the temperature had occasionally exceeded 8°C, which exceeds that documented in the home’s own medication policy and is considered too high. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. The routines of the home are very flexible, staff assist people to exercise choice as far as possible and according to their differing capabilities. The meals at the home are good, offering variety and catering for different nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection staff were seen initiating different activities with people, including singing, listening to music and of particular enjoyment for some people was when a staff member encouraged their participation to try juggling and plate balancing, promoting discussion and interaction. Other staff were promoting hand and nail care and using this activity positively to encourage a reaction from the person. Records show that the home provides a range of activities based on individual preferences and visits outside of the home are also undertaken. The staff are knowledgeable about advances in Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 13 Dementia Care, for example the home has piloted and found ‘doll therapy’ beneficial for some individuals-this was seen to be used and monitored appropriately during the inspection. The home has an excellent sensory garden, which provides people living at the home with an outside space specifically designed to promote sensory awareness; raised flower beds enable people to smell and touch flowers and plants with different textures. As an ongoing project the home is developing ‘memory boxes’ containing personal possessions, photographs and objects-and care plans confirmed the use of these. Signs are in place throughout the home to aid orientation and these incorporate pictorial representation and translation into alternative languages. A choice of dining areas provide people with alternative places to eat with staff recognising people’s preferences as to whether they prefer eating with others or in a quieter part of the home. The meal served during the inspection was well-presented and prepared to take account of peoples different capabilities. Written menus are supplemented by pictures of the meal to assist people with choosing and recognising food. Staff were seen to provide sensitive assistance to people who needed help and one member of staff sat and ate her own meal with people, prompting individuals to chat and eat their meal. Fresh fruit was seen in the kitchenette areas and a visitor spoke of how the home always has fresh fruit available. The provision of a visitor’s room provides a ‘quiet place’ for people and/or their representatives to meet and relax. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home ensures that people have access to a clear complaints procedure, which enables concerns or complaints to be dealt with promptly and professionally. Staff are provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a good procedure in place for dealing with any complaints, copies of this procedure were clearly displayed and one person visiting the home confirmed their awareness of this procedure. The manager showed where complaints are recorded and this process enables close auditing of any complaints and the action taken to address them-the home has not received any recent complaints. Observation of training records show that staff are provided with adult protection/abuse awareness training –one member of staff could not recall receiving training and this was brought to the attention of the manager, another member of staff gave a good account of adult protection and ‘whistleblowing’ procedures and confirmed that training had been given as part Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 15 of their induction. The manager demonstrated a sound knowledge of dealing with concerns, complaints and adult protection issues. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be maintained to a good standard providing safe and ‘homely’ accommodation. A selection of bedrooms on the two residential units, Warwick and Windsor, which were observed were all in a good state of décorall of these bedrooms have en-suite facilities, which were found to be very clean and well equipped with walk-in shower facilities. Ludlow unit does not have en-suite facilities although toilets and bathrooms are in close proximity to bedrooms. The décor on Ludlow unit was satisfactory, if a little dull and the Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 17 manager confirmed that a refurbishment of the home is planned. The home has a range of communal lounges and dining areas, which are generally spacious, apart from on Ludlow unit where these areas are quite cramped. All parts of the home were observed to be clean and steam cleaning of some carpets was in progress at the time of inspection. Training records show that staff have received training in infection control and observations show that this is put into practice as staff were seen using protective clothing appropriately during care activities and at mealtimes. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Training opportunities within the home are good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing rotas show that levels are maintained at a minimum of seven care staff each day plus an assistant team leader in the morning and at night. The manager is supernumerary and is available on-call outside normal hours. Staffing levels appeared satisfactory on the day of inspection, people had their needs attended to promptly and sufficient staff were available to supervise people if they wandered around the home. Staff spoke of how the levels had improved although occasional short notice staff sickness could cause staffing difficulties. The manager confirmed that the home currently has eight staff vacancies, so agency staff are used to supplement home staff, it was also identified that delays in the decision to recruit staff can lead to lengthy delays in recruiting staff to vacant posts. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 19 One staff file checked showed that pre-employment checks had been undertaken –other information pertaining to recruitment and selection is held centrally and an assessment of these processes will be undertaken in the near future. All staff have an individual training profile and observation of training records show that staff are provided with a wide range of training, including- personcentred planning, multi-sensory stimulation (SONAS), dementia care, ageism and observation of a training plan shows that future training includes nutrition in mental health and Management of Violence and Potential Aggression (MAPA) for all staff. The manager was due to provide a workshop for staff on ‘recording and reporting’ during the afternoon of the inspection. The home provides a comprehensive induction programme, which incorporates a theory based induction pack and a period of ‘shadowing’ the new member of staff –and a staff member provided confirmation that this induction is provided. Staff confirmed that the home supports the provision of NVQ 2 training. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. The manager is focused on positive outcomes for people living at the home and leads and supports a strong staff team who have been recruited and trained to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new manager has been appointed, Julie Craig, who has worked at the home in the capacity of Deputy Manager for sometime. Discussion with Julie and observation of the home’s statement of purpose confirms that she has the skills and abilities for this position-with an excellent Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 21 range of qualifications, such as the Registered Manager’s award, basic and advanced dementia care mapping and a ‘masters module’ in person-centred care for older people with mental health needs. A discussion with Julie confirmed her awareness of the need to apply to CSCI to enable the registration process with CSCI to be progressed. Copies of minutes for staff meetings show that these are held on a regular basis and additional care management meetings provide a focus of reviewing people’s care and risk assessments. The home has recently ‘signed up’ to the West Midlands Mental Health Older Person’s Mental Health Collaboration with Staffordshire University, which is looking at raising the profile and improving the services of older people with mental health and their carers-copies of questionnaires show that the process of obtaining views from relatives, GP’s and consultants is in progress. Regular relatives meetings are held and evidence of regular Dementia Care Mapping shows that the home is continually monitoring the service from the view of each person with dementia. Senior management undertake regular visits to monitor the service and observation confirmed a visit to the home the day before this inspection. Observation of financial records confirm a robust process of managing people’s finances-all transactions are checked by two staff members and the manager audits these records on a regular basis. Staff supervision and appraisal is carried out-and observation of these records show a good process which enables and encourages staff to reflect and improve on care practice and provides opportunity for personal development. Observation of maintenance records show that equipment is well-maintained, and fire training records confirm staff access to fire safety training. Training records show that staff have received training in safe working practice topics and during the inspection staff were seen using good moving and handling techniques to ensure people were moved safely. Bed rails which were seen in use on one bed were fitted correctly and discussion with the manager confirmed that they had been fitted by the ‘community moving and handling’ team-a risk assessment was available, although to enhance safe use it is strongly recommended that individualised risk assessments are undertaken and staff working in the home are made aware of guidance for their continued safe use. The manager was informed that if the home’s staff do become involved in the fitting of bed rails than they must be suitably trained and competent. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 3 3 Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP9 Regulation 13(2) Requirement All staff should be made aware of the home’s medication policy so as to ensure that medication needing refrigeration is consistently stored according to manufacturer’s instructions. This is to ensure that people are not placed at risk of harm from receiving ineffective medication Timescale for action 01/08/07 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 OP38 Good Practice Recommendations To enhance safe use of bed rails individualised risk assessments should be completed and it is strongly recommended that all staff are made aware of MHRA/HSE guidance in the Safe Use of bed rails-this is to ensure that staff are able to monitor bed rails to ensure their continued safe use. Blakenhall Community Resource Centre DS0000036769.V343030.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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