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Inspection on 17/05/07 for Blakesley House Nursing Home

Also see our care home review for Blakesley House Nursing Home for more information

This inspection was carried out on 17th May 2007.

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 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

People wishing to live at the home are assessed prior to admission in order to ascertain if the home is able to meet their needs. Overall the service user plans were comprehensive and gave a good picture of peoples` individual needs. They had been reviewed monthly and there was evidence of involvement from the person. Staff care for people in a gentle and professional manner and religious and cultural needs are respected. Activities are provided and people can choose whether or not to join in. There is an open visiting policy and visiting is encouraged. Information on advocacy services is available. The food provision is good, offering variety and choice. There are clear procedures in place for the management of complaints and POVA issues. The home

What has improved since the last inspection?

What the care home could do better:

The Service User Guide does not contain all the information required under the Care Home Regulations 2001 and action to update the document must take place. Minor shortfalls were identified in the prompt completion of a care plan following admission and in the recording of receipts of one persons medication,however these should be easily addressed. Several of the people spoken with in the double rooms expressed a preference for a single room, and the home need to take appropriate action to discuss and make plans to meet peoples needs in this area. Although an improvement in the environment has been seen, an ongoing redecoration and refurbishment plan needs to be available with timescales for completion. Several fire doors were wedged open and this had not been identified as a problem, with the exception of a broken magnetic closure. A health & safety environmental audit must be carried out in order to identify any such issues and prompt action taken to address them. Although the home was generally clean, the freezer and the cupboards in the kitchen needed attention. There was no hot water available at 3.30pm on the day of inspection and the importance of ensuring hot water is available at all times was discussed. Some of the recording for fridge and freezer temperatures was in need of clarification to ensure accurate daily checks are carried out and records are maintained.

CARE HOMES FOR OLDER PEOPLE Blakesley House Nursing Home 7 Blakesley Avenue Ealing London W5 2DN Lead Inspector Ms Jean Bovell Key Unannounced Inspection 17th May 2007 11:05 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 Blakesley House Nursing Home DS0000010942.V338398.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. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blakesley House Nursing Home Address 7 Blakesley Avenue Ealing London W5 2DN 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) 020 8991 2364 020 8991 5256 Mrs Margaret Nyambura Lane Mrs Margaret Nyambura Lane Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 16 Nursing beds for the care of the elderly 6 Personal care beds Date of last inspection 12th December 2006 Brief Description of the Service: Blakesley House is a care home for twenty-two older people. There are sixteen beds for older people who need nursing care and six beds for service users who require personal care. The Registered Manager is also the owner of the home which is a four storey detached house located in a quiet residential area of Ealing. The home is close to Ealing Broadway, with its shopping centre, buses, and underground and main line station. There are eleven shared bedrooms and five bathrooms within the home. The lounge, separate meeting room, kitchen and conservatory, which is also used as a dining area, are situated on the ground floor. There are no communal areas on the upper floors. The home has a passenger lift and it can be accessed from the lounge via steps or a portable ramp. Laundry facilities and a food store are within an out-building that is located in the rear garden. The fees are £500 per week for personal care and £600 per week for nursing care. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 15 hours was spent on the inspection process and two CSCI Inspectors conducted the inspection. A tour of the home was carried out, and service user plans, medication records, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire has also been used to inform this report. 6 people living at the home, 1 visitor and 3 staff were spoken with as part of the inspection process. Completed CSCI questionnaires received from people living at the home have also been used to inform this report. The term ‘service user’ refers to a person living at the home. What the service does well: What has improved since the last inspection? What they could do better: The Service User Guide does not contain all the information required under the Care Home Regulations 2001 and action to update the document must take place. Minor shortfalls were identified in the prompt completion of a care plan following admission and in the recording of receipts of one persons medication, Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 6 however these should be easily addressed. Several of the people spoken with in the double rooms expressed a preference for a single room, and the home need to take appropriate action to discuss and make plans to meet peoples needs in this area. Although an improvement in the environment has been seen, an ongoing redecoration and refurbishment plan needs to be available with timescales for completion. Several fire doors were wedged open and this had not been identified as a problem, with the exception of a broken magnetic closure. A health & safety environmental audit must be carried out in order to identify any such issues and prompt action taken to address them. Although the home was generally clean, the freezer and the cupboards in the kitchen needed attention. There was no hot water available at 3.30pm on the day of inspection and the importance of ensuring hot water is available at all times was discussed. Some of the recording for fridge and freezer temperatures was in need of clarification to ensure accurate daily checks are carried out and records are maintained. 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. Blakesley House Nursing Home DS0000010942.V338398.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 Blakesley House Nursing Home DS0000010942.V338398.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a Service User Guide in place, however a review is required in order to provide people living at the home with all the required information so they are clear about all aspects of the services provided. People wishing to live at the home are assessed prior to admission to ensure the home is able to meet their individual needs. EVIDENCE: A copy of the Service User Guide was viewed. Although the document gave a good picture of the services provided by the home, it did not contain all the information required in line with the Care Home Regulations 2001 and the areas of omission were discussed. The Registered Person said that they would arrange for it to be reviewed. Contracts had been issued to people living at the home and these included the fees payable by or on behalf of each person. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 9 The home has a simple pre-admission assessment document and this gives a good picture of the needs of the person being assessed. Three service user plans were viewed and pre-admission assessments had been carried out, one being part complete, however a Social Services needs assessment plus a discharge letter from the hospital were available and detailed the full needs. Blakesley House Nursing Home DS0000010942.V338398.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plans in place were comprehensive and up to date, providing a clear picture of individuals’ needs and how these are to be met. The shortfall should be easily addressed. Medications are being well managed at the home, thus safeguarding people living there. Staff are caring and show respect to people living at the home. However issues identified regarding peoples preferences to be in single rooms not being met compromises their privacy and dignity. EVIDENCE: One Inspector viewed 3 service user plans. Overall these were comprehensive and provide a good picture of each individual and their needs. A document containing assessments for mental health, physical health, personal risk, moving & handling, behaviour, pressure sore risk, nutrition and falls risks, plus updates on the identified care needs is completed monthly. The Head of Care reported that these are also completed if someone returns to the home Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 11 following a hospital admission, so that up to date information regarding their condition and needs is maintained. A ‘Care Plan Diary’ booklet was also available for each person, and this lists each persons care needs and also includes information such as personal care records, monthly observations and daily records. For one person some of their needs had not been recorded until they had been at the home for over 2 weeks and the need to ensure needs are recorded promptly was discussed. At the time of inspection none of the people living at the home had pressure sores and there were no dressings required. Continence assessments for the Primary Care Trust are carried out every 6 months and copies of these were available. Continence care needs had been identified. Nutritional assessments were in place and people are weighed monthly. Where someone does not wish to be weighed this is clearly recorded. There was evidence of input from healthcare professionals. Medication management was viewed. The home uses a monitored dosage system and the blister packs for the morning medications were viewed and the stocks were correct. The medication administration record (MAR) charts were viewed all administration entries had been signed with correct codes being used for any omitted or refused medication. Receipts of medications had been recorded with the exception of the actual amounts received for one person admitted from hospital, and this was discussed with the Head of Care. Medications are being correctly disposed of and records were up to date. There were no controlled drugs or medications requiring refrigeration. Medications are being securely stored. Staff were seen caring for people living at the home in a gentle and professional manner. Some of the bedrooms had been individualised and people can bring in personal possessions in line with fire safety. On the day of inspection a clothing shop was at the home and people were able to choose what items they wished to buy, showing individuality. Religious and cultural needs are identified and action taken to respect them, for example, the provision of suitable meals and also the church service at the home. Several of the bedrooms are double rooms, and during discussions with some of the people living at the home it became clear that they would prefer to live in a single room, rather than sharing. This was discussed with the Head of Care and the Registered Person and a review of all those living in double rooms must take place to ensure they are happy with the arrangement. Where someone would prefer a single room this must be planned for when such a room becomes available. Blakesley House Nursing Home DS0000010942.V338398.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 good. This judgement has been made using available evidence including a visit to this service. The activities provision is good and information regarding individuals’ hobbies and interests is obtained, so they can be considered when planning entertainment. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: On the day of inspection a music activity was taking place. The home has an activities programme in place and the care plans viewed did evidence that people had been asked about their hobbies and interests. People have the choice if they wish to join in any activities, and some of the people living there said that they preferred to stay in their rooms and that their choice is respected. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. A visitor spoken with said that they are always made welcome at the home. Comment was made that it can be difficult to chat with visitors in the double bedrooms due to the lack of privacy, and the Registered Person said that there is a quiet room available for this purpose. Information regarding advocacy services is contained in the Service User Guide along with other useful contact information. One Inspector viewed the kitchen. Generally the area was clean and tidy and shortfalls identified have been noted in Standard 26. The lunchtime meal was viewed and people were enjoying their meals and staff were available to assist those who needed it. One Inspector sampled the meal and it was well presented and tasty. People spoken with said that the food is satisfactory and that they are offered a choice, and there was evidence of choices being provided. A stock of dry, frozen, fresh and tinned foodstuffs was available. A 6week menu was viewed and the cook explained that any changes to the menu are because of choices or stocks available. The Inspector recommended that any changes to the menu be recorded. Blakesley House Nursing Home DS0000010942.V338398.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. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the people who live there. EVIDENCE: The home has a clear complaints procedure with timescales for completion. A copy of this was displayed in the entrance hall and was also contained in the service user guide. One Inspector viewed the complaints record and there had been no complaints since the last inspection. The home has comprehensive policies and procedures for adult protection and also follows the Safeguarding Vulnerable Adults in Ealing procedures. There had been no POVA issues since the last inspection. Staff spoken with had received POVA training and said that they would report any concerns. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the environment is being maintained however shortfalls identified with fire doors were placing people at risk. Procedures for infection control are in place, however some shortfalls identified could potentially place people at risk. EVIDENCE: One Inspector carried out a brief tour of the home. Overall the home is being maintained and action is taken to carry out repairs. The redecoration and refurbishment programme for 2007 evidenced redecoration activity from previous years and did not provide a plan of redecoration and refurbishment for the future. This was discussed with the Registered Person. Since the last inspection there was evidence that some work had been done in respect of redecoration and refurbishment. Several of the bedroom doors, which are fire Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 16 doors, had been wedged open and people spoken with said that they wanted to have their door open. A fire door opposite the first floor office had been wedged open as the magnetic closure was broken. This wedge was removed at the time of inspection and the Registered Person said this had been reported to the electrician. Fire doors must never be wedged open and the need to install an approved door closure system without delay was discussed with the Registered Person. Overall the home was clean. The laundry room is situated in a building in the rear garden. There is one washing machine and one tumble dryer in use. Stocks of linens and towels were available. Personal clothing was clean and cared for. Dust and spilt foodstuffs were seen in some of the kitchen cupboards, plus the top of the locked freezer was dirty and needed cleaning. Hand washing facilities were available, however at 3.30pm when the hot water was checked the tap was running cold, and the Head of Care explained that the heating system is such that the water heater is turned on and off manually. The need to ensure hot water is available at all times was discussed. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 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 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. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate to meet the assessed needs of the people living at the home. Training provision is good, thus providing staff with the skills and knowledge to care for people living at the home. Systems are in place for the vetting and recruitment of staff, thus safeguarding people living at the home. EVIDENCE: On the day of inspection there were 2 registered nurses and 2 carers on duty, plus the cook. In the afternoon there was one registered nurse and one carer on duty. The Registered Person explained that she helped provide cover on a Thursday afternoon and that on all other afternoons 2 carers were on duty. The cook also carries out some of the cleaning duties as do the care staff. The Registered Person said that the home has a ‘deep clean’ every 6 weeks. Should the occupancy increase, consideration must be given to employing a cleaner at the home. The pre-inspection questionnaire detailed that 2 of the care staff are qualified to NVQ level 2 or above, which is equivalent to 40 of the care staff. The planned training record indicates that further NVQ in care training is to be carried out. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 18 4 sets of staff employment records were viewed and these contained the information required under Schedule 2 of the Care Home Regulations 2001. The induction programme follows the Skills for Care common induction standards. The home also is approved to accept 2 supervised practice nurse students from overseas. There is a registered nurse on duty throughout the 24 hour period. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 19 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the experience and qualifications to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of management and practice review. Monies held on behalf of people living at the home are being managed and securely stored, thus safeguarding them. Training in respect of health & safety takes place, however shortfalls identified in recording and safety issues could place people at risk. EVIDENCE: The Responsible Person is also the Registered Manager and is a first level nurse. She has recently completed the NVQ level 4 Registered Managers Award and is awaiting the certificate. The Responsible Person has also completed Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 20 assessors training for NVQ. Other training to include tissue viability and dementia care training had been undertaken. Staff reported that the Responsible Persons is now more approachable and supportive. The importance of ongoing training in topics relevant to her role and keeping up to date with CSCI information provided via the CSCI website was discussed. The home has introduced a system for quality assurance. This includes surveys for people living at the home, their relatives and healthcare professionals. The need to collate the results of these surveys and send a copy to CSCI in line with legislation was discussed. Staff meetings take place every 3 months. No evidence was seen of meetings with the people living at the home taking place, and these should be introduced to allow those people to express their views and for the home to respond appropriately. Audits of areas of care to include medications are carried out. The Registered Person holds personal allowances on behalf of 8 people living at the home. One Inspector viewed 4 sets of records and these were up to date and the balances of cash held were correct. The home has a safe facility. Staff had undertaken health & safety training to include fire safety, moving & handling, food hygiene, infection control and first aid. Fire lectures and drills are carried out 3 monthly. Maintenance and servicing records viewed were up to date. Risk assessments for equipment and safe working practices were in place, plus risk assessments for any individual risks identified were seen in the service user plans and these had been updated monthly. The fridge and freezer temperatures for the equipment in the outside food store had been recorded, however it was not clear what thermometer had been used to obtain these readings. The need to ensure all readings are taken daily and recorded by the person carrying out the task was discussed. One person had been given a chipped glass to drink out of and this could have caused an injury. As identified under Standard 19, several fire doors were wedged open. A full health & safety audit must be carried out and action taken to address any shortfalls identified. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5 Requirement The Service User Guide must be reviewed and updated to include all the information required, in order to provide the reader with a full picture of the services provided and costs involved. Following admission, all the needs of each person must be recorded so that they can be planned for and met. All medication received into the home must be recorded. People living in double rooms must be consulted about their wishes. If people wish to be accommodated in a single room then plans must be made to address this, in order to respect their privacy. There must be an up to date programme of redecoration and refurbishment in place with timescales for completion to show how the environment is being maintained. Fire doors must not be wedged open. Action must be taken to provide approved door closure devices for all those who wish to DS0000010942.V338398.R01.S.doc Timescale for action 01/08/07 2. OP7 15 01/07/07 3. 4. OP9 OP10 13(2) 12 18/05/07 01/08/07 5. OP19 23(2(b) & (d) 01/07/08 6. OP19 23(4) 08/06/07 Blakesley House Nursing Home Version 5.2 Page 23 7. OP19 23(2)(j) 8. 9. OP26 13(3) 13(3) OP38 10. OP38 13(4) 11. OP38 13(4) have their doors held open, in order to ensure their safety. There must be hot water available in the home at all times in order to minimise the risk of infection. All areas of the home must be kept clean in order to minimise the risk of infection. The records for fridge and freezer temperatures must be a reflection of the actual checks carried out, for safety purposes. A full health & safety audit of the home must be carried out and action taken to address any shortfalls identified, in order to provide a safe environment. Chipped glasses must be disposed of to avoid the risk of injury to people. 01/06/07 08/06/07 08/06/07 01/07/07 18/05/07 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 OP33 Good Practice Recommendations It is strongly recommended that regular meetings take place with the people living at the home, so that their views are heard and responded to. Minutes of these meetings should be recorded. Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Blakesley House Nursing Home DS0000010942.V338398.R01.S.doc Version 5.2 Page 25 - 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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