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Inspection on 28/05/08 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 28th May 2008.

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

The home provides a service to people who have different religious and/or cultural needs. Full assessments are carried out on prospective residents and it was indicated on surveys that people were assured that their needs would be met at the home prior to admission. People`s changing needs are comprehensively assessed within care plans and are regularly reviewed. Related risk assessments are appropriately undertaken. Contact with relatives, friends and/or advocates is encouraged and facilitated. Residents informed us that they were able to receive visitors in their bedrooms. A variety of nutritious and appealing meals are provided to residents and everyone spoken with confirmed that they received satisfying portions of enjoyable meals at the home. Care staff who responded to CSCI surveys indicated satisfaction with the support and training they received for meeting the needs of the people who use the service. Health and safety records were up-to-date. Fire drills are regularly undertaken and environmental risk assessments were in place. Surveys were reflective of people being generally happy with the care and support they received. Residents appeared appropriately dressed and healthy at the time of the inspection. Overall, the home was clean, hygienic, reasonably well maintained and calm.

What has improved since the last inspection?

All requirements made at the last inspection had been met. Specifically, the Service User Guide has been updated. The care needs of new residents are being assessed and recorded. A programme for redecorating and refurbishment is in place. Approved door closures devices have been fitted to all fire doors. Health and safety checks are being kept up-to-date. All areas of the home were clean and hygienic at the time of the inspection.

CARE HOMES FOR OLDER PEOPLE Blakesley House Nursing Home 7 Blakesley Avenue Ealing London W5 2DN Lead Inspector Ms Jean Bovell Key Unannounced Inspection 28th May 2008 11:00 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.V364040.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.V364040.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.V364040.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 17th May 2007 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 approximately £500 per week for personal care and £600 per week for nursing care. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who us the service experience adequate quality outcomes. This unannounced inspection was carried out between 11:00 am and 4:30 pm on 28th May 2008 by two CSCI Inspectors. The Registered Manager, Assistant Manager/Registered Nurse, two Care Assistants and sixteen residents were at the home. During the course of the inspection, the home’s records, documents, policies and procedures were viewed. A tour of the building was undertaken and observations were made. Two Care Assistants and Fourteen residents were spoken with. A completed Annual Quality Assurance Assessment – self assessment document and CSCI surveys received from residents and care staff were considered. The requirements that were made at the last inspection and all key Standards were examined. The Registered Manager and Assistant Manager provided appropriate assistance throughout the inspection. What the service does well: The home provides a service to people who have different religious and/or cultural needs. Full assessments are carried out on prospective residents and it was indicated on surveys that people were assured that their needs would be met at the home prior to admission. People’s changing needs are comprehensively assessed within care plans and are regularly reviewed. Related risk assessments are appropriately undertaken. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 6 Contact with relatives, friends and/or advocates is encouraged and facilitated. Residents informed us that they were able to receive visitors in their bedrooms. A variety of nutritious and appealing meals are provided to residents and everyone spoken with confirmed that they received satisfying portions of enjoyable meals at the home. Care staff who responded to CSCI surveys indicated satisfaction with the support and training they received for meeting the needs of the people who use the service. Health and safety records were up-to-date. Fire drills are regularly undertaken and environmental risk assessments were in place. Surveys were reflective of people being generally happy with the care and support they received. Residents appeared appropriately dressed and healthy at the time of the inspection. Overall, the home was clean, hygienic, reasonably well maintained and calm. What has improved since the last inspection? What they could do better: Fourteen requirements were identified at this inspection. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 7 The home must ensure that instructions from GPs are act ed upon. Risk assessments must be carried out on equipment used by residents and medication administration sheets must be accurately recorded. People’s needs must be met as set out within individual care plans and delay in responding to calls for assistance must be avoided. A variety of weekly indoor activities must be arranged and people should receive opportunities for engaging in activities within the community. People rights – in all aspects - must be respected. Fresh water should be placed in individual bedrooms each day and when required. Cash allowances paid to residents should be reasonable, related to need and must be signed for. The home must also ensure that people are aware of lockable facilities in which cash can be secured. There must be sufficient lighting in all areas of the home and people sitting in the lounge must be supervised. This service has been given an adequate - one star rating. 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.V364040.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 Blakesley House Nursing Home DS0000010942.V364040.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and had been well completed. Where available the home also obtains a copy of the needs led assessment undertaken by social services. Blakesley House Nursing Home DS0000010942.V364040.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 adequate. This judgement has been made using available evidence including a visit to this service. Overall the healthcare needs of the residents are being well managed, thus addressing their needs. Shortfalls should be easy to address. Shortfalls in the medication management could place residents at risk. Whilst overall staff are courteous to residents, shortfalls were identified that could compromise residents choice and dignity. Shortfalls in identifying end of life care wishes place residents at risk of their wishes not being met. Residents’ personal care needs are not – in every case - being met satisfactorily. EVIDENCE: Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 11 We viewed three service user plans. Overall these were well completed and provided a good picture of each resident and their needs. There is a comprehensive monthly assessment document that covers all aspects of care needs and how these are to be met. There is evidence of the involvement of the resident as they sign to agree the assessment each month. Risk assessments for falls are in place and are reviewed monthly. The personal care needs of residents were identified within their separate care plans and the majority of those spoken with felt that their personal needs were being met satisfactorily. However, one resident assessed as requiring the assistance of two carers reported that he/she received assistance from one carer only. Some people reported that care staff responded quickly to calls for assistance. Others said that responses were slow. A resident who was sitting in the lounge at the time of the inspection alleged that repeated calls for assistance with toileting needs over a period of approximately two hours remained unheard. This was reported to the Registered Manager and resulted in an immediate appropriate response. There was evidence of input from healthcare professionals to include the GP and District Nurses. In one instance there was no evidence that a specimen requested by the GP had been collected. Where residents receive input from the District Nurse this is clearly documented in the service user plan. Written consent for bedrails had been obtained, however there was no risk assessment for their use available for one resident for whom they were in place. We reviewed the medication management in the home. The home uses a monitored dosage system and the majority of the medication is supplied in blister packs. Some medication had been supplied in boxes. The controlled drugs are securely stored and receipt and administration records were clear and up to date. All medication was being securely stored. Some receipts of medication had not been recorded on the medication administration record (MAR) and initially information regarding the receipts of these medications was not available. However, it was identified that the home has an ‘ordering’ books in which some receipts are recorded and the information was found. We strongly recommend that all receipts are recorded on the MAR. For one medication that required the combination of tablets of two different strengths, just the actual dose to be given had been recorded on the MAR. Separate entries for each strength of medication must be made on the MAR and the actual dose to be given of each clearly identified. One medication is use has very specific administration instructions. These were not recorded on the MAR and staff spoken with were not aware of these instructions. Seven boxed medications were audited. Four had the correct stock, however one had an excess of three tablets and two had a deficit of two tablets each, indicating shortfalls in administration and recording. For one resident, administration Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 12 records for one particular day could not be found. Medications are being correctly disposed of. The management of oxygen was discussed, to include recording it on the MAR and placing of appropriate signage on the door, for safety purposes. Copies of the prescriptions were not available and we were advised that the prescriptions are faxed directly from the GP to the chemist. The need to ensure copies of prescriptions for all medications prescribed are available in the home was discussed. Some issues were identified with the practices in place for any resident for whom self-medicating might be appropriate. A comprehensive risk assessment must be carried out, plus a full record of each resident’s medication, to include all receipts, must be maintained. A lockable facility with a key must be available for the resident to store medication securely. We advised that the home obtain up to date medication securely. We advised that the home obtain up to date medication management guidance issued by the Pharmaceutical Society. People who use the service wear their own clothes. Preferred names were used by care staff and they were observed being friendly and respectful in their interactions with residents. The information regarding residents’ end of life care wishes was very general and did not reflect the wishes of the individual. The importance of ensuring that the wishes of residents in the event of deterioration in their health and for their final days are ascertained and recorded, so that these can be respected, Blakesley House Nursing Home DS0000010942.V364040.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): 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. A variety of regular outdoor and indoor activities are not being provided. People are able to maintain contact with family, friends and/or advocates. People are able exercise choice and control over their daily living routines. Varied and wholesome meals are being provided. EVIDENCE: Organised activities at the home include a weekly sing-a-long session, individual birthday celebrations and Christmas parties. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 14 People were seen sitting and watching television in the lounge. Others read newspapers or books, watched television or rested in separate bedrooms. Bingo was played in the lounge during the afternoon of the inspection. Residents who replied to CSCI surveys indicated that they always participated in activities at the home. Some residents appeared content. Others confirmed being bored. But everyone spoken with revealed that organised indoor activities were few and that they did not participate in activities within the local community. An open visiting policy is in place and contact with relatives and/or friends are encouraged and facilitated. People are given choice in relation to clothing, hairstyles, personal purchases, times of getting up in the morning/retiring at night and meals. They can remain in their bedrooms and have meals delivered to them or sit and/or eat with others in the lounge/dining area. Telephones are installed in people’s bedrooms and they are able to maintain control over their private affairs. Despite having choices in relation to their daily living routines, residents revealed that they felt uncomfortable speaking freely to Inspectors as they were advised against reporting negatively about the service and that any difficulties should be reported to the home. A trained cook is employed at the home and varied and nutritious meals were listed on the menus. Appealing lunch options were offered at the time of the inspection and everyone spoken with confirmed that good portions of enjoyable meals were provided. Tea and snacks were also served but fresh water was not available in every bedroom viewed. Blakesley House Nursing Home DS0000010942.V364040.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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is in place and satisfactory. People are not being fully safeguarded from financial abuse. EVIDENCE: The complaints procedure is clear and concise, and accessible to residents, relatives, friends and/or advocates. The complaints book was viewed and indicated that no complaints had been made to the home following the last inspection. Complaints that had been made to Social Workers by clients during Social Services reviews were separately recorded. These complaints were investigated by the placing Authority and the Commission were informed. Policies and procedures on safeguarding adults that includes whistleblowing are in place. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 16 The records were indicative of staff training on Safeguarding Adults being delivered. The home does not hold overall responsibility for residents but individual personal allowances are being held in safekeeping at the home. The financial records relating to two residents were viewed and indicated that they had received large amounts of cash within a relatively short period. The particular residents were unable to confirm these payments but an individual was able to produce a purse in which a significant amount of cash was held. The other person maintained that he/she had no cash on his person and there was no physical evidence of cash being held. It emerged, also, that he/she was unaware of keys being available to a personal lockable facility. These issues were discussed with the Registered Manager and we were assured that action would be taken to prevent similar occurrences. We were subsequently informed on the telephone by The Registered Manager that cash had been found in a resident’s ‘glasses case’ following the inspection. This matter was reported to the Safeguarding Adults Co-ordinator at the Ealing Borough of Ealing who will be taking separate action. Blakesley House Nursing Home DS0000010942.V364040.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): 19, 20 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic and reasonably well maintained. The environment is calm and homely but lighting in the lounge is not at all times sufficiently bright. EVIDENCE: The home is being adequately maintained and comfortably furnished. The communal areas are suitable for shared and/or individual activity and includes a medium sized lounge/dining area and an adjoining conservatory. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 18 The garden is accessible to residents and was reasonably tidy at the time of the inspection. There were no issues regarding the laundry. The overall environment was clean, hygienic, reasonably well maintained and calm. However, on entering the service people were seen sitting in a darkened lounge. The television was switched on but watched by only a few and the environment dull. A resident described the environment as being like a ‘morgue’. The lights in the lounge were switched on following a specific request from Inspectors. People who replied to CSCI surveys indicated that the home was fresh and clean. Blakesley House Nursing Home DS0000010942.V364040.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): 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. Care staff are suitably qualified and trained for meeting the needs of people who use the service but people are not at all times supervised. Systems for vetting and recruitment practices are in place and are followed, thus protecting residents. EVIDENCE: The rota was reflective of one registered nurse and three care assistants being on duty at all times during waking hours. One registered nurse and one care assistant covered waking duty at night. At the time of the inspection, two care assistants and one registered nurse were on duty during the morning shift and three care assistants and one registered nurse covered the afternoon shift. One trained cook was also present. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 20 It was indicated on the completed Annual Quality Assurance Assessment (AQAA) that of eight care staff employed at the home, three had achieved NVQ level 2 or above. A staff training programme was in place and indicated that between September 2007 and January 2008, training and refreshers delivered to care staff included Moving and Handling, Medication, Infection Control, Food Hygiene, Safeguarding Adults and Dementia. Residents were observed sitting unsupervised in the lounge during the early and latter stages of the inspection. People that were spoken with confirmed that this was often the case. We were informed by the Registered Manager that people were left unattended only when there was in-house staff training but that a senior member of staff was always at hand to respond to residents’ needs. Care assistants were seen being friendly in their interactions with residents and were competent in meeting their needs. We viewed three sets of staff records. These contained all the information required under Schedule 2 of the Care Homes Regulations 2001. Evidence that the registrations of all the registered nurses working at the home were up to date was available. Blakesley House Nursing Home DS0000010942.V364040.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): 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 is appropriately qualified and experienced. Personal allowances are being separately secured and individual financial records are in place. The AQAA has been completed as required. The health, safety and welfare of people are being protected satisfactorily. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager is suitably qualified and experienced. The Annual Quality Assurance Assessment – self assessment document was returned at the required time and completed appropriately. The home does not hold overall responsibility for people’s financial affairs but individual personal allowances are being separately secured and individual financial records are in place. Health and safety records were satisfactory and reflective of up-to-date checks being carried out on gas maintenance, portable appliances, fire safety, hot water temperature and fridge/freezer temperatures. Tests for legionnaires had also been undertaken. Fire drills were carried out on a three monthly basis and clearly recorded. Environmental risk assessments were in place. Blakesley House Nursing Home DS0000010942.V364040.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X X X X 3 STAFFING Standard No Score 27 2 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 3 Blakesley House Nursing Home DS0000010942.V364040.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. 1. Standard OP7 Regulation 13(4)(b) (c) 15 Requirement The Registered Person must make sure that personal care needs are met as assessed in care plans to avoid unnecessary risks to the health and safety of residents. The Registered Person must ensure that people’s toileting needs are met as quickly as possible to avoid unnecessary risks to their health and welfare. There must be evidence that any instruction from the GP has been actioned, to ensure healthcare needs are being met. Prior to their use, a risk assessment for bedrails must be carried out to ascertain the appropriateness of their use for each individual, to safeguard them. Where a combination of tablets is needed to obtain the correct dosage, each strength tablet must be written up separately on the MAR with full administration instructions. Timescale for action 29/06/08 2. OP7 13(4)(c) 29/06/08 3. OP8 17 01/07/08 4. OP8 13(7) 01/07/08 5. OP9 13(2) 28/06/08 Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 25 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) 10. OP12 16(2)(m) (n) Medication must be accurately recorded when administered. Reasons for any omissions must be recorded. Those responsible for the administration of medications must be aware of any specific administration requirements. Administration instructions must be clearly recorded on the MAR. Oxygen must be recorded on the MAR and appropriate signage must be displayed on the door where oxygen is in use. The homes medication policies and procedures must be updated in line with current pharmaceutical guidance. This must include the policy for selfadministration of medications. The Registered Person must make sure that increased indoor activities are arranged and that people are given opportunities to engage in activities within the community to ensure that their social needs are being met. The Registered Person must ensure that people’s right to speak openly and freely to Inspectors is respected. The Registered Person must make sure that appropriate amounts of cash is paid to residents and that cash is signed for and secured, to prevent risks of abuse. The Registered Person must ensure that there is suitable lighting in the lounge at all times. The Registered Person must make sure that people in the lounge are at all times supervised to ensure that their needs are being met. DS0000010942.V364040.R01.S.doc 28/06/08 01/07/08 01/07/08 01/07/08 30/07/08 11. OP14 12(4)(a) 01/07/08 12. OP18 13(6) 01/07/08 13. OP20 13(2)(p) 28/06/08 14. OP27 12(1)(b) 18(1)(a) 28/06/08 Blakesley House Nursing Home Version 5.2 Page 26 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 OP9 Good Practice Recommendations It is strongly recommended that the home have copies of prescriptions for each resident identifying all the medication currently being administered. Blakesley House Nursing Home DS0000010942.V364040.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V364040.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!