Inspection on 14/08/07 for Blenheim Avenue Care Home

This inspection was carried out on 14th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blenheim Avenue Care Home 04/05/06

Blenheim Avenue Care Home 17/11/05

Blenheim Avenue Care Home 26/04/05

Blenheim Avenue Care Home 08/12/04

Blenheim Avenue Care Home 05/07/04

Blenheim Avenue Care Home 29/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Blenheim Avenue Care Home 9 Blenheim Avenue Mapperly Nottingham NG3 6GD Lead Inspector Jayne Hilton Key Unannounced Inspection 14th August 2007 07:45 Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 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 Blenheim Avenue Care Home DS0000008633.V340714.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 Adults 18-65. 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. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blenheim Avenue Care Home Address 9 Blenheim Avenue Mapperly Nottingham NG3 6GD 0115 9555221 0115 9555221 mlesleyr@ncha.org.uk www.ncha.org.uk NCHA 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) Lesley Rawlinson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 4th May 2006 Brief Description of the Service: Blenheim Avenue Care Home is a detached bungalow located within the residential area of Carlton. There are some local shops and amenities nearby. The home is registered to provide care and support for four adults with a learning disability who all have additional physical disabilities. There are new adaptations and equipment in the home enabling full and flexible assistance to residents with physical disabilities and who use wheelchairs. The accommodation comprises of four single bedrooms, a lounge/diner, and a bathroom/shower with toilet, separate toilet suitable for wheelchair users, kitchen and a laundry room. The office is in the loft conversion, which also acts as a sleep in room for staff. There is an attractive garden to the back of the bungalow, which is accessible to wheelchair users. The current weekly fee range is £398.00 with top a top up amount paid by The Primary Care Team - this information was provided by the manager at the home on 14th August 2007. [This information is not supplied within the Service User Guide]. A Statement of Purpose and Service User Guide was on display in the home on the day of the inspection and a copy of the Inspection report was available on request. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection was undertaken in six hours and was unannounced. The preferred method of inspection used is usually ‘case tracking’ which involves selecting residents and tracking the care they receive through review of their records, discussion with residents where possible, discussions with the care staff and observation of care practices. Due to communication issues this was, not able to be fully utilised. Of the four residents, three went out early, during the inspection. The inspector was introduced to the residents briefly and was able to make some observations of interactions with staff prior to them going out. There were no relatives spoken with at the inspection. Four members of staff were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and the Annual Quality Assurance Assessment document completed by the manager. Four completed service user satisfaction questionnaires were also received prior to this inspection report being produced. A review of the Registration Certificate was undertaken at this inspection. It was established that there was a change in the Responsible Individual for the home. What the service does well: Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 6 The manager and support staff have a very good understanding of the needs of the residents living at the home and care plans record the needs of residents clear detail. Risk assessments are also very informative for staff, which is important for promoting the safety and independence of residents. There are good methods of communication between staff, which means that staff are up to date with when residents needs have changed and when tasks need doing. Staff who spoke with the inspector are clearly committed to promoting the quality of life of residents. The manager ensures that specialist professionals are called upon for their input on how to best meet the needs of people that live at Blenheim Avenue. Staff support residents to maintain contact with family and friends. The structure and culture within the home is that of putting resident’s needs and independence first. The staff group ensure that residents are actively engaged in getting out and getting involved in day-to-day events and activities. There is an appropriate complaints procedure in place and staff are encouraged to act on behalf of residents to enable residents to access this procedure. Staff demonstrated an understanding of their responsibilities in protecting residents from abuse. What has improved since the last inspection? What they could do better: Although there was evidence that recruitment practices were robust in respect of Criminal Records Bureau (CRB) disclosures and references obtained for staff employed, not all files had photographic evidence as required by regulation and a requirement is therefore set in respect of this. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 7 There was no evidence that staff are issued with a copy of the General Social Care Councils ‘Code of Conduct ‘Booklet-again this is required by Regulation. A requirement is set in respect of this. Twelve good practice recommendations are set in addition to these. 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. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed before moving in to the home. Care planning is thorough and enables clear action plans to be developed for residents to fulfil their own potential. EVIDENCE: A Statement of Purpose and Service user guide, which contained signs and symbols, was on display in the home on the day of the inspection and a copy of the Inspection report was available on request. Some updating to the Service User Guide is needed however. Contracts were seen for the two people ‘case tracked’, which were signed where appropriate. Service users are informed about any increase of fees, but the manager reported she was currently addressing errors for the most recent fee increase with the relevant department. The records of two resident’s files were checked as part of this inspection. Both files contained assessments conducted by the manager, or deputy manager or the relevant agencies. All of the assessments were comprehensive and contained sufficient information to enable staff to ensure that they could meet the residents assessed needs. There were detailed action plans for Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 10 support staff. The plans are computerised within a large secure database, paper copies were observed. The manager and staff spoken with explained how they used information on these plans and how they were regularly updated to reflect changes in residents needs, preferences and behaviour. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All residents have assessment plans detailing their support requirements, preferences and areas of risk. Residents are supported to make their own decisions where possible and balance their decisions with appropriate risks. EVIDENCE: Staff spoken with demonstrated a good understanding of the individual needs of the resident group and it was evident that the resident plans are utilised effectively in order to meet the needs of residents and that changing needs are identified and recorded. Records are held both on the computer system and on a paper file, which means that the care plans are accessible at all times. Care plans are reviewed every 90 days and the computer system actually prompts this. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 12 Communication needs were identified clearly in resident plans seen. Visual tools such as pictures and photographs are used to enable residents to make choices and decisions about their lives. Staff spoken with gave examples of residents choosing activities, holidays and meals. Staff were observed offering residents choices about breakfast and positive relationships and interactions were also observed between residents and staff. Care plans and staff provided clear evidence of how residents interests are put first. Support is flexible enough to enable residents to make spontaneous decisions about what they did and where they wanted to go. The staff team have developed Life story books- listen to me, choices, books, holiday books, menu books and activities books to promote choices and rights of the individuals. Care plans detail individual needs and balance the risk involved for that resident in day-to-day living activities. Residents are supported to go out regularly to engage in variety of different activities. Residents have little or no comprehension of their resident plans and assessed needs. The manager reports that the consent and involvement of relatives is sought although not all the residents have family that want to be involved. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Current resources are managed well in order to provide some meaningful and therapeutic activities for residents and meals offered are healthy and varied. Daily routines within the home ensure that the rights of residents are respected. EVIDENCE: Care plans and support staff described the list and range of activities that residents have access to it is clear that their individual recreational and social needs are well promoted in the home and the wider community. The home has its own vehicle and staff also utilise their own cars. Staff described what an enormous improvement having the minibus has made to the residents every day life, in terms of attending social events and medical appointments. Also for longer term activities like holidays, which are already frequent events. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 14 One resident has been able to access a trip to France and delighted in reporting this in the survey questionnaire and at the inspection. It was evident from discussion with staff and also by looking at the relevant care plans, that residents’ contact with their family and friends is promoted. The inspector was shown the kitchen where meals were made with some involvement of residents. Residents are able to make choices on the day over what to eat and records are kept. The garden area was also observed which provides extremely pleasant surroundings. The manager and staff demonstrated items of craftwork completed by residents, which is now used to decorate garden walls. Separate areas have been developed to provide innovative sensory stimulation, privacy and relation and other areas have been dedicated to fruit trees and herb gardens, which the home uses for cooking. The home won first prize in a recent garden competition for the last two years. Staff were able to described how they had worked with one resident to provide culturally appropriate meals that he enjoyed. They went on to describe how he had developed his own methods of communication with them and what great steps he had made in terms of confidence and self esteem. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs are well met and careful consideration has been given to ensuring that the essential and appropriate equipment has been installed. The system for medication administration needs some improvements. EVIDENCE: Detailed plans for health, personal and social care needs were seen on resident plans and staff spoken with all demonstrated an awareness of individual residents needs and preferences. The manager discussed the new ‘healthcare MOT’ package, which is to be introduced for residents. There is evidence that the staff team is well established and trained and the collective experience of all the team ensures the residents are treated in a manner that is appropriate for them. There is evidence on care plans that Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 16 physiotherapists and occupational therapists advice has been obtained on how to best meet the needs of residents and where possible this has informed changes to care plans and the way support to residents is given. Equality and diversity is well promoted in the home. Health care plans were observed and found to be satisfactory with health care appointments and outcomes seen recorded on daily notes. Medication management was assessed briefly and although there were good systems in place for storage and assessment of staff competence, there were several gaps on the medication administration records [where medication was to be administered at the day centre] and handwritten prescriptions had not been signed or witnessed to minimise the risk of error. Policies and procedures are in place including the procedures to follow in the event of a drug error. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded by the homes complaints and adult protection procedures. EVIDENCE: There have been no complaints made by either residents or their relatives / representatives over the last year. There are policies and procedures available at the home concerning adult protection issues including responding to suspicion of abuse/neglect, dealing with physical and verbal aggression and management of resident’ finances. Financial records were observed and found to be accurate and well maintained, providing an audit trail for all transactions conducted on resident’s behalf. Two staff interviewed said they had received training in adult protection issues and were fully aware of their responsibilities to safeguard people in their care. Appropriate policies were in place for use of restraint including mechanical aids such as use of bedrails and lap belts, however there was no evidence of consent to the use of these within the care plans despite the homes policy specifying this will be put into place. Appropriate risk assessments were in place however. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy at the time of this inspection. The home is generally well maintained, domestic and personalised by individuals living there. Residents live in comfortable surroundings. EVIDENCE: Overhead tracking for electric hoists now enable residents to transfer to more areas of the home in greater comfort and safety. The bathroom is fully equipped with a fixed shower and a mobile bath and shower combined. This equipment is highly effective and enables staff and residents to find the most effective and enjoyable ways for residents to bathe. The manger demonstrated how this device could support individuals with very complex needs safely and with minimum effort for staff. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 19 All equipment is stored safely not causing obstructions or hazards. The home was clean throughout. The home was undergoing some redecoration at the time of the inspection. Radiators were thermostatically controlled and some were covered to protect residents from hot surface temperatures or knock injuries. One resident’s bed has had to be moved and a request has been made for the radiator to be moved. It is recommended that the radiator be covered in the interim. The laundry facilities were adequate but the washing machine does not have a sluicing facility, which is an identified need of the home. It is recommended that a replacement washer is purchased with the appropriate facilities and a continence management policy be developed. There were systems in place for infection control, colour coding, gloves and aprons used throughout. Paper towels and antibacterial hand scrubs were also observed. Some staff have not undertaken training in Infection Control, however the manager reported that this was in hand. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users, benefit from well-supported, trained and supervised staff. Improvement is needed to the information held about staff and in respect of information about the Code of Conduct. EVIDENCE: The staffing rota is organised within budgetary limitations and residents need two staff to support them when out and about in the community. There was three staff on duty on the morning of the inspection. In the afternoons and at weekend there are mostly only two staff on duty. The rota demonstrated that adequate extra staff are additionally allocated to enable residents to go out regularly during the week, but that this is restricted on weekends should anyone wish to go out spontaneously. That said arrangements had been made to ensure that two residents were supported to Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 21 the football matches they enjoyed and to ensure residents safety, much organisation was needed prior to any trips being undertaken. Both staff members spoken with demonstrated a sound understanding of their roles and responsibilities and a great insight into the methods of promoting independence whilst supporting residents. Both of the staff spoken with during the inspection said that training is very good at Blenheim Avenue. They said all of the necessary mandatory training is provided and there is the opportunity to go on other courses if it enables staff to carry out their roles more effectively and efficiently and will ultimately benefit the residents. Although there was evidence that recruitment practices were robust in respect of Criminal Records Bureau (CRB) disclosures and references obtained for staff employed, not all files had photographic evidence as required by regulation and a requirement is therefore set in respect of this. There was evidence on staff files of regular supervision sessions taking place. Staff said they felt well supported by the manager in all aspects of their work and with other issues as well. There was no evidence that staff are issued with a copy of the General Social Care Councils ‘Code of Conduct ‘Booklet-again this is required by Regulation. A requirement is set in respect of this. From the comments and observations made, the staff team are held in high esteem amongst the residents for their commitment, attitude and support. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39,41 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s interests are key to any decisions made at the home. Resident’s wherever possible are consulted over issues in the care home and their safety and well - being are put first. EVIDENCE: The manager is highly thought of and has created a home where resident’s well-being and dignity is a priority. Staff said they felt the home was well run and the management team were always on hand for support and advice. Staff spoken with, confirmed that they felt supported by the manager and that they are approachable to discuss any issues. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 23 The manager of the home is a registered nurse. She has some years of experience and knowledge to manage a care home. Staff spoken with spoke highly of the manager and stated they felt well supported within their job role. The manager explained how there are internal audits held approximately three to four times per year and other initiatives for quality assurance are used by Nottingham Community Housing Association such as ‘Better Lives’, ‘ Promoting Person-Centred Services’ and the Nottinghamshire document ‘The Quality Tree’ [not yet fully implemented]. Advocates are accessed to represent the views of residents for identifying ways to develop the service. The manager said that a representative of the organisation makes monthly visits and reports were seen, however these were not consistently recorded every month. Incident and accident records were viewed and a discussion held of what needed to be notified under Regulation 37. As the manager had not realised that at least two of the incidents were notifiable the manager was asked to send these retrospectively to ensure that the Commission has the appropriate information in needs to monitor the service. Risk assessments were observed on individual files and are in place for the building and individual residents. Records were observed for the appropriate testing and servicing of the following systems and appliances. Electrical circuit test Annual Gas Safety Check Fire risk assessment Water supply There were no health and safety issues identified at the inspection. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 4 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 4 4 3 X 3 4 X Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 25 N/a Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA34 YA34 Regulation 19 18 Requirement Ensure that all staff files contain the documentation as required in Schedule 2 and 4. Provide all staff with a copy of the General Social Care Councils Code of Conduct Booklet. Timescale for action 14/10/07 14/10/07 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 2 3 4 5 Refer to Standard YA1 YA1 YA20 YA20 YA23 Good Practice Recommendations Inform visitors to the home how they can access a copy of the inspection report including the CSCI website. Update the Service user Guide to meet with the requirements of Regulation 5 and The Commission for Social Care Inspection details and current fees. Improve the practices in respect of identifying that medication has been sent with the residents to the day centre. Where prescriptions have to be handwritten they need to be signed dated and witnessed to minimise any risk of error. Ensure that residents/representatives are fully informed of the potential risk of the use of bedrails and obtain signed DS0000008633.V340714.R01.S.doc Version 5.2 Page 26 Blenheim Avenue Care Home 6 7 8 9 10 11 12 YA24 YA30 YA30 YA30 YA33 YA41 YA39 consent for their use as stated in the homes policy for restraint. In the interim period, until the radiator can be moved, cover the radiator in the resident’s bedroom discussed at the inspection to prevent any risk of injury. Provide evidence to the Commission that all staff have undertaken training in infection control. Replace the washing machine with a type that has an integral sluice facility. Ensure that the home has a policy for continence management in place for staff to follow. Review the staffing levels at weekends in consideration of community events. Send the notifiable incidents discussed to the Commission Ensure visits made under Regulation 26 are consistently documented on a monthly basis. Blenheim Avenue Care Home DS0000008633.V340714.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Blenheim Avenue Care Home DS0000008633.V340714.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!