Inspection on 17/10/05 for Blenheim Care Centre

This inspection was carried out on 17th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Blenheim Care Centre 06/10/08

Blenheim Care Centre 08/10/07

Blenheim Care Centre 19/06/06

Blenheim Care Centre 25/04/05

Blenheim Care Centre 13/01/05

Blenheim Care Centre 01/06/04

Blenheim Care Centre 04/12/03

Blenheim Care Centre 01/07/03

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

CARE HOMES FOR OLDER PEOPLE Blenheim Care Centre Ickenham Road West Ruislip Middlesex HA4 7DW Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 10.15 17 , 18 & 26 October 2005 th th th 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 Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Blenheim Care Centre Address Ickenham Road West Ruislip Middlesex HA4 7DW 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) 01895 622 167 01895 622 240 blenheim@lifestyle.co.uk Life Style Care Plc Mrs Mary Elizabeth Horsfield Care Home 64 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 8 beds for service users with a physical disability requiring nursing care. 12 Beds for service users in the category of old age requiring nursing care 10 Beds for service users with dementia requiring nursing care. Of these 10 beds, 5 may be used to accommodate service users with dementia requiring personal care or nursing care. 22 Beds for service users falling within the category of old age requiring personal care. 12 Beds for service users with Dementia requiring personal care. 4. 5. Date of last inspection 17th June 2005 Brief Description of the Service: Blenheim Care Centre is a purpose built Care Home providing care for 64 service users. There are 5 separate living units divided into the categories as stated in the Conditions of Registration. The units are designed to provide a homely environment consisting of single accommodation with en-suite toilet and hand washbasin facilities and fitted telephone sockets and service users can have a land line or mobile phone as they so wish. Each unit has a spacious lounge, with separate smoking areas available on two floors. There is an enclosed garden and some service users bedrooms and a communal lounge open out onto it.The home is located on the Ickenham Road next to West Ruislip underground station and visitors’ car parking is available. The Registered Manager has been in post for several years, and the home also has a Support Manager. There is also a Regional Manager for the home. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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 17 hours was spent on the inspection process. The Inspector carried out a tour of each unit of the home, and inspected service user plans, staff files and maintenance records. 16 service users, 7 visitors and 8 staff were spoken to at the time of inspection. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? What they could do better: There is an ongoing issue with the heating system throughout the home, and the temperature on the second floor in particular was noted to be a problem, which could pose a risk to service users. The home and, in turn, Life Style Care plc must have systems in place so that such issues are identified and addressed as a matter of priority. The maintenance man has a very high workload, and this needs to be reviewed to allow him to carry out the appropriate health & safety checks for the home. The staffing of the personal care units at night needs to be reviewed to ensure a senior carer is on duty to Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 6 be in overall charge of the personal care units. In conjunction with this, more care staff need to receive training in the management and administration of medications, to ensure that there is a member of staff present at all times on all units who is competent to manage and administer medications. Some shortfalls in the management of medications, particularly on the general personal care unit, were identified. The importance of ensuring that the home has on file all documentation relating to the servicing and maintenance of equipment and systems within the home, and follows up any gaps in documentation was highlighted at this inspection. Correspondence has taken place between the CSCI and the Responsible Individual since the inspection regarding several shortfalls noted at the time of inspection, and assurances have been received that these will and are being addressed. 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. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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 Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Service users are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: The Service User Guide had been updated to include all the information required under the Care Homes Regulations 2001. In the service user plans viewed on each unit, pre-admission assessments were complete and comprehensive. In addition, copies of the Social Services assessments had been obtained. The service users had been assessed appropriately to ascertain that the home would be able to meet their needs. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Information regarding service users is generally comprehensive and up to date, providing staff with a clear picture of each service users needs. Medications are generally well managed in the home, but shortfalls identified pose a risk to service users. Staff treat service users in a courteous manner, respecting their privacy and dignity. EVIDENCE: Samples of service user plans were viewed as part of the inspection process. Overall these were up to date and gave a clear picture of the service users needs. For one service user on the general personal care unit, an additional need had been identified, for which a care plan was not seen. This was addressed at the time of inspection. Risk assessments for falls were in place. One required rewriting due to the wrong name having been written in and not corrected adequately. There was evidence of monthly updates to the service user plans. Service user or representatives involvement had not always been evidenced in the service user plans and this was discussed at the time of inspection. Assessments for nutrition were in place and there was evidence of weight loss assessments being completed where any significant weight loss had been Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 10 identified. Weekly weights had been introduced in such cases, and there was evidence of steady weight gain for those viewed. Pressure sore risk assessments had been carried out and some needed reviewing on the dementia personal care unit to identify skin breaks, plus the care plans needed to reflect the fact that the service user was being attended to by the District Nurses for wound care. On the nursing units wound care documentation was clear, comprehensive and up to date. Pressure relieving equipment was seen in use in the home. Continence assessments had been carried out, one of which required updating on the general nursing unit to reflect a change in continence care needs. Others viewed had been updated where changes had occurred. Moving and handling assessments were in place and the moving and handling equipment to be used for each service user was identified. Risk assessments for identified areas risks had been carried out and one for a service user who smokes was completed at the time of inspection. Risk assessments for the use of bedrails had been carried out, with one to be updated on the general nursing unit. Some additional details to clearly identify the appropriateness of the use of bedrails and a wheelchair seatbelt were required for one service user on the young physically disabled (YPD) unit, and this was discussed at the time of inspection. Medications are securely stored in the home. There were no controlled drugs in use at the time of inspection. Medication records were sampled on each unit. On the nursing units and the dementia personal care unit medications were generally being well managed. There were no gaps in signing noted on the medication administration record (MAR) charts. Liquid medications had been dated when opened. Variable doses were being clearly recorded. Receipts had been signed for. The arrangements in place for the disposal of medications were appropriate for each unit. On the dementia personal care unit one medication had been increased and this needed to be clarified, to ensure the correct dose is given. On the YPD unit a coding had been used but an explanation of the coding had not been recorded. On the dementia nursing unit no stock was seen for a service user on paracetamol. In addition this prescription needed to be reviewed by the GP as this was prescribed ‘as required’ and there was evidence of regular administration. On the general personal care unit there were some shortfalls noted. Gaps in signing for medications were seen, and no coding for the reason for omission had been recorded. Some service users are prescribed alendronic acid, which is to be taken 30 minutes before any other medication and food or drink, and the administration time for this needs to be reviewed to ensure the 30 minute gap is allowed for. One liquid medication had not been dated when opened. The other liquid medications had been dated when opened and the one omission was discussed at the time of inspection. Full administration instructions had not been included for two medications viewed. An alteration in the dose of one medication needed to be clarified, but copies of the prescriptions had not been retained in the home, so this would need to be checked with the GP. Additional medication had been identified as being required for one service user, as the Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 11 prescription had not allowed for a full 28 days supply. The home uses a monitored dosage system, and in two blister packs viewed one tablet was missing from each, although the full amount had been signed as received. This was to be brought to the attention of the dispensing chemist to ensure a full supply for the month. Air conditioning units were present in all the clinical rooms. The drugs fridge temperatures are recorded daily, and it was noted that on occasion these had been outside of the acceptable range of 2º-8º centigrade, which should be easily addressed by adjusting the temperature setting. Night care staff on the personal care units had not all received training in the management and administration of medications. All staff expected to administer medications must receive appropriate training in this area. The Registered Manager showed the Inspector the document used when assessing staff in medication management and administration, and this was an audit document to be used when carrying out medication audits. The Registered Manager said that she would look into this and ensure that an appropriate document for the assessing of carers for medications is in place. Staff were heard to converse with service users in a gentle and courteous manner. Service users spoken with said that they were satisfied with the care they receive at the home. At the last inspection a concern regarding a service user wearing another persons’ clothes, plus an examination by the GP in the day room were raised. No issues of this nature were noted or commented on at this inspection. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meals in this home are good offering both choice and variety and catering for the service users dietary needs. EVIDENCE: The lunchtime meal was sampled on two of the inspection days and these were well presented and tasty. The chef has been on leave for some while, and satisfactory alternative arrangements had been made in his absence. Staff were seen to assist service users with their meals in a discreet manner. Service users spoken with said that they are offered a choice of meals. One of the kitchenette refrigerators was reported as out of order on the second day of inspection and action was taken to address the situation temporarily until a repair could be carried out. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were viewed at the last inspection and were met. Service users and visitors spoken with said that any concerns raised are addressed. The Registered Manager said that she is happy to arrange to meet with any service users and visitors that may have any concerns. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Redecoration and refurbishment programmes have improved, thus providing a homely environment for service users. Ongoing problems with the heating system in the home pose a risk to the wellbeing of the service users. Systems are in place for infection control, thus safeguarding service users. EVIDENCE: An audit of the home had been carried out to identify the redecoration and refurbishment needs. Several areas of the home had been redecorated and vacant rooms are now being audited and any necessary work carried out prior to a new admission. There are ongoing issues with the heating system in the home. At the time of the inspection the heating on the second floor dementia care units was of particular concern. The units were somewhat chilly and the bedrooms at each end of the corridor were quite cold. Additional heaters were seen, but many of the service users in these units are mobile and are at higher risk of accident. Also, service users with dementia may not always recognise when they are cold and are therefore more susceptible to the risk of hypothermia. Following Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 15 the inspection the Inspector spoke with the Responsible Individual for the home and requested a full report to include the action being taken to ensure that the heating system is restored to full working order without delay. Action had been taken to ensure that toiletries are not left out in areas where service users could be at risk of ingesting them, for example, on the dementia personal care unit. The home was clean and tidy and no malodours were noted. This standard was viewed in depth at the last inspection. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing during the day is appropriate to meet the needs of the service users. Medication training issues identified for the night staff on the personal care units could potentially be a risk to service users. Staff have otherwise received much training input, thus ensuring they have the knowledge to care for service users appropriately. EVIDENCE: The staffing of the units was discussed with staff. The staffing during the day was appropriate to meet the needs of the service users. A shortage in the number of night care staff assessed and competent to administer medications on the personal care units was identified. Several staff commented on the fact that the registered nurse on night duty is regularly administering the medications on one or both of the personal care units, in addition to the three nursing care units, due to care staff not being trained to do so. It was also stated that if there are any incidents on the personal care units at night, the registered nurse is often called to assist. This is not acceptable and action must be taken to ensure that there is a senior carer on duty at night able to take responsibility for the management of the personal care units. This includes ensuring that staff qualified to do so administer medications, plus managing any incidents that may occur. The registered nurse should only be called to the personal care units in exceptional circumstances and there needs to be adequate numbers of appropriately qualified and experienced staff on duty at all times to meet the needs of the service users. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 17 The staff employment files viewed contained details of the applicants completed application forms, health check questionnaire, work permit/leave to remain details, 2 references and proof of identity to include a recent photograph. Evidence that Criminal Records Bureau checks have been carried out was also available. There was evidence of Nursing and Midwifery Council verification having been carried out for the registered nurses. The administrator stated that she writes to staff when there are any updates in work permissions or Nursing & Midwifery Council due, and obtains copies of these once completed. This improvement in the completion of staff employment records must be maintained. NVQ in care training is ongoing in the home to maintain appropriate numbers of care staff trained to NVQ level 2 or 3, or the equivalent. The home has 19 staff qualified to NVQ level 2 or 3 in care with 5 additional staff nearing completion of one of these qualifications. The home also has student nurses and supervised placement students working at the home. The Registered Manager was unsure if the Agency care staff employed had an NVQ or equivalent qualification, and the Inspector recommended that she make enquiries regarding this. The home has one registered nurse who is in charge of all the training. Records are maintained for each member of staff for all mandatory training plus any other training undertaken. The induction and foundation training programmes are based on the Skills for Care (formerly TOPSS) core standards. The registered nurse said that all new staff undergo induction training, and then go on to NVQ in care or foundation training. The Registered Manager said that all staff are given the opportunity to attend a minimum of 5 paid days training, to include mandatory training. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36 and 38 There are systems in place to promote good communication between the management and staff, thus promoting effective teamwork. Quality assurance systems are in place, to include the opportunity for service users and their representatives to give their views regarding the home provision. Service users monies are well managed and secure procedures are in place. Staff providing care receive regular supervision, thus promoting communication and review of practice. The maintenance for the home is generally well managed, but the need to ensure all records are accurate and up to date to safeguard service users, staff and visitors was identified. EVIDENCE: At the last inspection it was identified that processes needed to be put in place for effective communication between the Registered Manager and the heads of each unit and department, to promote teamwork and cohesion. The Registered Manager has introduced more frequent meetings for each unit, for the heads of Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 19 departments and for night staff. Staff spoken with said that there was better communication between the management and each unit, and it was acknowledged that with continued work in this area, communication should continue to improve. In addition, a daily report form is completed by each unit, which provides the Registered Manager with ‘at a glance’ information, plus there is a document to list any points or issues raised over the weekend when the Registered Manager is not present in the home, so that she can follow these up promptly and ensure they have been fully addressed. The home has an annual development plan for quality assurance, and there was evidence of audits being carried out to cover all areas of the home. Satisfaction questionnaires are sent out to service users and their representatives and the results are collated and published. Relatives meetings are held every 6 months, and the activities co-ordinator has service user meetings to discuss the activities they are interested in, for the young physically disabled and the general personal care unit. Activities are arranged for all the units. Policies and procedures are reviewed annually by Life Style Care plc and updates are sent through to the home from Head Office with the new policies and procedures included. Evidence of this was viewed. The system of personal finances has been updated and individual monies are held for each new service user, so that any expenditure items can be paid for directly. Some of these monies were checked and apart from one discrepancy rectified at the time of inspection, these were up to date and tallied with the clear income and expenditure records maintained. For some service users who have been accommodated at the home for a longer time, the money is still held in the ‘z account’, a separate account for service users monies. Again, clear income and expenditure records are kept and generally the amounts of money involved are kept to reasonably small amounts. Work has and is being carried out to reduce the need for the ‘z account’. At the last inspection it was identified that the nursing staff were not receiving supervision. This has been addressed and now all the nursing and care staff are undergoing supervision sessions every 2 months and records are maintained. The maintenance man works a 40 hour week and in addition to his usual work, had been carrying out the redecoration programme for the home, with assistance for one corridor only. It was noted that some of the health & safety checks, for example the water temperature checks, had been carried out at 3 monthly intervals, and some of the other maintenance checks had not been recorded. Following the inspection this was discussed with the Responsible Individual and action must be taken to address these findings. At the visit to the home 26.10.05, some servicing records were viewed. Those viewed were up to date with the exception of the passenger lift information, which indicated that the lift had failed a safety examination carried out in March 2005, and about which there was no further information on file. An Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 20 Immediate Requirement was set and the Registered Manager has since confirmed that the required work had been completed in June 2005 and the company concerned had omitted to send through the pass certificate, a copy of which has since been faxed to the CSCI to evidence this. A risk assessment for Legionella was carried out in August 2005 and the maintenance man is addressing the shortfalls identified. The chlorination certificate viewed was dated June 2004 and the Registered Manager said she would follow this up. Risk assessments for the kitchen and laundry were also viewed and were up to date. The home has health and safety policies and procedures in place. There was evidence that staff had undertaken health and safety training. Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 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 3 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 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 1 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 X 3 3 X 3 3 X 1 Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 17 Requirement All documentation must be clearly identified for each individual, to include the risk assessments for falls. Where a service user is receiving input from a healthcare specialist, to include the District Nurse, this must be identified in the service users plan. All documentation to include continence assessments and falls assessments must be reviewed to reflect any relevant changes in a service users condition. Assessments must be carried out for all areas of risk identified, and an action plan put in place to minimise the risk. Appropriate action must be taken to ensure any changes to the dosage instructions for a medication are adhered to. All medications must be signed for at the time of administration. (previous timescale of 28/04/05 not met). It the code for ‘other’ is used then the reason for use must be recorded. (previous timescale DS0000010926.V257368.R01.S.doc Timescale for action 11/11/05 2 OP8 17 11/11/05 3 OP8 17 11/11/05 4 OP8 13(4) 11/11/05 5 OP9 13(2) 05/11/05 6 OP9 13(2) 05/11/05 7 OP9 13(2) 05/11/05 Blenheim Care Centre Version 5.0 Page 23 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 12 13 OP9 OP9 OP9 13(2) 13(2) 13(2) 14 OP9 13(2) 15 OP25 23(2)(p) 37 14/07/05 not met). Medicines must be thoroughly checked on receipt and quantities signed for on receipt. Any discrepancies must be reported to the supplying pharmacist. (previous timescale not met). Clear and full instructions for administration must be recorded for all medications and individual stocks must be maintained. Alendronic Acid must be given in accordance with the manufacturers and GP instructions. The time of administration must be reviewed to meet these administration requirements. Copies of the prescriptions must be kept on each unit. The drugs fridge temperatures must be maintained between 2º-8º centigrade. There must be sufficient numbers of staff trained in the management and administration of medications on the personal care units to ensure that there is a member of staff on every shift who is competent to administer medications. The documentation used when assessing staff in the management and administration of medications must be reviewed to ensure it is appropriate for the purpose. The heating system must be restored to full working order. (previous timescales of 10/02/05 and 01/09/05 not met). Thereafter any concerns must be addressed as a matter of priority without delay. The CSCI must be kept up to date with any issues that affect the wellbeing of service users, in DS0000010926.V257368.R01.S.doc 01/12/05 05/11/05 05/11/05 01/12/05 05/11/05 05/11/05 18/11/05 11/11/05 Blenheim Care Centre Version 5.0 Page 24 16 OP27 18 17 OP38 23(2) 18 OP38 23(2)(c) 19 OP38 12, 13 accordance with Regulation 37 of the Care Homes Regulations 2001. The staffing provision must be reviewed to ensure that at all times the staffing is appropriate to meet the needs of the service users on each unit. Senior carer cover must be provided at night for the personal care units. The maintenance man must have time to carry out all the safety checks within the home and record them. Where necessary, additional input must be provided to maintain the home in good order throughout. There must be evidence that any shortfalls identified with the equipment in use of the home are promptly addressed and restored to full working order. Any health and safety risks identified within the home must be addressed. For evidence that all necessary remedial works to the passenger lift have been carried out to be available. (immediate requirement set). 18/11/05 18/11/05 18/11/05 28/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Blenheim Care Centre DS0000010926.V257368.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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