Inspection on 08/10/07 for Blenheim Care Centre

This inspection was carried out on 8th October 2007.

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

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

Other inspections for this house

Blenheim Care Centre 06/10/08

Blenheim Care Centre 19/06/06

Blenheim Care Centre 17/10/05

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 Key Unannounced Inspection 11:20 8 & 9th October 2007 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.V344733.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. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 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 bcarecentre@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Mrs Tatree Preece 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.V344733.R01.S.doc Version 5.2 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 19th June 2006 Brief Description of the Service: Blenheim Care Centre is a purpose built Care Home providing care for 64 residents. There are 5 separate living ‘houses’ divided into the categories as stated in the Conditions of Registration. The houses are designed to provide a homely environment consisting of single accommodation with en-suite toilet and hand washbasin facilities and fitted telephone sockets and residents can have a land line or mobile phone as they so wish. Each house has a spacious lounge, with a designated smoking room on one floor. There is an enclosed garden and some residents 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 18 months. The fees range from £393.58 to £949.84 dependent on the residents needs and the house on which they are therefore accommodated. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 18 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 12 staff and 5 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) completed by the home, plus comment cards received from residents, staff, healthcare professionals and representatives/visitors have also been used to inform this report. The home has 5 sections, and each one is now referred to as a named house. What the service does well: What has improved since the last inspection? Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 6 Any injuries to include bruising are being recorded and reported. Medications on all houses are now being well managed. Work has been carried out on the heating system, with further checks in progress to ascertain if any further work is required. The heating system was in working order at the time of inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 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 ascertaining that the home is able to meet each persons needs. EVIDENCE: Southern Cross has a comprehensive pre-admission assessment document that is completed for all prospective residents and those viewed had been fully completed. In addition, where available a copy of the Social Services or Primary Care Trust needs led assessment is also obtained. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. EVIDENCE: 8 service user plans were viewed as part of the inspection. Overall these were well completed and gave a clear picture of the needs of each resident and how these are to be met. There was evidence of monthly review and involvement by residents or their representatives in the review of the service user plans. Risk assessments for falls were in place. For one resident who had experienced a fall, documentation had been completed to include an accident form, entry in the daily record and body mapping carried out to identify any injuries. The falls risk assessment is updated monthly to reflect any falls during the month. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 10 Wound care documentation was viewed on the nursing houses. On the ground floor wounds had been clearly documented, with individual care plans and progress charts for each wound, and records had been updated frequently. On the dementia care nursing floor wound care records were in place, with some information regarding wound dressing changes being unclear. The importance of maintaining a clear record was discussed with the registered nurses. On the residential houses information regarding wounds had been recorded and the residents had been referred to and seen by the District Nurse. Clearer recording to evidence the input from the District Nurse was discussed and the Senior Carer said that this would be completed. Moving & handling and continence assessments were in place. Nutritional assessments had been carried out. On the dementia care nursing floor the dementia care needs of one resident had not been included on the nutritional assessment. For another resident who had experienced marked weight loss this had not been reflected in the care plan and there had been no increase from monthly weights. A referral had been made to the GP. Bedrail risk assessments were in place and with one exception the consent section had been signed by the resident or their representative. Evidence that for the one resident consent was obtained promptly following the inspection has been forwarded to CSCI. It is noted that the home has been transferring the service user plan information from the old documentation onto the Southern Cross documentation. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, district nurses, physiotherapist, chiropodist and optician. Medication records and management was viewed on all houses. A list of staff signatures and initials for medication signing is maintained on each house. Records of receipts, administration and disposal were complete and up to date. Any hand written entries on the medication administration record (MAR) are signed for by 2 staff. Liquid medications are dated when opened. Minimum, maximum and actual temperature recordings for the medication fridges were being recorded on all but one floor, where only the actual temperature was being recorded, and all records were within safe range. Minimum and maximum temperature recording was recommenced on the ground floor at the time of inspection. Room temperatures were also being recorded and each clinical room has air conditioning to maintain a satisfactory storage temperature for medications. Some of the labels on inhalers did not have full administration instructions, however full instructions were printed on the MAR. For one medication with specialist administration instructions these had not been printed on the MAR, however the instruction did state that the manufacturers instruction leaflet be followed. Staff spoken with were able to clearly explain to the Inspector the administration instructions to be followed. The home has recently changed their dispensing pharmacist and a second dispensing pharmacist supplies some items. The need to ensure all administration instructions are printed on the MAR and on the labels of medicines supplied was discussed and staff said that they would discuss this with the dispensing pharmacies. Most medications are supplied in blister packs using a monitored dosage system (MDS). For medications supplied in boxes a Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 11 stock balance is recorded after each administration. Warfarin records were clear and up to date and a copy of a recent blood test result was available. Controlled drugs were in use on one house and records were up to date with evidence of stock checks being carried out. Medications are being well managed at the home. Staff on each floor were seen caring for residents in a gentle, courteous and professional manner, respecting their privacy and dignity. Individuals clothing is labelled and residents were well dressed, reflecting individuality. Bedrooms are personalised and residents are able to bring in small items of furniture, in line with fire safety. Staff were heard addressing residents using their preferred term of address. The gender preference of staff giving personal care to each resident is ascertained and respected. The Roman Catholic priest visits each week and there is a monthly visit from the Church of England representative. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision is adequate and residents are not always offered a choice, thus not respecting their preferences. EVIDENCE: The home has a full time activities co-ordinator who plans a good variety of activities and outings. Copies of the activities programmes were on display in the home. Activities are arranged to meet the needs of the residents on each particular house. An ‘Italian Afternoon’ was arranged recently and further afternoons on the theme of a particular country are to be organised. Outings to the theatre and places of interest are arranged using the Hillingdon Community Bus service. The activities co-ordinator said that there are regular residents meetings and people voice their ideas for activities and outings. Several residents get a daily paper and it was clear from discussion with the activities Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 13 co-ordinator that she strives to provide activities to provide a ‘home from home’. A garden party and barbeque had taken place. Pet therapy is provided by way of Pat Dogs visiting each week and the home also has a cat in residence on the second floor. Residents on the first floor were enjoying the company of the cat, and consideration was being given as to the most appropriate floor for the cat to live on in the future. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and representatives are kept up to date with any issues. Information regarding advocacy services to include Care Aware and Age Concern is available, and the home has a befriender from Age Concern who visits the home each week to meet and chat with the residents. The Registered Manager also had information regarding the Mental Capacity Act 2005 and the implications of this. The kitchen was clean and tidy and records were up to date. Forms to record meal choices are available, however this was not available on the first floor during the suppertime meal and residents spoken with had not all been offered a choice. The food stocks were mainly frozen, tinned or dried, with limited amounts of fresh produce available. Apart from potatoes, most other vegetables provided are frozen. It was noted that bowls of fresh fruit were available on each floor. Comment was received that on occasions the suppertime meal starts as early as 4.30pm and the food is often cold and unappetising. The Inspector sampled the soup and fish fingers on the first floor house, both of which were barely warm. Sandwiches are available overnight, however comment was also received that these are cold and hard and other snacks are not available. The lunch and suppertime meals were observed on different houses and appeared quite rushed, with staff numbers not always sufficient to ensure all residents who require assistance receive it in a timely manner. At lunchtime a meal was left on a table for one resident who required help, while staff were helping other residents with their meals. All these points were discussed with the Registered Manager, who said that new menus are being introduced and this would also mean a change in the meal provision to include more fresh produce in line with the Southern Cross nutritional programme being rolled out in their homes. Staffing is commented on under Standard 27. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure and all complaints and concerns are recorded. There had been 3 complaints/concerns since the last inspection and the documentation evidenced that these had been investigated and responded to. Representatives spoken with said that any concerns raised are addressed promptly. The home has policies and procedures in place for adult protection and also follows the Hillingdon Safeguarding Adults procedures. Staff had received training in adult protection and those spoken with said that they would report any concerns and were clear on the procedure to follow. Since the last inspection 2 incidents had been reported by the home to the Hillingdon Safeguarding Adults team, and both were investigated and found not to be POVA issues. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 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 being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: A tour of each house was carried out. There was evidence of redecoration and refurbishment, with plans for further work in these areas. The dementia care residential unit had been redecorated and door furniture put in place on each bedroom door in line with current dementia research. Care staff had also been involved in the redecoration in order to complete it in a timely manner, with some of the work being done overnight. The importance of ensuring there are no health & safety implications or staffing issues involved was discussed with the Registered Manager. Some of the chairs in the lounge areas were worn and in need of replacement and comment was received about some chairs being uncomfortable. The Registered Manager said that 18 new armchairs had been Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 16 ordered and they were awaiting delivery. The annual capital expenditure budget approved for the home was viewed and identified the expenditure for refurbishment in the next 12 months. The heating system had been problematic at the last inspection, and the Registered Manager reported that since then work had been carried out to rectify the problems. An audit of all the radiators in the home was in progress and the findings were to be reported to the Facilities Manager, who would in turn decide if further work was required. At the time of inspection the home was pleasantly warm. Additional heaters were available in some bedrooms and the Registered Manager said that risk assessments are carried out when additional heaters are in use. The home has an enclosed garden and some of the bedroom doors open out onto it. The laundry room was clean and tidy and records were up to date. The washing machines have sluice programmes for disinfection purposes and laundry is sorted into colour-coded bags for infection control. Protective clothing to include gloves and aprons was available. The home was clean and smelled fresh throughout. One isolated odour was noted, and on discussion with staff it was clear that action is taken daily to minimise the odour in this area. Policies and procedures are in place for infection control. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some shortfalls were noted with the staffing, thus residents needs were not being met at all times. Systems for vetting and recruitment practices are in place to safeguard residents. There is an ongoing training programme, providing staff with the skills to meet the needs of residents. EVIDENCE: On the 2 days of the inspection the staffing on the ground and first floors was appropriate to meet the assessed needs of the residents. There was a shortage on the second floor of one carer on the dementia care residential house, with 2 carers being present. There were 3 rooms vacant and staff spoken with said that they were able to manage and that if both of them were needed to assist a resident then they would call for help from the nursing house, where there were 3 staff present, so that the residents were not left unattended in the lounge. On the dementia care nursing house staff were rushed during the lunchtime meal as 5 residents require assistance with their meals and others require supervision. The suppertime on the residential floor was also somewhat rushed and several comments were received regarding residents in their bedrooms receiving their meals lukewarm or cold. The need to ensure the staffing is appropriate at all times, to include at mealtimes, in order to meet the needs of the residents was discussed with the Registered Manager. CSCI received information in June 2007 regarding a planned significant reduction in staffing. Correspondence took place between CSCI and Southern Cross, who Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 18 refuted this. Following this inspection CSCI has been informed that the staffing levels were reduced for both day and night shifts as from Friday 12th October 2007. The Inspector has contacted the Registered Manager who confirmed that this was the case. The home must be staffed to meet the assessed needs of the residents at all times and there must be evidence that any changes in staffing are based on the dependency levels of the residents in each house. The home was clean and fresh and ancillary staff are employed in appropriate numbers to meet the overall needs of the home. Information provided by the home shows that over 50 of the care staff are trained to NVQ level 2 or above in care. 11 staff are presently undertaking NVQ level 2 in care training. 2 domestic staff had completed NVQ level 2 in housekeeping. 1 of the kitchen staff has completed an NVQ level 2 in catering. Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has an induction programme that meets the Skills for Care common induction standards. Staff surveys indicated that staff receive a full induction when they start work at the home. There was some evidence of training in topics relevant to the diagnoses of the residents. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so in a professional and approachable manner. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and has a degree in healthcare management. She has undertaken periodic training in topics relevant to her role. Staff, residents and visitors spoken with said that the Registered Manager is approachable and does address any concerns raised. The Registered Manager has a weekly surgery for staff and residents and a Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 20 monthly surgery for visitors. These are specific times put aside so that staff, residents and visitors can meet with the Registered Manager individually to discuss anything they wish to. Residents also said that they are sometimes invited to have tea with the Registered Manager, which they enjoy. The home has a system in place for quality assurance. Regulation 26 monthly unannounced inspections on behalf of the Registered Provider are carried out and the reports are clear and informative. As well as the Registered Managers surgeries, weekly head of house meetings, monthly health & safety meetings, 3 monthly relatives meetings and general staff meetings, plus ancillary staff meetings. There is a comprehensive system of audits covering all aspects of the home and these monitoring tools ensure that standards at the home are maintained and action is taken promptly to address any shortfalls identified. Any personal monies held on behalf of residents are stored securely. Computerised records of income and expenditure are maintained and receipts are given for monies received. Receipts are kept to evidence any expenditure. Four sets of records and balances were checked. Some minor discrepancies were noted, however the administrator was on leave and therefore some of the computerised records were still to be updated. Confirmation has been received since the inspection that the balances and records are now accurate and up to date. The maintenance and servicing records were sampled and those viewed were up to date and clearly recorded, with evidence of corrective action being taken if any problems are identified, for example, if a hot water temperature is too high or low, then the valve is adjusted and the temperature re-checked and recorded. There was evidence of regular fire drills taking place for day and night staff. Risk assessments for fire, equipment and safe working practices were in place. Good practice notices were seen in the laundry and the kitchen. The training records showed that staff had received training in health & safety topics to include fire safety, moving & handling, food hygiene and infection control. First Aid training had been arranged for the following week. Staff were seen using moving & handling equipment correctly and good practices were observed. Health & safety is being well managed at the home. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 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 Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 17 Requirement All assessments must be up to date and the information must be accurate, so that each resident has been correctly assessed. Where weight loss is identified, robust systems must be put in place for monitoring and review, to ensure the residents condition is effectively managed. The evening mealtime must be reviewed to ensure it is at an appropriate time for the residents. The hot food must be served hot and residents’ choices must be ascertained and met. There must be a variety of snacks available throughout the 24 hour period to meet the needs and preferences of the residents. Staff must be employed in such numbers so that the needs of the residents can be met at all times. Staffing levels must be calculated according to resident dependencies. Timescale for action 30/11/07 2. OP8 17 01/11/07 3. OP15 16(2)(i) 26/10/07 4. OP15 16(2)(i) 02/11/07 5. OP27 18 02/11/07 Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 23 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. Refer to Standard OP8 OP9 OP15 Good Practice Recommendations Information regarding District Nurse input should be included in the service user plan to clearly identify the input being received by an individual. The dispensing pharmacists include full administration instructions on both the MAR and the medication label. More fresh vegetables should be included in the meal provision. Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Blenheim Care Centre DS0000010926.V344733.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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