Inspection on 10/10/05 for Blenheim Lodge

This inspection was carried out on 10th October 2005.

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 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 Lodge 01/07/08

Blenheim Lodge 28/01/08

Blenheim Lodge 16/05/06

Blenheim Lodge 23/05/05

Blenheim Lodge 02/02/05

Blenheim Lodge 01/06/04

Blenheim Lodge 01/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Blenheim Lodge North Road Minehead Somerset TA24 5QB Lead Inspector David Kidner Announced 10 October 2005 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 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 Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Blenheim Lodge Address North Road Minehead Somerset TA24 5QB 01643 703588 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) West Somerset Home (Blenheim Lodge) Limited Mrs Linda Mary Vaughan Care Home 34 Category(ies) of 1. Old age. registration, with number of places Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one service user on respite care as detailed in a letter to the Commission for Social Care Inspection dated 22nd October 2004 from social worker. Date of last inspection 23 May 2005 Brief Description of the Service: Blenheim Lodge is registered with the Commission for Social Care Inspection to provide personal care to 34 service users over the age of 65 years. A Board of Governors who serve voluntarily administers the home as a Charitable Trust. The Registered Manager is Mrs Linda Vaughan. Blenheim Lodge is situated close to the town and seafront in Minehead. Blenheim gardens are nearby and enjoyed by many service users residing at the home. Accommodation is provided over three floors. A passenger lift is available to the first floor and there is a stair lift to the second floor. The home has three assisted bathrooms and two shower rooms available for service users. A call bell system is provided and grab rails have been installed in communal hallways. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted the Inspection over one day (9.75hrs). At the time of the Inspection there were 30 residents residing at the home. Mrs Linda Vaughan, Registered Manager was available throughout the day. However, Mrs Elizabeth Cooper, Deputy Manager, hosted the inspection. The Inspector also spent some time talking to a member of the Board of Governors. A large number of service users were spoken to in private and in small groups. The Inspector also attended the Residents Meeting and spoke to five staff in private. The Inspector viewed most areas of the home, records relating to staff recruitment, care plans, administration of medicines and health and safety matters. As part of the Inspection process the Inspector forwarded Service User Comment Cards to all service users living at the home and requested that the home forward the Relatives/Visitors Comment Cards to all relatives/visitors of the service users. The Inspector was most impressed with the response. A total of 27 Service User Comment Cards were received and a total of 23 Relatives/Visitors Comment Cards were received. The feedback received was extremely complimentary of the services that are provided at Blenheim Lodge. It was evident that the vast majority of service users are very happy living at the home and that relatives and friends have a high regard of the services that are provided. An audit of the comment cards was provided to the Registered Manager and Deputy Manager. The Inspector was made to feel welcome at the home and would like to thanks the service users and all staff for their involvement and contribution to the inspection process. As a result of this inspection the home had four requirements and four recommendations. What the service does well: Blenheim Lodge provides a homely atmosphere. Service users are encouraged to participate in the running of the home. Service users are offered choices in many aspects of daily living. A large number of service users commented that they enjoy the activities that the home provides and they like the meals that are provided. Feedback from service user comment cards identified that service users feel safe at the home and that they feel well cared for. The vast Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 6 majority of the relatives/visitors commented that they are made to feel welcome at the home and that they are kept informed of important matters. Service users spoke very well of the Registered Manager, Deputy Manager and the staff team. Care Plans are detailed and reviewed on a regular basis. There are good records of the health and safety checks that are conducted at the home. The Registered Manager audits all accidents at the home. What has improved since the last 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. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 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 standard(s) 1 2 3 4 5 The Registered Manager ensures that the home conducts a detailed assessment of need prior to any service users being admitted to the home. The pre-admission process is well documented and is fully explained to service users. EVIDENCE: The Home has a detailed Statement of Purpose and Service User Guide. The Service User Guides are located in all bedrooms. Each service user has a written contract/statement of terms and conditions with the home. Prior to any service user moving to the home a detailed pre-admission assessment is carried out using the SHARP care plan system. Evidence of this has been seen at this and previous inspections. The Registered Manager and or the Deputy Manager usually conduct the assessments. The inspector viewed the care plan for one recently admitted service user. The Registered Manager had included the pre-admission process on the Residents Meeting agenda. The Registered Manager explained the reason why these assessments are conducted prior to any service user moving to the home and prior to Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 9 returning to the home following time spent in hospital following a fall or being unwell. This was good information sharing and service users comments and questions were sought. Service users, relatives and friends are always invited to visit the home prior to admission. Standard 6 is currently not applicable. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10 11 The home operates the SHARP system for care planning. The home ensures that all care plans are current and are reviewed on a regular basis. Service users have access to appropriate health care professions. The home has made improvements in relation to the administration, recording and storage of medicines. However, the home must address some issues raised as a result of this inspection. Service users are treated with respect and their privacy is upheld. EVIDENCE: The inspector viewed four care plans. Care plans were very detailed including Waterlow Assessments, Nutritional Screening, Moving and Handling needs, Medication needs, risk assessments and written preferences and social needs. The staff have received further training in the SHARP system since the last inspection and meetings have been held with staff at all levels to ensure the care plans are maintained and amended when needed. Care Plans are reviewed monthly or sooner if needed. It was evident that some service users have been fully involved and consulted in the development as much as they wish including their wishes in relation to death and dying. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 11 Service users have access to all health care professionals. The Inspector viewed documentation in relation to this. Service users also confirmed that if they request to see their GP this is actioned as soon as possible. The service users that the inspector spoke to unanimously stated that the staff promote their privacy and always knock on bedroom doors before entering. The comments received from the comment cards also reflected this. The inspector witnessed staff addressing the service users in an appropriate and professional manner. The home operates the Monitored Dosage System. The Inspector viewed the MAR sheets and noted that not all variable doses had been recorded correctly. The Inspector raised this with the Registered Manager and Deputy Manager at the time of the inspection. The home has installed safes in each bedroom for the storage of individual medicines. This system will be brought into operation in the near future. Staff have received further training in the administration of medicines at Strode College. The home has reviewed the stock levels at the home and has made appropriate adjustments. Records are kept of the minimum and maximum temperature of the fridge used to store insulin. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 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 standard(s) 14 15 The home promotes service users to have choice and control over their lives. The vast majority of service users enjoy the meals that are provided. The meals appeared to be wholesome and service users have a choice in the meals offered. EVIDENCE: The Inspector was advised that the home does not handle the financial affairs of any of the service users. Their families are mainly responsible for this. The home displays information in relation to Advocacy. Service users are able to bring personal possessions to the home and have access to their personal records in accordance with the Data Protection Act 1998. The home displays the main meal of the day on the menu board in the main dining room. However, some service users that the inspector spoke to confirmed that they are asked every morning if they would like the choice for lunch or would they prefer an alternative. The home now consults with service users each afternoon as to what they would like for tea. This is good practice. The inspector viewed lunch and dinner being served. Some service users that the inspector spoke to commented that the food is very nice, “it’s hot and nicely presented”. The service user comment cards also indicted that the vast Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 13 majority of service users were happy with the food at the home. The dining room was nicely presented with napkins and condiments placed on the table. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 17 18 The home has robust process to ensure that service users are protected. The home has a Complaint Procedure, Whistle blowing Policy and an Abuse Policy. EVIDENCE: The Complaints procedure was displayed in the home. Some services users stated that they feel that they are able to make comments about the service that they receive and would make a complaint if they felt it was needed. The service user comment cards indicated that a vast majority of service users knew who to speak to if they were unhappy with their care. The Inspector viewed the complaints Log. There were three recorded complaints since the last inspection. The Inspector viewed the detail of the complaints and the action taken to address the complaints. The complaints had been resolved satisfactory. The staff that the Inspector spoke to confirmed that they were aware of the Whistle blowing and Complaints Policy. The home also has a Safeguarding of Vulnerable Adults Policy. Service users are registered to vote and exercise this right if so wished. The home has Policies and Procedures in the management of service user’s money and financial affairs. The Inspector was advised that the home does not handle the financial affairs of any of the service users. Their families are mainly responsible for this. The home does keep small amounts of money for some service users on their behalf and this is stored securely with records kept of all transaction with two staff signatures and wherever possible the service Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 15 user’s signature. The Inspector did not view the records in relation to this at this inspection. The records are also spot checked by the Registered Manager or the Deputy Manager. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19 23 24 25 26 Blenheim Lodge is very nicely decorated, has a homely atmosphere and is maintained to a good standard. Bedrooms reflected individual needs and preferences and were clean and well maintained. The home is proactive in ensuring that the service users live in safe and comfortable surroundings. EVIDENCE: The home has a programme of routine maintenance and renewal of the fabric and redecoration of the home. Since the last inspection the home has redecorated some areas and has improved the facility for one bedroom area as an en-suite facility of a toilet and washbasin has been installed. The Inspector spoke to the service user whose bedroom had received this improvement. The service user was delighted with the changes made. The grounds of the home are well maintained and appear safe and accessible. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 17 The Inspector viewed a number of bedrooms and sought the opinion of the service users. Service users commented that they were very happy with their rooms. The Inspector noted that the bedrooms reflected individual needs and preferences. Service users had their personal possessions around them including items of furniture, ornaments and pictures of family members. Thirty-one of the home’s bedrooms have en-suite facilities. Eight have ensuite bathrooms and nine bedrooms have en-suite shower facilities. Specialist equipment is provided where needed. Windows have been restricted to promote health and safety. The home keeps records of the temperature of the hot water outlets and takes appropriate action to make adjustments where needed. All bedrooms viewed were clean and well presented. Service users commented that the staff are very conscientious that bedrooms and all parts of the home are kept clean and tidy. Service users commented that they are able to assist in cleaning their bedrooms if so wished and that they liked this, as they are able to have some independence. On the day of the inspection the home was clean and tidy and free of malodours. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 30 The home ensures that there is adequate staff on duty with appropriate skills to meet the needs of the service users. The homes recruitment process is not robust as to protect vulnerable people. The home is proactive in providing staff with training opportunities and support staff to gain NVQ Qualifications. EVIDENCE: The Inspector spoke to a number of staff at the time of the inspection. Staff commented that they felt that they had enough staff on duty to meet the needs of the service users. The duty rota that the Inspector viewed indicated that there is usually five care staff on duty on a morning and four care staff on duty on an afternoon/evening. The Registered Manager also works hands-on. On occasions due to staff sickness, staffing levels may fall slightly. However, the home makes every effort to address this when it occurs. The relatives/visitors comment cards indicated that a majority of relatives/visitors felt that there is adequate staff on duty. The home employs domestic staff a cook and kitchen assistants. The home has twelve staff qualified with an NVQ 2 or above. At the time of the Inspection this equated to 50 of the workforce. Other staff are enrolled to undertake NVQ Qualifications. The home also has a number of staff with Registered Nurse Qualifications. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 19 The Inspector viewed recruitment files of recently appointed staff. The Registered Manager must ensure that the files contain all the documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The Inspector also recommends that the home review the format of the Application Form as discussed with the Registered Manager at the time of the Inspection. The home is committed to provide staff with training opportunities and keeps records of all the training that staff have undertaken. The Inspector viewed the Training Record Summary. Since the last Inspection staff have received training in diabetes, infection control, moving and handling, health and safety, SHARP, employment law and food hygiene. Staff who require this training are waiting for dates for these. Following discussion and feedback from staff the Inspector recommends that the home give consideration to staff receiving training in dementia care and mental health. The Registered Manager and Deputy Manager agreed to give this further consideration. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 34 35 36 37 38 Blenheim Lodge is run and managed by a very competent Registered Manager and is support by a competent Deputy Manager. The ethos of the service is that of consultation, involvement and empowerment. Service user’s financial affairs are safeguarded Staff are not receiving formal supervision and this should be addressed as a matter of priority. The home is proactive in promoting health and safety. EVIDENCE: The Registered Manager has a wealth of experience in care of older people and is currently undertaking her NVQ Level 4 and is also a Registered Nurse. She also ensures that she keeps herself updated and attends refresher training Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 21 when needed. Staff spoken with felt well supported and confirmed they would be confident in going to the management team with any concerns. The service users also spoke very well of the Registered Manager, Deputy Manager and the care team. The Inspector observed all staff at the home interacting with service users in a professional and sensitive manner. It was evident at the time of the Inspection that service users are consulted and are encouraged to speak up. The home conducts Residents Meetings and service users are encouraged to participate in the running of the home. For example, one service user has taken responsibility for running the home’s library. Service users commented that they feel that they are involved in decision-making and the vast majority did not wish to be further involved. The home has staff meetings. The last staff meeting was conducted in June 2005. The Inspector recommends that the Registered Manager consider that staff meetings occur more frequently. The home displays the Insurance Policy. The Inspector was advised that the home does not handle the financial affairs of any of the service users. Their families are mainly responsible for this. The home does keep small amounts of money for some service users on their behalf and this is stored securely with records kept of all transaction with two staff signatures and wherever possible the service user’s signature. The Inspector did not view the records in relation to this at this inspection. The records are also spot checked by the Registered Manager or the Deputy Manager. Service users are able to bring personal possessions to the home and an Inventory is maintained for each service user. Following discussions with the Registered Manager, Deputy Manager and a number of care staff it is strongly recommended that the home should improve on the supervision process. Staff are not receiving formal supervision at least six times a year as stated in Standard 36 of the National Minimum Standards. The Inspector had detailed discussion with the Registered Manager and Deputy Manager in relation to the importance of supervision and how staff performance is managed and addressed as needed. Records of Induction are kept and Staff Appraisals are conducted with records kept. Weekly fire checks are conducted with records kept. The Emergency Lighting was last serviced on the 06.10.05. The Fire System had an annual service on 06.09.05. The home also conducts monthly checks on the emergency lighting and conducts regular fire drills. The fire evacuation process was also discussed at the Residents Meeting. All staff have received fire training. Some staff had signed to confirm this. The Deputy Manager will ensure that all staff sign to say that they have received this. The home must keep records of the maintenance of the home’s torches. The Electrical Hardwiring Certificate is dated 27.08.03 and the Gas Safety Certificate is dated 13.09.05. The hoists and bathing aids were serviced on 29.04.05. Portable Appliance Testing was Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 22 conducted in October 2004 and equipment that needed replacing prior to this date had been attended to. The Registered Manager audits all accidents at the home on a monthly basis and details the time of the day they took place and possible reasons for the accident occurring. This is good practice. Following this the Registered Manager takes steps to address such accidents. It appears that most accidents occur at night. Those service users that are most vulnerable are checked on a regular basis by the night staff with records kept. The Inspector noted that one wardrobe in one bedroom area was not secured. This must be addressed to promote health and safety. Records are kept of fridge and freezer temperatures and food probe temperatures. The kitchen has a cleaning schedule. The food products stored in the fridges were wrapped and dated. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x x x x Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 24 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. 2. Standard 9 29 Regulation 13 (2) 19 Requirement Timescale for action 29.10.05 3. 4. 38 38 23 (4) 13 (4) The home must ensure that variable doses are recorded on MAR sheets. The Registered Manager must 29.10.05 ensure that the staff recruitment records contain all the items as listed in Schedule 2 of the Care Homes Regulations 2002. This is an outstanding requirement from the last inspection conducted on the 23.05.05. The home must keep records of 31.10.05 the maintenance of the home’s torches. The home must ensure that all 29.10.05 wardrobes in bedrooms are secured so as to promote health and safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 29 Good Practice Recommendations The home should review the format of the Application Form as discussed with the Registered Manager at the time of the Inspection. D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 25 Blenheim Lodge 2. 3. 4. 5. 30 32 36 The home should consider providing staff with training in dementia care and mental health. The Registered Manager should consider conducting staff meetings more frequently. It is strongly recommended that the Regsitered Manager ensure that staff supervision is given priority so staff receive formal supervision at least six times a year. Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Blenheim Lodge D53_D02 S16019 Blenheim Lodge V245239 101005 Stage 4.doc Version 1.40 Page 27 - 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. 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