Inspection on 14/01/07 for Bluebell Court

This inspection was carried out on 14th January 2007.

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

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

Other inspections for this house

Bluebell Court 16/04/09

Bluebell Court 12/12/08

Bluebell Court 11/06/08

Bluebell Court 21/06/07

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

CARE HOMES FOR OLDER PEOPLE Bluebell Court Stanley Road Grays Thurrock Essex Lead Inspector Helen Laker Unannounced Inspection 17th January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bluebell Court DS0000067279.V316194.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. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bluebell Court Address Stanley Road Grays Thurrock Essex 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) 0191 419 3414 Primrose Care Home Limited Care Home 80 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (80), of places Physical disability over 65 years of age (10) Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home should appoint a registered manager for the home, within three months of the homes premises registration, who should obtain a suitable qualification equivalent to NVQ level 4 - care and management by 2007. Following initial registration, no persons requiring nursing care must be admitted until a Nurse Manager is appointed. Date of last inspection Not applicable Brief Description of the Service: Bluebell Court is a purpose built three storey care home with Nursing for older people who have physical disabilities and dementia and is registered with Commission for Social Care for the continuing care of 80 residents in total. The Home is located centrally in the town of Grays within walking distance of local amenities. The M25, the A13 and Grays railway station are in close proximity. The building has been adapted to provide three purpose built floors, to provide a homely atmosphere for the service users and families. Trained nursing staff and carers are available for the provision of personal and nursing care. Parking is available to the front of the building. The home was registered in July 2006 The Service User Guide and Statement of Purpose are available and are updated as required. The residents and their representatives are provided with this information and also the manager was informed that latest Commission for Social Care Inspection reports must also be available At the time of this report the manager confirmed that the fees ranged from £395.43 to £657.00 per week and a completed pre inspection questionnaire was provided. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over one day with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. The acting manager in charge of the day to day management of the home and the regional operations manager were spoken with. Further feedback was also received from service users and care staff through survey and discussion. Responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the staff on duty were also used as evidence to inform this report. Twenty one National Minimum Standards were inspected on this occasion, ten overall outcomes were met and there are ten requirements and one recommendation detailed in this inspection report. An immediate requirement form was left for one requirement with major shortfalls Discussion of the inspection findings took place with the acting manager in charge of the day to day management of the home and the regional operations manager at the end and throughout the inspection and guidance was given. Key standards as identified in the intended outcomes sections of this report are inspected at least once every twelve months during a key inspection. What the service does well: What has improved since the last inspection? Since the homes registration visit, Bluebell Court have endeavoured to ensure that they provide a consistent professional service to current residential service users. The premises is registered for 80 service users, provide space for equipment, meetings and training facilities. The home needs to still register a manager for the home, who should obtain a suitable qualification equivalent to NVQ level 4 - care and management by 2007. Following initial registration, no persons requiring nursing care must be Admitted until a Nurse Manager is appointed. The home presently does not have any nursing clients, as this condition of registration is not yet fulfilled. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 6 Requirements and recommendations highlighted at this first inspection have been discussed with the manager. What they could do better: New service users must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. A detailed service user plan of care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and be completed sufficiently and reviewed comprehensively monthly. Risk assessments must be in place contain adequate information and be reviewed regularly The registered person must ensure that there is a policy and staff adheres to the procedures for the receipt of recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. This with specific reference to the documentation of omissions, recording room and fridge temperatures. The proprietor should also ensure that all drug storage areas are adequately ventilated. Service users must not be restricted with lap belts permanently for any reason or be subject to any form of restraint. Consideration must be given to the issue of formulating individual plans within a risk-managed strategy. On the day of inspection one service user was noted to be using a lap belt. The opportunities for stimulating activities, which are provided for the people living at the home, should be reviewed and residents should be consulted so as to find out how they would like to spend their days including how they would like to spend free time. Where activities are provided records could be better maintained. Consideration should be given to employing more activities staff. Records should be kept regarding any complaints made or concerns raised verbally or informally. These records should clearly indicate whether the complaint was upheld and what action was taken to address the issues raised. The registered person must ensure that the homes Adult Abuse Policy is in accordance with the Public Disclosure Act 1998 and Department of Health Guidance ‘No Secrets’. This with reference to staff training in POVA issues. The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice and that records required by regulation, including CRB and POVA first checks for the protection of service users and for the effective and efficient running of the business must be maintained, up to date and accurate. People must only be employed at the home after all of the checks have been carried out so as to determine that the person is suitable to care for older people. A serious concerns letter has been issued to the home in The registered person must ensure that all staff employed at the home receive regular updated training for the work undertaken. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 7 respect of this at this inspection and must be addressed within the given timescales. The registered person must ensure that the home has a registered Manager. 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. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective service users and their supporters have adequate information about the home so that they can make informed choices. The admission procedure does not include an adequate assessment, which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: A pre-admission assessment is generally carried out by the manager or identified staff member. Pre admission assessments were reviewed for the homes most recent admissions and were found to be inadequately completed and were very non specific. Attention should be paid to dating and signing documentation any assessments at the time of completion to ensure accurate Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 10 information is maintained. Wherever possible it is advised that residents or their relatives are involved in the assessment process. Bluebell Court does not provide intermediate care. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 11 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 adequate This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan and service users are generally supported to take risks as part of an independent lifestyle via a process of assessment. Further progress is required to ensure that service users needs are met. The health needs of service users are met, although better documentation would ensure clarity of needs. Medication storage issues were noted to require attention. Personal support is provided in a way that promotes dignity. Not all staff are totally aware of the fundamental concepts of restraint. EVIDENCE: Evidence of four service user care plans indicated that their basic health, personal and social care needs are recorded within an individual plan of care. Instructions for staff to meet service users’ care needs were not on all Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 12 occasions clear and comprehensive. Care plans did not always evidence service users’ or relatives’ involvement and those seen were reviewed on a regular basis. Daily recording requires much improvement to ensure staff details the welfare of the service user, how they spend their day and the progress of the care plan. Risk assessments were available for some service users but were also noted to require more detail in some areas and include potential complications of the risk. Care plans did not always include consultation on restraint agreements, likes and dislikes, evaluation of care needs though monthly reviews and have plans in place so as to minimise these risks and their impact on the lives of residents living at the home. The acting manager and regional operations manager were advised of these issues during the inspection. There was evidence to show that the home ensures that residents are supported to access all the community health facilities. The inspector was informed that only trained staff administer medication. Completed drug histories should refer to dose changes on the form. All individual entries on the drug sheets should be signed by the transcriber and checked for accuracy with a countersignature. The dose form and strength and time of medication were clearly recorded on treatment charts inspected. Minor shortfalls were noted with the maintenance of records in respect of room and fridge temp recording and all of the three drug storage rooms were noted to have no ventilation. The home must adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Residents and relatives spoken with expressed their satisfaction with the care they received and felt that staff generally respect their privacy. Observations throughout the day indicated that staff treat residents in a caring and unhurried manner. The manager stated that most residents open their own mail, those that are not able to usually have their relatives’ assistance. The home provides visitors areas, including a small café in the main reception foyer. This enables service users to see their visitors in privacy, if they do not wish to use their bedroom. Service users were being restrained with lap belts in chairs with inadequate documentation in their plans of care or no risk assessment. On the day of inspection one service user was noted to be using a lap belt. This was discussed with the manager at this inspection Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A wider range of meaningful pastimes needs to be developed to promote the residents mental and physical wellbeing. Links with families are good and contacts are maintained. Choice in the routine of the day can be adapted to ensure resident’s rights are maintained. The home provided good food in ample quantities and is served in a congenial setting. EVIDENCE: The home presently employs one activities co ordinator for 25 hours a week for potentially 80 service users when at full capacity. A discussion was held regarding an increase in this provision in hours as occupancy increases. The home does not have a completely set activities programme yet. Residents spoken to stated that they play cards, bingo, listen to music, and have singalong; they also told of the regular visits by the clergy. Two residents spoken with stated that a mini-bus/car would allow them to go out. The manager confirmed that the home had no transport of their own. Information about resident’s choices and preferences for activities of living are not consistently Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 14 recorded for the people living at the home. It is accepted that a number of people living at the home may not wish to or be capable of participating in activities. However records in respect of meaningful occupational and stimulating activities are not consistently recorded and it was not clear on display what activities are planned on a day-to-day basis. More could be done in respect of the social and leisure activities provided by the home. Some of the residents said they had to rely on their relatives to take them out. Relatives spoken with said that they can visit when they wish and are always made welcome and can speak to the manager. Residents described the food provided by the home as “very good”. The home employs a cook who is prepared to cook any meal to accommodate individual residents needs. Residents spoken with said the food at the home is good and that they get three courses. The dining areas are spacious and clean. The food was well presented in served in sufficient quantities. Visitors spoken with commented on the quality and the quantity of the food served. A small café is available in the main foyer reception area for relatives to order from a menu snacks and drinks. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy which informs complainants of their rights, in the event of any informal or formal complaint documentation must be maintained appropriately or fully. Staff may receive relevant training relating to the protection of vulnerable adults but this must be updated regularly. EVIDENCE: The home has a complaints policy and procedure and people may raise concerns formally or discuss any issues in a more informal way with the homes manager and operations director. It was reported by the regional operations manager that there have been about 15 complaints made since the homes registration last July. A number of these have been sent directly to the CSCI and at the time of this inspection it was noted that at least two, are being dealt with under POVA. It was noted that informal and verbal complaints are not logged in a manner, which recorded the outcomes, and the home would benefit from this to avoid recurring issues and highlight areas where services could be improved. The home has an Adult Abuse Policy and Whistle Blowing procedure. Not all staff have attended “Protection of Vulnerable Adults” training. The home must continue to ensure that all staff receive training and updates in the protection Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 16 of vulnerable adults and ensure through the home’s supervision procedures that all staff are fully aware of what is expected of them. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Bluebell Court is bright and airy and provides the service users with homely and comfortable surroundings. EVIDENCE: The home Bluebell Court is presented in an attractive and comfortable way and adequately meets the current needs of the resident’s. The premises are generally well maintained with a garden area to the rear. The home was clean and hygienic on the day of inspection with a few minor isolated odours in one room. Appropriate systems were in place to control cross infection. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 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 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 poor. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are currently maintained to meet the needs of service users. Recruitment practices currently are poor and have major shortfalls, which need addressing. Staff training is addressed but more prominence should be paid to appropriate updates being undertaken to provide a competent work force. EVIDENCE: Staff rotas indicated that agreed staffing levels are maintained. Staff on duty during the inspection matched those stated on the duty rota. There is presently one qualified nurse employed at the home the acting manager and, once an application to register her as manager has been completed the home must ensure nursing staff are on duty at all times is on duty at all times to comply with the conditions of registration for the home and to enable the home to admit nursing service users. The first floor is presently empty and is designated for nursing service users. The home has had some staff problems since registration but these were temporary and have not affected the general running of the home overall. The home needs to ensure that more of the staff team undertake NVQ training. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 19 Of the staff records reviewed it was noted that some major shortfalls were evident and documentation was missing. The Inspector was informed that Criminal Record Bureau checks have been obtained but were not available to inspect. There was little or no evidence of inductions or job descriptions and some documentation was noted to not be signed or dated or even in place in some cases. The process regarding agency and volunteer recruitment should the need arise, and CRB checks was discussed. Attention should be paid when recruiting, to addresses for references, incomplete application forms, comprehensive work history, permissions to work and proof of identity. The home should be satisfied that all references are authentic and application forms are fully completed; and any gaps in employment should be explored. The manager was advised that staff members must not start work at the home until all relevant recruitment checks have been completed. The manager was also advised of current immigration requirements and regulations and the recruitment checks required. She was advised to inspect all other staff personnel records to ensure that the home was compliant with all legal requirements. An immediate requirement form was left on the day of inspection for the home. Although new staff have an induction to the home at the beginning of their employment, this is not evidenced as recorded. All mandatory training can be carried out as part of the TOPSS induction; specialist training should be identified according to the resident needs. Staff spoken with said that training is provided by the home. A plan was discussed and is informally in place but a number of updates and mandatory courses still need to be addressed. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 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 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 adequate. This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: At the time of this inspection the acting manager had only been in post for approximately one month. She is appropriately qualified and is a qualified nurse. An application for registration still needs to be made and the inspector Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 21 discussed with her the need to seek guidance on how her present qualifications equate to NVQ level4 in management. Service users, staff and visitors who were spoken with all confirmed that the home was managed in a manner which was open and promoted free exchanges of views, comments and suggestions. A resident’s meeting was planned for 17.30pm hours on the day of inspection. The acting manager works at the home most days in a supernumerary capacity and oversees the day-to-day running and provision of care and treatment. Residents and their relatives can discuss care and any issues with the acting manager informally or formally when they visit. Records in respect of the service were noted to be stored appropriately. Certificates in respect of service and maintenance of gas, electric (including portable appliance testing), lifting and fire safety equipment at the home were noted to be satisfactory. Fire drills are being regularly documented and undertaken and attendees’ names documented. The acting manager is aware of her duties under health and safety. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 22 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 2 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A as this is homes first inspection since registration. 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 OP3 Regulation 14(1)& (2) Requirement Timescale for action 05/03/07 2 OP7 15(1)(2) 17(1)(a)( b) 2a OP7 13 (4) & 13 (8) New service users must be admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. A detailed service user plan of 05/03/07 care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and be completed sufficiently and reviewed comprehensively monthly. Risk assessments must be 05/03/07 carried out for the example: -use of bed rails and includes details of potential implications of their use for the service users within individualised plans of care. This with regard to all other risk assessments formulated especially those at risk of falls, pressure sores and those for COSHH and environmental health and safety issues. DS0000067279.V316194.R01.S.doc Version 5.2 Bluebell Court Page 24 3 OP9 13 (2) 17 (1) 12 (1) – (4) 13 (4) 14 (2) 4 OP10 13 (7) & (8) 5 OP12 16 (2) m &n 6 OP16 17(2)Sch 4 12(1) 7 OP18 The registered person must ensure that there is a policy and staff adheres to the procedures for the receipt of recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. This with specific reference to the documentation of omissions, recording room and fridge temperatures. The proprietor should also ensure that all drug storage areas are adequately ventilated. Service users must not be restricted with lap belts permanently for any reason or be subject to any form of restraint. Consideration must be given to the issue of formulating individual plans within a riskmanaged strategy. The routines of daily living and activities made available must be flexible and varied to suit service user’s expectations preferences and capacities. This with reference to the formulation of a formal activities plan in appropriate formats, with regard to differing service users needs and with a view to an activities coordinator covering adequate hours for 80 residents when home full to capacity. A comprehensive record must be kept of all complaints made and includes details of investigation and any action taken. The registered person must ensure that the homes Adult Abuse Policy is in accordance with the Public Disclosure Act 1998 and Department of Health Guidance ‘No Secrets’. This with DS0000067279.V316194.R01.S.doc 05/03/07 05/03/07 05/03/07 05/03/07 05/03/07 Bluebell Court Version 5.2 Page 25 8 OP29 7, 9, 19 (1) to (7) Schedule 2 reference to staff training in POVA issues. The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. This includes having CRB and POVA first checks available at all times within the home for unannounced inspections 19/02/07 A serious concerns letter has been issued to the home in respect of this at this inspection 9 OP30 12(1) & 18(1) 10 OP31 8(1&2) 9(1&2) This must be addressed with immediate effect and within the 4 week time limit. The registered person must ensure that all staff employed at the home receives training for the work undertaken. It is recommended this meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfils the aims of the home and meet the changing needs of service users. The registered person must ensure that the home has a registered Manager. 05/03/07 05/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations It is recommended that minor isolated odours be addressed and carpet replaced where necessary and where deep cleaning has not resolved the problem. Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Bluebell Court DS0000067279.V316194.R01.S.doc Version 5.2 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. 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