Inspection on 25/05/05 for Bluebell Lodge Care Home

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Lodge Care Home 15/05/08

Bluebell Lodge Care Home 26/11/07

Bluebell Lodge Care Home 07/02/07

Bluebell Lodge Care Home 29/06/06

Bluebell Lodge Care Home 12/10/05

Bluebell Lodge Care Home 29/11/04

Bluebell Lodge Care Home 11/05/04

Bluebell Lodge Care Home 20/11/03

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

CARE HOMES FOR OLDER PEOPLE Forest Lane House Care Home Forest Lane House Forest Lane Chippenham Wiltshire, SN15 3QU Lead Inspector Alison Duffy Unannounced 25th May 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. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Forest Lane House Care Home Address Forest Lane House Forest Lane Chippenham Wiltshire SN15 3QU 01249 443501 01249 447506 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) Mr Nichola Mackey Mrs Ann Elizabeth Macdivitt Care Home 19 Category(ies) of MD(E) Mental Disorder (1) registration, with number OP Old Age (19) of places Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Maximum number of service users who may be accommodated in the home at any one time is 19. 2. Not more than 1 service user aged 65 years and over with a mental disorder may be accommodated at any one time. 3. Not more than 1 service user in the age range 50-64 years may be accommodated at any one time. This person may only occupy the accommodation referred to in the variation application dated 27th March 2004 for respite or intermediate care and for a period not exceeding 4 weeks (except by prior consultation with the Commission). This bedroom is numbered 19 and located on the first floor immediately next to the medication storage room. The room may not be used for any mental disorder placement. Date of last inspection 29th November 2004 Brief Description of the Service: Forest Lane House is registered to care for nineteen older people. Within the nineteen places, one room is fully designated to respite care. The home is located in a residential area of Chippenham. There are 16 single rooms and one double. All contain en-suite toilet or bathing facilities and are located on both the ground and first floors. A passenger lift is available to give level access to all areas. The communal areas of the home consist of two lounges and a separate dining room. All areas are comfortable, homely and furnished to a good standard. The current owners took over responsibility of Forest Lane House in March 2003 and currently have two other care homes, in Kent and Suffolk. Mrs MacDivitt was appointed manager in September 2003 and works on a full time basis from Monday to Friday. There are generally three care staff on duty during the morning and this reduces to two during the afternoon and evening period. At night two members of staff undertake a waking night. The home does not provide intermediate or nursing care. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 09.15am and 6.40pm on the 25th May 2005. The Inspector undertook a tour of the premises and spoke with eight residents and three staff. Discussion also took place with Mrs Christine Jenkins who is currently Acting Manager while the Registered Manager is absent on leave. Daily records, care planning information, personnel and training records were viewed and the Inspector observed the serving of lunch. The Pharmacy Inspector examined the medication systems. What the service does well: What has improved since the last inspection? What they could do better: All prospective residents must be fully assessed in order to determine whether his or her needs will be met prior to being admitted into the home. Such needs must be documented and addressed within the care plan. Consultation with other professions must be made as required before admission. Care planning information and daily records must be further developed to reflect current practice, significant events and general wellbeing. Greater organisation within such record keeping is required. Medication systems require a thorough review. The administration sheets must be a correct reflection of the medication given to residents and a record of all medication received and disposed of is required. Risk assessments are required for those residents who self medicate and training must be given to staff who are required to carry out identified medical tasks. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 6 Attention must be given to adult protection. Staff require abuse awareness training and all must be made aware of the reporting procedures in the event of a suspicion or allegation of abuse. The recruitment procedure must be addressed in order for it to be a thorough and robust system. The receipt of two appropriate written references, a POVAFirst check and the application of a CRB disclosure must be undertaken before the commencement of a member of staff. Health and safety could be much improved with attention given to the risks of hot water, radiators and first floor windows. Additional Visits: There have been two additional visits made to the home since the last inspection. Both visits were made to investigate two separate formal complaints. The first complaint raised concerns of some parts of the home being without heating over the Christmas period. This was upheld. Satisfactory contracts are now in place in the event of heating failure out of office hours. The CSCI and the Provider both investigated the second complaint. A number of shortfalls were identified. These included a number of medication errors both in receipt and administration, lack of clarity within recording procedures and lack of written guidance to staff when dealing with challenging behaviours. Four requirements were made which will be addressed within follow up visits to the home. 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. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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) 3 There are significant shortfalls within the assessment process placing residents at risk of inappropriate care and not having their needs met. The home offers respite but not intermediate care. EVIDENCE: One resident was being admitted on the day of the inspection. It was said that her needs had been assessed on her initial visit to the home although there was no written evidence of this. Mrs Jenkins was planning to complete the assessment form when the resident had been settled into her room. Another resident had been admitted following a referral from her daughter. There was no available written information about her other than her son’s name. A full Community Care assessment had been received for one resident who had been placed via a placing authority. The detail however within the assessment had not been noted and transferred to a plan of care or used within the risk assessment process. The resident’s needs were not discussed with the community nurses as required. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 9 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 and 9 Care plans do not reflect individual need and therefore residents are at risk of inappropriate practice or not having his or her needs met. While generally receiving appropriate medical input, not recognising the need for professional input in one instance gave significant risk to the individual concerned. Poor recording systems do not demonstrate whether some residents’ needs are met. The storage and handling of medication is poor, potentially placing residents at risk. Insufficient records and staff training contribute to this. EVIDENCE: The care-planning format has recently been developed although does not reflect some residents’ current level of need. One resident with insulincontrolled diabetes had no information regarding this. Another had asthma and self-administered her inhalers. This was not addressed within her plan of care. Other plans contained basic needs but did not reflect individual conditions. The daily notes although containing less subjective language did not give sufficient detail. One resident was in hospital although this was not reported on within the daily notes. Another resident appeared to be having difficulties with a catheter although follow up action was not apparent. Many of the daily recording sheets were poorly organised with only the Christian name of the Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 11 resident apparent. Some sheets were not completed and not in date order. Some were also mixed within other residents’ notes. At the last inspection a requirement was made to provide training and written guidelines regarding the management of specific challenging behaviours. There was no evidence of this and therefore the requirement is repeated. The medication was stored in locked cupboards and a trolley in a locked clinic room. Loose tablets, unlabelled strips of tablets and medication not listed on the administration records were found. The printed medication administration records did not accurately reflect the medication being given to some residents, and changes had not been signed. No record had been made of medication received into the home or disposed of. One resident required a regular injection. Staff had not received sufficient training for this procedure, and the care plan did not record that this was taking place. Residents who wish to retain responsibility for some of the medication they receive were allowed to do so, but no risk assessment or review was carried out. At the time of the last inspection consideration was being given to the admission of a gentleman with insulin-controlled diabetes. A requirement was therefore identified to ensure that arrangements were made for the Community Nurses to give the prescribed insulin and all staff would receive diabetic training before the admission. Mrs Jenkins reported the admission did not take place, yet it is of concern to the Inspector that this knowledge was not used to secure suitable procedures for a resident noted within this inspection. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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) 13 and 14 Visitors are welcomed within the home. Residents are encouraged to follow their own preferred routines and make their own choices. EVIDENCE: All residents spoken with reported that they were able to have visitors as they wished and there were no visiting hours. Family members were made to feel welcome and could have a meal if notice was given. Residents were able to entertain within their own room as they wished. Residents reported that they were able to follow their own routines such as getting up and going to bed. They could spend time in their own room and follow their own interests as required. They could also go out with family members without restriction or have a walk in the garden. During the inspection residents were met with in the communal areas and within their private accommodation. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure is readily accessible for residents and their relatives. Staff have insufficient knowledge regarding abuse and therefore residents are at risk of such. The lack of recognition of poor practise and the poor awareness of the abuse reporting procedure compromises residents’ safety. EVIDENCE: The home has a complaints procedure on the notice board in the entrance area of the home. It is however in need of updating as it still contains details of the previous registration authority. At the last inspection there were a number of entries within daily records stating that some residents were unhappy. Follow up intervention was not evident. There was no evidence of this during this inspection. Since the last inspection, CSCI has received two formal complaints about the home. There was no evidence within the home of the Wiltshire and Swindon Vulnerable Adults procedure. Staff were unaware of this and could not locate the documentation. Staff have not received up to date adult protection training. Within staff discussion, a member of staff was overheard to comment about how a resident didn’t want to get up and get washed. An element of verbal pressure was given and although it was reported that the resident ‘didn’t like it, she was now clean.’ Discussion took place with Mrs Jenkins regarding the need to address this issue with the member of staff and agree written guidelines to appropriately manage any such reluctance. Another resident reported that he had resulted to shouting to attract attention as he Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 14 couldn’t reach the bell and had had his extension chord removed. This was replaced following an instruction from the Inspector. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24 and 25 All communal areas are comfortable and furnished to a good standard. Residents are encouraged to make their room as homely as possible. Insufficient measures have been taken to protect residents from risks associated with hot water, hot surfaces such as radiators and falling from first floor windows. EVIDENCE: Residents’ rooms were personalised to varying degrees and all contained the furniture required. All residents spoken with reported that they were happy with their room and one resident reported moving on various occasions in order to meet her requirements. All rooms have en-suite facilities. Some residents said that this gave increased privacy and therefore a real benefit. Residents are able to have their own phone is they wish and one resident reported ‘it is just like home.’ Communal areas consisted of two lounges and a separate dining room. All areas were light, at a comfortable temperature and furnished to a good standard. Some residents reported that they spent the Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 16 majority of their time in their room although had the choice to spend time in the lounge as required. At the last environmental health inspection it was identified that the kitchen did not have hand-drying facilities. This remained the case at this inspection. There was also no toilet paper in the upstairs bathroom. At the last inspection Mrs MacDivitt reported that the bathroom was not used, as residents’ had their en-suites. It was agreed however that the room should be equipped in the event of a resident or visitor needing to use the facilities. This matter is therefore repeated. A programme to fit radiator covers has commenced although individual rooms whereby some residents are at risk of falling have not been addressed. Individual fail-safe devices have not been fitted to individual hand washbasins and some windows on the first floor did not have window restrictors. At the last inspection a requirement was made to address a frayed carpet, which was causing a trip hazard. The carpet was replaced. During this inspection however it was noted that another carpet needed attention to minimise the risk of falling. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 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, 29 and 30 Staffing levels are being maintained as required by the previous Registration Authority. However this does not, particularly with the evening shift, give time for any interactions other than general routines. Serious shortfalls within the recruitment procedures place residents’ at risk of poor practice and abuse. The home gives training high priority, yet adult protection has received limited attention. EVIDENCE: There are three members of care staff on duty during the morning period and this reduces to two for the afternoon and evening shift. There are two waking night staff. The home has a domestic assistant and the position of cook is currently vacant. The administrative assistant is generally covering this until a replacement is found. The manager generally works during the week and is not an integral part of the working roster. Although maintaining staffing at agreed levels, there was on entry within a daily record stating a resident was told by a staff member ‘they didn’t have long to talk as there were only two staff on duty.’ Since the last inspection the home has had a number of new staff. The dates of the staff members commencement were not however available. All personnel files of the new staff were examined and major shortfalls were identified. One Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 18 reference was poor and another was returned with ‘Not known at XXX.’ Both staff members were however recruited. One file only had one reference and another had two references from friends. There was little evidence of CRB disclosures and POVAFirst checks had not been undertaken. Training information was in the process of being reviewed and certificates demonstrating training undertaken were being photocopied for a file. Such certificates demonstrated a range of topics such as first aid, manual handling, infection control, health and safety and customer care. Although the home has undertaken a range of training, shortfalls within adult protection and managing challenging behaviour require addressing. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 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) 36 and 38 Priority must be given to identifying the significant shortfalls identified at this inspection. There is limited staff supervision, which gives the potential for poor practice and unmet need. Residents’ safety is also compromised through insufficient attention to health and safety matters. EVIDENCE: Mrs Christine Jenkins is undertaking the role of acting manager in the temporary absence of the Registered Manager. Mrs Jenkins has worked at the home as a senior carer for a number of years and has undertaken various training courses. Mrs Jenkins’ remit during her time, as acting manager is generally to take care of day-to-day matters. Mr Mackey is available as required for advice. A requirement was made at the last inspection to develop and implement formal supervision for staff. This has not been implemented although consideration has been given to developing such systems and devising recording formats. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 20 A programme to commence the fitting of radiators has commenced. A bathroom radiator was however hot to the touch. Some radiators within rooms of residents prone to falling remain uncovered. Hot water temperature regulators have not been fitted and at this time a record of hot water temperatures has not been maintained. Some windows on the first floor do not have window restrictors. At the last inspection it was noted that one carpet was fraying causing a trip hazard. This carpet had been replaced although another carpet was noted to be similar. The recording of fire safety has been transferred to a smaller book. This does not portray information as clearly as the fire log book. There was no evidence of the visual checks of the means of escape and fire drills. It was difficult to assess if all staff had had fire instruction although it appeared that only three staff had received training since October 2004. The weekly check of the fire alarms did not portray which fire point was used. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 3 x x 3 3 1 x STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x x x x x 1 x 1 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement The Registered Person must ensure that all prospective residents have their needs assessed before admission to the home. Such needs must be identified within written form. The Registered Person must ensure that confirmation is given in writing detailing that the home can meet assessed needs before admission. The Registered Person must ensure that all care plans identify individual need and reflect key information that is identified within the assessment process. A similar requirement was identified at the last inspection. The Registered Person must ensure that daily records are detailed, reflect current wellbeing and significant events and are clearly organised with the residents full name. A similar requirement was identified at the last inspection. The Registered Person must ensure that management guidelines are available for staff in the event of incidents of Timescale for action From 25th May 2005 2. 3 14(1)(d) From 25th May 2005 3. 7 15 31st July 2005 4. 7 17(1)(a) From 25th May 2005 5. 8 12(1)(a) 31st July 2005 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 23 6. 9 13(2) 7. 9 13(2) 8. 9 13(2) 9. 9 18(1) (c)(i) 10. 9 13(4)(c) 11. 16 22(7)(a) challenging behaviour. This was identified at the last inspection. The Registered Person must ensure that all medicines received into the home and sent for disposal are recorded. The Registered Person must ensure that all medication administration records are accurate and up to date. Written additions to the medication administration record must be dated and signed by two members of staff. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that all medication is stored in the original container with the prescriber’s instructions attached. The Registered Person must ensure that all staff, who are required to carry out additional medical tasks, receive the appropriate training from the responsible nurse. A similar requirement was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that residents who wish to self medicate are supported within a risk assessment framework and regularly reviewed. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that all copies of the complaints procedure contain contact details of CSCI. This was identified at the last inspection. Failure to comply will lead to the From 25th May 2005 From 25th May 2005 From 25th May 2005 From 25th May 2005 30th June 2005 30th June 2005 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 24 12. 18 13(6) 13. 18 13(6) 14. 18 13(6) 15. 25 13(4) (a)(c) 16. 19 13(4)(c) 17. 19 13(4) (a)(c) issuing of an Enforcement Notice. The Registered Person must ensure that the Wiltshire and Swindon Vulnerable Adults procedure is readily assessible. Staff must be aware of their responsiblities within. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that all staff receive adult protection training. Written guidelines must be developed for those residents who find the management of their personal care difficult. The Registered Person must ensure that all residents have access to a call bell system within their reach. The Registered Person must ensure that all residents are individually assessed regarding the risk of radiators. The programme of fitting radiator covers must continue with attention given to those most at risk. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that all matters as identified within the recent Environmental Health Inspection are addressed and fully maintained. This includes the provision of hand drying facilities in the kitchen. This was identified at the last inspection. The Registered Person must ensure residents safety from the possible risks of the bathroom and corridor windows on the first floor. 31st July 2005 31st August 2005 From 25th May 2005 31st July 2005 31st July 2005 31st July 2005 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 25 18. 25 13(4) (a)(c) 19. 29 19 20. 29 19 21. 29 17 Schedule 4, 6 18(1)(a) 22. 36 23. 38 13(4) (a)(c) 24. 38 23(4)(d) (e) The Registered Person must ensure that all hot water outlets are monitored, with records kept and individual fail-safe devices are fitted accordingly. Individual risk assessments in relation to hot water must be undertaken. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. The Registered Person must ensure that two written references are received as part of the recruitment process. In the event of a reference not being satisfactory, a written assessment must be undertaken detailing why the appointment has been made. This was identified at the last inspection. The Registered Person must ensure a CRB disclosure is applied for and a POVAFirst check is undertaken before the commencement of a new member of staff. The Registered Person must ensure that a record of all staff members commencement dates are maintained. The Registered Person must ensure all staff are aware of the policies and procedures within the home and receive formalised supervision. This was identified at the last inspection. The Registered Person must ensure that the carpet within the identified room is made safe and a system is devised to identify any such problems at an early stage. A similar requirement was identified at the last inspection. The Registered Person must ensure that regular fire drills take place and all staff have fire instruction on a regular basis. 31st July 2005 From 25th May 2005 From 25th May 2005 30th June 2005 31st July 2005 30th June 2005 30th June 2005 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 26 25. 38 13(4) (a)(c) The Registered Person must ensure that attention is given to the radiator in the unused bathroom in order for the temperature of such to be reduced. This was identified at the last inspection. Failure to comply will lead to the issuing of an Enforcement Notice. 30th June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 29 38 38 Good Practice Recommendations The Registered Person should ensure that staffing levels enable sufficient time with residents, including time for social intearction and reassurance. The Registered Person should consider returning to the previous Fire Log Book in order to record all fire safety measures. The Registered Person should record the rotaing procedure of fire points used when testing the fire alarm systems. Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 27 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Forest Lane House Care Home D51_D01_S40675_FORESTLANEHOUSE_V209848_250505_Stage4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!