Inspection on 11/04/05 for Bluebells

This inspection was carried out on 11th April 2005.

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

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

Other inspections for this house

Bluebells 21/08/07

Bluebells 27/07/06

Bluebells 12/10/05

Bluebells 07/10/04

Bluebells 01/04/04

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 Bluebells 152 Moredon Road Swindon Wiltshire SN25 3EP Lead Inspector Bernard McDonald Unannounced 11th April 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. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Bluebells Address 152 Moredon Road Swindon Wiltshire SN25 3EP 01793 611014 08708318894 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 Abitalib Ebrahimjee Mrs Lesley Ann Hunt Care Home 16 Category(ies) of Old Age (16) registration, with number of places Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 07/10/04 Brief Description of the Service: Bluebells is a large bungalow in the Moredon area of Swindon offering accommodation and care to 16 older people. The home is close to local shops and services and on a bus route. The home offers a mixture of double and single rooms. There is an open plan area incorporating two lounges and a dining room. These rooms can be used for social and religious activities. The sitting rooms are smoke free. There is wheelchair access to the garden and there were two ramps. There is seating in the garden in the form of plastic bench and chairs. Lighting is domestic in style. The home offers long term and occasional respite care. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over eight hours. The inspector viewed all areas of the home and met with thirteen service users and three care staff on duty. The inspector had the opportunity to meet with the relatives of six service users who were visiting on the day of the inspection. A number of records were examined including four service users care plans, risk assessments, health and safety records and staff recruitment files. What the service does well: What has improved since the last inspection? What they could do better: Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 6 Overall there is a general lack of improvement in any of the standards inspected. The home needs to ensure that service users are treated with dignity and respect at all times. Improved training in the care needs of older people and service users who may challenge the service must be provided to ensure staff have the skills necessary to meet their needs. The home must ensure care plans are in place for all service users and that these are reviewed a minimum of once a month. The home needs to ensure service users are fully involved in the review process. Attention must be given to providing suitable activities following consultation with service users Overall the home needs to look at ways of consulting with service users and involving them in the running of the home. Further improvements are needed in risk assessments paying particular attention to service users at risk from pressure sores. An immediate requirement notice was issued at the inspection to improve the recording of medication received at the home. The significant number of requirements made at this inspection and comments received from service users and staff clearly identifies a need to improve the staffing levels at the home. Training in abuse awareness needs to be improved especially in light of the comments made by service users regarding the way staff and management speak to them. Following the inspection the registered provider and registered manager were required to attend a meeting with the Commission to discuss the findings of the inspection and advise the registered person’s of what action the Commission will be taking if these concerns are not addressed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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 Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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) 1,3,4 and 6 There is a clear admission procedure that ensures service users needs are assessed prior to admission. However staff need training specific to the needs of older people to ensure they have the skills necessary to meet the needs of service users. EVIDENCE: The home has admitted one service user since the last inspection. Discussion with the service user and their relative confirmed opportunities were provided to visit the home, view the room and meet with staff and service users. The home’s manager also completed a pre assessment visit to the home of the service user. Information on the service in the form of a service user guide had been given to the service user. Copies of the guide were evident in all service users bedrooms. The ability to meet the needs of service users was not evident from the documentation examined. One service user had no care plan to demonstrate the homes capacity to meet their needs. Though a number of service users Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 9 commented that they were well cared for. Two service users stated that staff and the manager sometimes “shout” and staff are sometimes “grumpy.” A requirement was made at the last inspection that care staff receive training in managing difficult and challenging behaviour; this requirement had not been met. Comments made by service users clearly identify that there is need for specific training in managing behaviour that may be challenging and additional training on meeting the care needs of older people. The home does not provide intermediate care. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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 and 10 The lack of care reviews and minimal daily records demonstrate the home is not ensuring the health and personal care needs of service users are being safely met. Not all service users are treated with dignity and respect. EVIDENCE: Since the last inspection the homes has introduced a care plan diary with the objective of supporting the service user plan. Examination of four care plans and diaries did not reflect how the needs of service users were being met or where service users or their families have been offered opportunities to participate in the care review. Care plans examined had not been reviewed since September and October 2004, which falls far short of the required standard of every month. Risk assessments on service users at risk from pressure sores had not been reviewed. One service users pressure risk assessment had not been reviewed since 24/11/03. This is a particular concern as the service user had been assessed as needing a pressure relief mattress. The inspector found the service user did have the required mattress on their bed but was sat in a normal chair Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 11 without any pressure relief support. This was brought to the attention of the manager who immediately provided a pressure relief cushion. The inspector found medication was not being recorded when it is received at the home and issued an immediate requirement to ensure medication is accurately recorded. Observations made during the inspection demonstrated service users were being treated with dignity and respect and interactions were positive. However conversations with service users raised concerns about the way some staff and the manager speak to service users. One service user commented that staff talk to her like an “animal” and tell her to “sit down”. This was raised with the manager during the inspection. The manager confirmed she had shouted at one resident. This issue was subject to a vulnerable adult investigation and a further investigation was undertaken by the provider. The registered provider must provide the commission with details of what action they will be taking. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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) 12, 13, and 15 There are limited opportunities provided at the home to promote service user choice and provide a varied lifestyle that meets service users expectations, religious and recreational interests. EVIDENCE: A number of service users commented on the lack of opportunity to exercise any choice in daily activities. One service user commented, “there is nothing to do” and we “just sit and watch the clock go round” It was recommended at the last inspection that the home should seek the views of service users on what activities they would like and provide a timetable of activities each week. The manager stated this recommendation had not been met due to a reduction in staff numbers. This has also impacted on the homes ability to provide any activities for service users. There is a religious service held at the home each month, however this does not meet the spiritual needs of all service users. One resident commented that they were unable to receive communion, as they did not belong to that particular church. The service users did not want to make a fuss but this highlights the need for the home to ensure all service users religious preferences are as far as possible met. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 13 Opportunities for service users to access the wider community are being restricted. One service user stated that they had asked to be taken out of the home for a short trip “round the block” but have been unable to go due to staff shortages. Service users were complimentary about the meals provided in the home. The inspector shared the lunchtime meal with service users and found it was tasty and well presented. Choices are routinely offered at each meal. The inspector met with the relatives of six service users who commented they have a good relationship with the home and could visit their relative at any time. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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 and 18 The home is not complying with their written complaints procedures. There appears to be reluctance on the part of the service to provide staff with abuse awareness training to ensure service users are protected from any form of abuse. EVIDENCE: Since the last inspection the CSCI has received one complaint that has been passed to the registered provider to investigate. The timescale for responding to the complaint has not been met. The Commission has written to the registered provider regarding this matter. There is a detailed complaint procedure and an abridged format is on display in the home. Service users were asked whom they would make a complaint to if they were unhappy about the care they received. Several service users did not know who they would complain to while other service users stated they would complain to their family. A requirement was made at the last inspection that care staff must receive training on the protection of vulnerable adults. This requirement has not been met. The manager advised that staff have been put forward for the next available course in September. This information directly conflicts with the information provided at the last inspection when the inspector was informed that the home had been provided with details of a course in January 2005. In view of the comments made by service users there is a clear need for staff to Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 15 understand what constitutes abuse and what action must be taken to report any concerns regarding the protection of vulnerable adults. Service users names have been include in the electoral register and have the choice of a postal vote or being taken to the polling station. Information on advocacy services is available in the service user guide. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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, 21, 22, 23, 24, 25 and 26 The service is generally improving the standard of accommodation. The home needs to continue with the improvement agenda and replace the carpet in the hallway and one bedroom identified during the inspection. EVIDENCE: The inspector viewed all areas of the home and found it was clean, comfortable and free from offensive odour. The grounds were in need of attention, in particular to the garden areas to the side of the property. This area was overgrown and if appropriately maintained would be an asset to the home and provide service users with a safe outdoor area in the summer months. Discussion with service users confirmed they were satisfied with the standard of accommodation in their bedrooms. There are ten single bedrooms and three double bedrooms. The shared rooms all having appropriate screening to ensure privacy to service users. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 17 The home is upgrading the bathing facilities and is currently replacing one bathroom with a walk-in shower room to meet the bathing needs of service users. The inspector is aware the home is currently seeking advice with Wiltshire infection control service with regard to the purchase of a new sluice. The accommodation is all on one level enabling service user access to all areas of the home. There is a hoist in place in the bathroom to assist with the safe moving and handling of service users. The communal living area has recently been decorated and a new carpet fitted, which has greatly improved the standard of communal living accommodation. There are further improvements required to replace the corridor carpet. The manager stated this would be completed following the completion of building work in the bathroom. Service users commented that they were happy with the standard of accommodation. Service users had a choice of furniture and fittings provided. One service user commented they brought all their personal furniture with them and the relatives of the service user confirmed their room was decorated to their choice prior to them moving in. The inspector found that one bedroom carpet needed to be replaced and three commodes were rusty and also needed to be replaced. These were brought to the attention of the manager during the inspection. Laundry facilities are sited in a separate area adjacent to the main building. Service users confirmed their laundry is washed and returned promptly. Policies and procedures for reducing the risk of infection were in place at the home. The inspector was informed there are no outstanding requirements from the environmental health service. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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 low numbers of staff employed on each shift means only the basic needs of service users are being met at the home. There is evidence to demonstrate the home has supported staff in achieving NVQ level two training, though staff are struggling to put into practice what they have learnt. Safe recruitment practices are not being followed at the home. EVIDENCE: There were thirteen service users living at the home on the day of the inspection and the home had three vacancies. Examination of the rota and discussion with staff confirmed there were two members of staff on each shift. The numbers of staff have been reduced since the last inspection. The manager stated this was at the direction of the registered provider due to a decrease in the number of service users currently being accommodated. The decrease in the number of staff employed on each shift is having an impact on the daily lives of service users. The inspector arrived at the home at 08.10am and the two staff on duty had to prepare breakfast and assist service users with personal care. This resulted in service users being left at the breakfast table unsupervised and waiting for their breakfast while staff assisted other service users still in bed. Discussion with staff confirmed the reduction in staffing levels is having an impact on the quality of care they can provide and their ability to spend time with service users. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 19 This has already been highlighted in previous standards where the low levels of staff have resulted in a lack of recreational activities, a lack of care plan reviews and no clear direction or focus on outcomes for service users. The manager stated the home cannot employ agency or bank staff. Additional staff employed at the home includes a domestic assistant 10am to 2.00pm and a cook from 10.am to 2.00pm. Discussion with staff and examination of training records demonstrate all but one member of staff have completed NVQ level 2. The challenge for the service and staff is in the ability to transfer the knowledge gained into providing an improved service that focuses on outcomes for service users. Records demonstrated staff had received additional training in first aid, food hygiene and manual handling. Induction training is provided to new staff in line with TOPSS accreditation. Details of the induction training were available for inspection. There has been one member of staff employed at the home since the last inspection. Examination of the recruitment records found the home had not followed safe recruitment practices. The home had failed to obtain a second written reference although a criminal records bureau check had been obtained. A birth certificate, marriage certificate and passport to support proof of identity were not available for inspection. The manager stated these records had been taken away to be copied. No photographs of staff were held at the home. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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) 31,33,35 & 38 The home is not being effectively and safely managed or run in the best interests of service users. The service continues to have difficulty in meeting requirements made from previous inspection reports. Safe working practices are being followed in the home with the exception of up to date risk assessments. EVIDENCE: The registered manager has extensive experience of working with older people having worked at the home for twenty years and being manager of the home for seven years. The manager confirmed she has completed NVQ 4 in management but she is clearly struggling to put into practice the knowledge and skills learnt on the course The manager stated that she is under pressure and has to work long shifts to cover care duties. The manager reported she has little or no time off rota to effectively manage the home or provide supervision to staff. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 21 The manager has confirmed that she has shouted at service users on one occasion. This behaviour falls far short of the standards expected from a registered manager and does not provide staff with the appropriate model of care to meet service users needs. As previously stated this matter has been subject to a vulnerable adult investigation and is being pursued by the Commission. The home has implemented a quality assurance survey that has been completed by the relatives of service users. The outcome of the survey has been collated but not made available to service users their representatives or stakeholders. Requirements continue to be outstanding from previous inspection reports. The manager confirmed the home does not act as agent for service users benefits or hold any money on their behalf. Examination of records and discussion with staff indicate safe working practices are being observed on the home. Records indicate fire safety drills are being held every three months and training is proved for staff. Periodic routine safety checks to lighting and fire alarms systems are being completed. Electrical and gas safety checks are being carried out at the required intervals. Environmental risk assessments had not been reviewed in the past twelve months and several had not been reviewed since November 2003. There was a low level of recorded accidents in the home. Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 3 3 2 3 2 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 1 1 x 2 x 3 x x 2 Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 23 yes 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. 2. Standard 3 4 Regulation 15(1) 18(1)(c) (i) Requirement The registered person must ensure each service user has a plan for daily living The registered person must ensure staff training in managing difficult and challenging behaviour This was requirement at the last inspection The registered person must ensure staff receive training in the care needs of older people and the ageing process. The registered person must ensure service users care plans are reviewed each month, or earlier if the needs of the service users change. The registered person must ensure service user risk assessments are reviewed at least once a year or ealier if the risk to service users changes. The registered person must ensure that service users at risk of developing pressure sores have the appropriate equipment in place to reduce any risk to the service user. The registered person must ensure all medication received at Timescale for action 01/06/05 01/09/05 3. 4 18(1)(c ) (i) 15(1)(2) (b) 01/09/05 4. 7 01/06/05 5. 7 13(4)(c ) 01/06/05 6. 8 13(4)(c ) 01/06/05 7. Bluebells 9 13(2) 11/04/05 Page 24 D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 8. 10 & 31 12 (5) (a)(b)(4) (a) 16(2)(m) (n) 9. 12 10. 12 12(4)(b) 11. 13 16(2)(m) 12. 16 22(4) 13. 18 18(c)(i) 14. 19 & 24 23(2)(b) (c) 18(1)(a) 15. 27 the home is recorded. This was an immediate requirement made at the inspection. The registered person must ensure service users are treated with dignity and respect at all times. The registered person must consult with service users on what activities they would like provided at the home and after consultation provide service users with a weekly timetable of activities that will be offered. The registered person must ensure the religious needs of all service users are met at the home The registered person must ensure service users are provided with opportunities to maintain links with the local community. The registered person must ensure all complaints are investigated within the timescales specified in the homes complaints procedure. The registered manager must ensure staff receive training on the protection of vulnerable adults. Any training must be in line with Wiltshire and Swindon vulnerable adults procedures. In the interim staff must be advised on what constitutes abuse and what action must be taken to report any suspicion of abuse This was a requirement at the last two inspections. The registered person must replace the carpet in the service users bedroom identified during the inspection. The registered person must provide the Commission with an action plan on how it will ensure 11/04/05 01/06/05 01/06/05 01/06/05 11/04/05 01/06/05 01/07/05 01/06/05 Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 25 16. 29 19(4)(a) (b)(i) 17. 26 16(2)(j) 18. 33 24(1)(a) (b) 19. 38 13(4)(a) (c) staffing levels are increased. The action plan must ensure staffing levels are increased by 01/06/05. The registered person must ensure all records specified in Schedule 2 of the Care Homes Regulations 2001 are available for inspection. The registered person must provide sluicing facilities at the home This was a requirement at the last two previous inspections The registered person must seek the views of service users, relatives and stakeholders regarding the quality of care provided at the home and make the outcomes of the survey availabe to service users and other intersested parties. The registered person must ensure all environmental risk assessments are reviewed a minimum of once every twelve months or earlier if the risk has changed. 01/06/05 01/08/05 01/09/05 01/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Bluebells Refer to Standard 12 16 19 24 19 Good Practice Recommendations The registered person should consider employing an activities coordinator. The registered person should ensure all serivce users are fully aware of the homes complaints procedure. The registered person should replace the carpet in the corridor at the entrance to the home following completion of work on the new bathroom. The registered person should replace the three commodes identified during the inspection. The registered person should ensure the garden area is D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 26 6. 31 maintained to provide a safe area that can be used by service users. The registered person should ensure the manager is allocated sufficent time off the rota to effectively manage the care home Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection Suite C, 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 Bluebells D51_S3169_BLUEBELLS_V220089_110405 Stage 4.doc Version 1.20 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!