Inspection on 24/09/07 for Miranda House Nursing Home

This inspection was carried out on 24th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Miranda House Nursing Home 29/07/10

Miranda House Nursing Home 25/03/10

Miranda House Nursing Home 06/04/09

Miranda House Nursing Home 06/10/08

Miranda House Nursing Home 15/09/06

Miranda House Nursing Home 24/02/06

Miranda House Nursing Home 08/06/05

Miranda House Nursing Home 01/02/05

Miranda House Nursing Home 21/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH Lead Inspector Tim Goadby Unannounced Inspection 24th September & 8th October 2007 09:10 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 Miranda House Nursing Home DS0000015930.V346979.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. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Miranda House Nursing Home Address High Street Wootton Bassett Wiltshire SN4 7AH 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) 01793 854458 01793 853951 qualitycarewilts@aol.com Caring Homes Limited Mrs Gillian Gray Care Home 68 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (68), Mental disorder, excluding learning of places disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (68) Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons less than 45 years of age may not be accommodated. No more than 2 persons not less than 50 years in receipt of day care at any one time. Where the total number of persons accommodated exceeds 43, a maximum of 4 additional persons per week may be admitted during the following period 08/12/2005 to 26/01/2006 15th September 2006 Date of last inspection Brief Description of the Service: Miranda House provides accommodation and care with nursing for up to 68 adults. These may be people with dementia or other mental health problems. The homes registration conditions enable it to offer a place to anyone over the age of 45, although the majority of service users tend to be older people. The home is therefore inspected using the standards for this group. The service is also able to offer two day care places for people, aged 50 and over. The home was sold earlier in 2007 to Caring Homes Limited. The registered manager is Mrs Gill Gray, who has been in this role since 1998. Miranda House is in Wootton Bassett, near Swindon, Wiltshire. It opened in 1996, and was extended in 2005. The purpose built accommodation is on two floors, with passenger lifts between them. Most bedrooms have en-suite toilet facilities. Three double rooms are available. The rest are singles. Baths and showers are provided throughout the building. There is also a range of communal space, including lounges, dining rooms and a conservatory. Activity areas include a sensory room, which has a range of equipment to offer relaxing and calming experiences. There is a garden. The service also has several parking spaces at the front of the building. Fees charged for care and accommodation vary depending upon an individual service user’s assessed needs. The total amount charged includes contributions for nursing care, which do not have to be paid by the individual. Information about the home is available from the service itself, or by visiting the home’s website. Telephone enquiries and viewings are welcome. CSCI inspection reports can be seen at the home, and enquirers are also advised of how to access these via the internet. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in October 2007. It included a review of what we know about the home since its key inspection in September 2006. The main events during this period included a random inspection in March 2007. This was to follow up on issues identified the previous September; and in response to an anonymous set of concerns we received. The concerns were not substantiated when we followed them up. The home has notified us of significant events affecting service users. Some were also referred to the local process for safeguarding vulnerable adults. The sale of the home to a new provider, Caring Homes Limited, was completed in June 2007. This company operates a number of establishments in England and was already registered with the CSCI. The company was represented by its area manager on the second day of this inspection. In preparation for this inspection the home completed an Annual Quality Assurance Assessment (the AQAA). We also sent out surveys and had replies from nine relatives of service users and two members of the home’s staff. Two visits were carried out to Miranda House. The first was unannounced and involved two inspectors. The second was by appointment to conclude the inspection and give feedback. Only one inspector attended for this second visit. A total of 19 inspector hours were spent in the home. The visits included two hours spent observing the care being given to a small group of people in one communal area. These observations were followed up by discussions with staff and examination of records. Visits also included case tracking of other service users from all parts of the home; observation of practice; discussion with service users, visitors, staff and management; sampling a meal; checking medication systems and practices; sampling records on various topics; and a tour of the premises. The judgements made in this report are based on all of the evidence gathered, including the visits to the home. What the service does well: Service users maintain contact with their family and friends. Visits to the home are a regular occurrence. People appear confident in the visiting arrangements, and there is a relaxed and friendly atmosphere towards visitors. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 6 Relatives of service users are able to continue to participate in supporting their own family members, for instance by helping them at mealtimes. The service operates openly and transparently within Wiltshire’s procedures for safeguarding vulnerable adults. Due to the type of service users that Miranda House supports, there may be incidents due to disagreements or confusion amongst them. The home acts appropriately in recording and reporting all such events. This means that there can be a multi-agency approach to deciding upon the most appropriate action in response. Service users can be confident that the home takes suitable steps to uphold their welfare. The home provides a clean and comfortable environment which meets service users’ needs. The property is a modern building, with a recent extension. Most service users have single bedrooms with en suite facilities. There is a choice of communal areas on each floor. Various equipment is provided to meet specialist needs. Staff also have suitable facilities, including office space, break areas and an external smoking area. The service has a number of measures for auditing its own performance and identifying points for action. These include systems for consulting with all relevant groups of people, including service users and their relatives, as well as staff of the home. The quality assurance methods are new to Miranda House and are just beginning to bed in, but should offer a sound system for monitoring and developing the service over time. Our observation of the care provided in one part of the home over a two hour period showed examples of good practice, resulting in positive outcomes for some service users. We also saw similar examples elsewhere in the home. We observed warm, sensitive and respectful interactions between staff and service users. On balance we saw more of these than less good types. Feedback from some relatives of service users includes very positive comments. The experience of some families is that Miranda House provides a good quality of care for some service users with very complex needs. These relatives are grateful for the support that the home gives. They have confidence in the arrangements for keeping them informed about significant developments, and also have praise for the care that they witness staff giving. What has improved since the last inspection? An issue arose after the last key inspection regarding use of a lap strap as a form of restraint with a service user who is no longer at the home. The relevant professionals were not consulted, and indicated through a later multiagency review that they would not have consented to this step. As a result, a letter of concern was sent to the home advising them not to use this method again. The home have indicated that the practice will not be repeated. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 7 Service users and others are protected by fire safety arrangements. Records of tests, checks, practices and staff instruction are up to date. Action points identified at a fire safety inspection in January 2007 have been addressed. Suitable measures have been put in place to minimise infection control risks, so that service users and others are protected. The home is now aiming to review its approach again, and should refer to relevant guidance. Recruitment records show that all required checks are completed before new staff begin working in the home. This helps to protect service users by minimising any risk that unsuitable people will have access to them. All equipment which may present risks because it is damaged has been repaired or replaced. We saw one remaining example of an item in unsafe condition at our first visit. This was removed after we drew it to staff’s attention. A suitable replacement was available by our second visit. What they could do better: Our observation of the care provided in one part of the home over a two hour period identified some areas for improvement. Examples were seen of poor staff interactions with service users, which would be detrimental to the outcomes experienced by those individuals. We also saw that there was a general lack of awareness of what the experience for service users present in one space over a long period of time is likely to be. Service users are placed at risk by a failure to show effective assessment, planning and review of their care. The records we sampled show a range of deficits where important information has either not been recorded properly, or not at all. Service users’ records have not been reviewed and updated to reflect important events or changes in needs. This means the home has little or no evidence of the support it is providing in key areas, including the management of known risks to service users. The home plans to transfer all service user records to a new format soon, but in the meantime the current records must be maintained to a level that is fit for purpose. Some deficits in medication practice need to be addressed, to ensure the safety of service users. Some medicines may be given covertly, for instance by crushing tablets and/or giving them with food. If this is an appropriate course of action, permission must be obtained from the relevant GP and pharmacist. Agreement must be obtained for each individual drug, recorded in the care plan and reviewed regularly. Records we saw at this inspection are not sufficiently detailed or up to date. This requirement is unmet from previous inspections. Guidelines also need to be in place for use of medication which is prescribed ‘as required’. Objective definition of the circumstances in which such drugs Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 8 may be administered helps to ensure that they are given in line with the prescribers’ intentions, upholding the welfare and safety of service users. We found examples of medicines prescribed ‘as required’ but actually being given regularly, with no documented reasons to explain why this was so. The home must ensure that full records are maintained for any complaints received, including details of the outcome and any actions taken. We found that such records were not in place for all complaints received by the home since our last main inspection. This means that service users and others can not have full confidence in the arrangements for responding to their concerns. Service users who have money managed on their behalf by the home need these arrangements to be brought up to date, to ensure that they are properly protected. A delay in completing a changeover from arrangements under the home’s former ownership means that records were not up to date when we visited. Some money has also not yet been retrieved from an account operated by the previous owner. Practice in the use of bed rails needs to be managed safely to ensure that service users are protected from the risk of harm. We found evidence of unsafe practice at our first visit. Suitable steps were taken to remedy this before our second visit. But relevant records are still not fully in place or up to date. These need to be reviewed and brought into line with relevant guidance. The use and storage of substances which may be hazardous to health, such as cleaning materials, also needs to be managed more safely to protect service users. We saw some potentially hazardous substances left unattended in areas accessible to service users. This presents serious risks, due to the impairments of some of the service users at Miranda House. Service users need more opportunities for activities and engagement. Some relatives expressed serious concerns about practice in this area. We observed little evidence of input. Some service users received reasonable levels of engagement and interaction, but others had much less, especially when they were not as able to initiate this. Facilities available in the home were not observed to be in use. The home has activities staff and is aiming to develop its practice further, through additional resources and training. Miranda House has a good record of maintaining high ratios of staff to service users. But at this inspection a number of staff expressed concern that these have reduced since the change of ownership. Pressures have been heightened by increased staff turnover and a delay in being able to fill vacant posts. The provider acknowledged awareness of the issues arising from staff having to cover additional hours. Recruitment is ongoing. The home also intends to carry out a full review of staffing levels in all areas of service delivery, to ensure that these fit the needs of service users. This process should be carried out in consultation with all relevant persons, including the staff team. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 9 The new provider is focussing on training needs for the home. Service users would benefit from more staff developing knowledge and skills in key areas, such as the specialised care of people with dementia. Staff also need to develop confidence and competence in responding to questions or concerns that relatives or others may raise. The home needs to address issues of access and security, to ensure that service users are protected, with an appropriate balance between privacy and safety. Measures need to include suitable arrangements for service users’ bedroom doors which they wish to be kept locked. Spy holes in some bedroom doors, which enable people outside the room to look in, should be removed. Care should also be taken not to leave external doors open when areas are unattended, as this presents a risk of intruders gaining access to the home. Service users’ relatives and staff of the home have mixed views about how well Miranda House is caring for people. In particular, they have a number of anxieties associated with its recent change of ownership. The new provider needs to ensure that there are effective systems for informing and consulting with all relevant people, so that they are able to contribute to the ongoing development of the service. 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. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 10 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 Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed before they move into the home and receive written confirmation that these can be met. Standard 6 is not applicable to this service. EVIDENCE: The home is now using the Caring Homes procedures and format for the assessment and admission of service users. However, the overall process remains largely the same as under the previous ownership. Prospective service users are assessed by nursing staff. There is a ten page form which covers a range of areas. Relevant input is also obtained from the individual, where possible, their family or carers, and any professionals who have been involved. The form includes a statement about whether or not the home can meet the person’s needs. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 12 Most service users are visited by one of the nursing staff, in their own home, hospital or another care home. If people are transferring from another part of the country, then assessment may be through telephone discussions. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 13 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. Service users do not have all of their current abilities, needs and goals reflected in their individual plans. This may place them at risk. Some service users are placed at risk by failure to assess, plan and monitor fully for all their health care needs. Service users are placed at risk by failure to have clear guidance for all aspects of the management of medication in the home. Service users are usually treated with respect and have their privacy upheld. EVIDENCE: There were 63 service users living at Miranda House when this inspection took place. We looked at the care records for 12 of these people. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 14 There is a primary nurse for each area of the home. They have lead responsibility for care plans in their area. The first floor has more service users and is usually divided between two primary nurses. But it has been the responsibility of just one for a few months, due to a vacant nursing post. There are pre-printed care plans for some common areas. The relevant individual details can be entered into these. They are also expanded with further information, where necessary. Beyond this, for each service user more specific care plans are also devised, as indicated by people’s needs. The areas covered include physical health, mental state and behaviour, and engagement. Related risk assessments may also be put in place. People’s rights of access to care plans are set out in the home’s policy. This includes information about the arrangements if it is a service user’s representative who wishes to see the documentation. One relative’s survey form mentions events which they believe indicate that systems of recording and reporting are poor. We also found examples of deficits in all of the care records we looked at. Care plans are not being reviewed and updated regularly, especially over the period since June 2007 when the home changed owners. A number of documents in each file are not signed or properly dated, making it unclear how current they are or who is accountable for them. Assessments on topics such as dementia, nutrition, pressure areas and infection control are not all fully completed. Where these documents have produced a score indicating that a service user is at risk, they have not always led on to any suitable care guidelines. Monitoring of care is not always clear. For example, some service users’ folders contain charts headed as records of hourly care interventions, but are not being completed at hourly intervals. Injuries to service users are not always documented in their own notes and accident records. Treatments such as dressings have been applied with nothing on file to show who has done this or why. The home is due to change its format for service users’ care plans and other records, as part of its transition to become part of the Caring Homes group. Nursing staff were able to give verbal updates about current developments in service users’ care, where the record did not reflect these. Miranda House has input from a local GP, and a consultant psychiatrist. Other sources of health advice are accessed as necessary. People’s placement in the Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 15 home arises because of mental health needs. But most service users also tend to have significant physical health needs. Records show the contact which service users have with various health professionals. An anonymous allegation about inappropriate use of medication was received earlier in 2007. In response, our pharmacist inspector checked the handling of medicines in detail at the random inspection of March 2007. There was no evidence to support the allegation. Medication arrangements were checked again at this key inspection. The home has recently changed its pharmacist. It is now using a monitored dosage system. This means that medicines are dispensed in packaging that divides them according to when they are due to be given. All medicines are stored securely, including the additional measures required for some drugs. Appropriate records of receipts, administrations and returns are maintained. Service users’ medication administration record charts have their photos attached, to aid identification and reduce the risk of errors. There is some covert administration of medication; for instance, crushing tablets and/or giving with food, although this has reduced substantially. We found that the necessary information to support this practice is not in place. Some service users have consent documents on file, but these are not up to date. The pharmacist who signed them is not the one the home is now using. Some information refers to crushing tablets, but does not specify which ones. These guidelines have also not been reviewed and updated. Some service users are prescribed medication to be given ‘as required’. This means that staff have to make a clinical decision about when to use a drug. It is important to define the criteria for use as objectively as possible, so that the drug is given when it is indicated, and not more or less often. We found examples of drugs prescribed ‘as required’ which are recorded as being given every day. There is no guidance in service users’ records to show why these drugs are given, or why this is happening so regularly. Arrangements for privacy and dignity are set out in the home’s policies. There is a commitment to upholding service users’ rights in this area. If preferred, intimate personal care can be provided by staff of the same gender. The remaining double rooms have screens to provide privacy for each service user. Some bedroom doors in the original part of the building have spy holes which enable someone outside the room to look in. These are not required and the new provider has agreed to remove them. Some staff and relatives express concern that the products provided for use when carrying out personal care with service users are no longer as Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 16 appropriate since the home’s change of ownership. They state that supplies sometimes run out. Staff are also worried about further planned changes, in particular a switch from single use products to towels and flannels which will be washed and re-used. In response the manager acknowledged that there have been some difficulties in adjusting to a new approach. But she is confident that the arrangements remain suitable to meet service users’ needs. There will be flexibility, with a variety of products available as required. Feedback from relatives also includes specific concerns relating to the care of service users. Two responses mention issues such as failing to ensure that service users have access to important personal items such as watches, glasses and dentures, or losing these altogether. Another gives the view that personal care standards are poor. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 17 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 adequate but improving. This judgement has been made using available evidence including a visit to this service. Developments in support are needed to promote consistent outcomes for all service users. Service users are provided with some opportunities to undertake activities in line with their preferences and abilities. Further developments would enhance support in this area. Service users are able to maintain contact with family and friends. Daily lives for service users have an appropriate balance between necessary routines, and individual choice. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. But the effectiveness of mealtime support could be developed. EVIDENCE: Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 18 Part of this inspection included two hours spent observing the care given to a group of service users in a first floor lounge. Just over a third of these observations showed the sampled service users with signs of positive well-being, such as pleasure or active engagement. The remaining observations found service users to be passive, withdrawn or sleepy. No service users were seen displaying negative signs such as anger or distress. Service users were observed in various engagements. These included touching or adjusting their clothing and having a drink, a meal or medication. One service user occasionally reacted to another service user sat next to them, but otherwise service user interactions were very limited. Service users also engaged to only a limited degree with any visitors. Most engagement with other people for service users was when they interacted with staff. The amount of engagement for individual service users varied significantly and it correlated with the interaction they had with staff. That is, the service user with the most engagements in total also had the most staff interactions, and so on. In total, just under a third of observations showed service users interacting with staff. One service user did this in about half the observations, whereas the others did so on substantially fewer occasions. A mixed quality of staff interactions were observed with the sampled service users. Most were rated ‘Good’, but almost as many were ‘Poor’. A smaller number were ‘Neutral’. Examples of ‘Good’ interactions: • Taking the trouble to approach service users sensitively and make conversation with them, before carrying out a support task such as offering a drink or giving medication; Speaking to service users with appropriate respect; Not persisting with attempts to offer support, when the service user was clearly not responsive at that moment; Showing a service user verbal affection and physical contact, bringing a response of pleasure from them. • • • Examples of ‘Neutral’ interactions: • Carrying out a care task, such as helping with a drink, effectively - but without any additional communication; Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 19 • Ensuring that the service user was aware of their presence before intervening, but not extending this to any ‘social’ contact. Examples of ‘Poor’ interactions: • Not communicating with service users whilst supporting them. For instance, a staff member gave little attention to a service user they were helping with their meal and instead chatted to a nearby colleague; Waking a service user abruptly; Bumping into a service user, then handling the person to reposition their feet, without speaking to them about this; Not responding when a service user attempted to engage with staff, verbally or otherwise. In some cases staff didn’t notice the attempt. • • • Although some service users got more staff interaction than others, it was seen that some staff made a conscious effort to go round the room and try and speak with each service user. The television was on for the entire period. Only one service user glanced at it briefly on a couple of occasions. No other service users showed any sign of engagement with it. Some were sat in positions where they could not see the screen. Some staff were distracted by the television whilst supporting service users – for instance, watching it whilst helping someone with their meal. A fire alarm test took place during the observation. Service users were not given any warning beforehand, although staff did swiftly reassure them that it was only a test, once the alarm sounded. The room was very warm, which may have contributed to the sleepiness of a number of service users. Two surveys from relatives state very strongly that they feel service users are not provided with sufficient activity and stimulation. This was partly supported by what we saw. During the two hour observation in a communal area there were two main periods of activity. The tea trolley was brought round and all service users were offered a drink. This took about 15 minutes. Around 45 minutes later, staff began making preparations for lunch. They started serving the meal about 20 minutes after that. Some service users were still eating when the observation finished another 20 minutes later. There were no formal activity sessions during the observed period. Some service users received one-to-one attention, for instance with nail care. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 20 Facilities available in the home include a multi-sensory room, fitted with a range of special equipment. However, we did not observe this being used on these visits, although the manager reported that it remains a popular resource. Two part-time activities staff cover Monday to Friday between them, with a volunteer also present on one day. Activities staff have attended training on the provision of therapeutic activities for older people. One does more group work whilst the other concentrates on one-to-one input. The home is aiming to review its approach. It is planned to recruit more activities staff so that there can be one person per floor each day to lead on this. At present they have to divide their time between the two floors. New ideas to be implemented include ‘rummage boxes’ containing various items which will help to engage people in reminiscence and discussion. Service users’ relatives will also be asked to help in getting more life history information about each individual, including photos where possible. It is hoped that these initiatives will help care staff to engage with service users by providing interesting and relevant topics to stimulate conversation. The home is also considering getting some further training and advice for staff from the organisation Dementia Voice. Individual choice is facilitated wherever possible. People are able to personalise their own rooms by bring in items which are special to them. Previous service users have kept their own pets, where possible. Visitors are welcome to Miranda House at any time. Two relatives state in survey forms that they do not feel they are always kept informed of significant information about the service user they are related to. However, two relatives have the opposite view, saying that they are always kept well informed. A relative who was visiting the home when we inspected said that they call in regularly. They said they are satisfied with the care provided. They feel that they are told about any necessary information and also feel able to talk to staff if they have any concerns. Menus are drawn up on a four week cycle. They reflect the differing needs of the home’s service users. Specialist needs are supported, such as people with diabetes, or those with difficulties in chewing and swallowing. The kitchen is notified about the needs of new service users as part of the admission process. Lists of service users’ likes and dislikes are kept in the kitchen, so that these can be respected. Where necessary, alternative meals can be prepared. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 21 One relative expressed concern in their survey form that not enough fresh fruit is provided. Staff said that the budgets per meal have been reduced since the new owners took over. One of Caring Home’s audits focuses on arrangements for catering. Miranda House had such an inspection shortly before we visited. This identified some recommendations for change, and these have already been implemented. The home’s chef was also attending training in the first week that we visited. We observed meals being served on both floors and also sampled a cooked meal. The food was well prepared and tasty, and service users appeared to enjoy it. Care is taken over presentation, including for those service users needing to have their food pureed. Staff give support to service users where required. Some service users also have visitors who come specially to help them at mealtimes. The preparations for lunch in one first floor area began 20 minutes before the meal was served. When the meal started, some service users had to wait much longer than others to receive their food, especially any who needed staff support with eating. This appeared to be because there were more service users needing assistance than there were staff available to provide this. Future development plans include a review of the hours that the kitchen is staffed. At present the chef works from early morning until around 1 p.m. Caring Homes’ practice in its other services is to have a chef available between 7 a.m. and 6 p.m. The company believes that this will offer greater flexibility in providing service users with meals and snacks. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection, but practice needs to be supported by more effective record keeping. Service users are placed at some risk by deficits in the planning for management of needs associated with behaviour and mental state. EVIDENCE: There is a complaints procedure. This is on display in the main entrance hallway of the home. It is also incorporated into the Service User Guide. Contact details for the CSCI are included. One relative states that they do not feel concerns they raise are acted on. However, another relative states that they receive a good response if they have concerns. Records in one service user’s file referred to significant concerns raised by visitors in November 2006. When discussed with the manager, she was able to recall these and explain what action had been taken. But there was no record about this in the home’s complaints file. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 23 Another complaint in December 2006 did not have a recorded outcome. Again the manager was able to explain what had happened. An anonymous complaint about aspects of the service at Miranda House was received by the Commission in March 2007. This was passed to the home for their own investigation. Full and prompt replies were received, with no evidence to uphold the concerns raised. The home’s own findings were supported by a random inspection we carried out around the same time. Suitable procedures are in place for abuse and adult protection. These include information about the local multi-agency procedures. Miranda House supports service users who may present with disturbed or aggressive behaviour, associated with their mental health. The frequency of such issues varies. The home has gone through periods when there have been a cluster of such incidents, and other times when they are much rarer. When incidents have occurred, they have been recorded and reported appropriately. This has included referring some events under local multiagency adult protection procedures. The home has worked co-operatively and effectively within the required protocols to uphold the protection of its vulnerable service users. Suitable actions have been taken in respect of specific staff members if allegations have been made about their conduct. Guidelines are not all in place for service users presenting significant behaviour challenges. Records were sampled for a situation known to present risk management issues. Files for the relevant service users did not contain details about current issues or how these are being managed. This means that the home could not demonstrate how they are implementing protection guidelines agreed within multi-agency meetings. We raised these concerns at our first visit. Records had still not been updated when we returned two weeks later. Physical interventions may be required with some service users. All staff have received training in techniques approved for use in the home, and this instruction will also be provided to new employees. Comments from a relative that we met, and another relative in a survey form, mentioned that they feel staff cope very well with some difficult behaviours. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 24 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. Service users live in a comfortable and clean environment, suitable to their needs. However, their safety is not upheld at all times. EVIDENCE: Miranda House is a purpose built care home. Service user accommodation is on two floors, served by lifts and stairs. A security lock system is used on the doors to stairwells and exits, to reduce risk to any service users who are confused. There is a large garden to the rear of the property, and several off road parking spaces are available at the front. The home has a full time handyman. There is ongoing maintenance and redecoration for the older part of the property. Rooms are usually refurbished whilst they are vacant. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 25 Work on construction of two extensions, on either side of the original property, was completed in 2005. One of these is single storey. This increased the number of registered places to 68. The majority of service users have single bedrooms. Three larger rooms are available, so that the option to share is possible for anyone wishing to do so. Rooms are personalised to reflect the tastes of their occupants. People are able to bring in their own items of furniture and ornaments. The home provides a range of suitable equipment, such as adjustable beds. As well as increasing the number of bedrooms, the extension to the property provided additional communal areas, bathrooms and showers, staff office space and break areas, and storage space. There are lounges and dining areas on both floors. The ground floor also has a conservatory, and a sensory room. Miranda House has a garden, which service users can access when weather permits. Some space was lost to the building work, but the remaining grounds still provide a valuable resource. Work is needed to improve the area again, which was commented on by some relatives. The home is now looking for a new gardener to take this work on. All bedrooms have en-suite toilets and hand basins. Bathrooms and showers are also provided throughout the home. These include various adaptations and equipment suitable to the needs of service users. The home was clean and generally well maintained in all areas seen. There were no unpleasant odours in any part of the building. Three survey forms from relatives comment positively on the cleanliness of the home. Some relatives comment that they feel some new furniture is needed in parts of the home; for instance, replacement of older chairs. Smoking is not permitted within the building. Staff have been provided with a separate facility in the garden, well away from areas occupied by service users, and make use of this on their allocated breaks. There is no odour or discolouration to indicate smoking in any part of the home. There are appropriate systems in place for the management of laundry. All items are washed on site, and Miranda House employs its own staff to carry out this task. Extra staff were taken on when the home increased in size. Miranda House has two laundry rooms next to each other. This provides space for ironing and pressing of items. The home has four washing machines and three tumble driers. The equipment and practices for handling laundry are suitable for reducing the risks from any items which may be soiled or infected. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 26 Laundry staff are kept informed of any service users with known infection risks, so that their items can be handled separately. The kitchen and food storage areas were seen to be clean and hygienic. At our first visit we found one piece of equipment in a service user’s room which was in an unsafe condition. This was removed when we drew attention to it. There was a suitable replacement in use by our second visit. We also saw a potential security issue arising from the actions of staff in one part of the building. We discussed this in feedback with the manager. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff, but the home has experienced recent pressures in maintaining this. Service users are protected by systems for recruitment and selection of staff. EVIDENCE: Miranda House is registered to provide nursing care. This means that a qualified nurse is on duty at all times. Staff are allocated to both floors. Each shift on each floor is led by at least one nurse. They are supported by senior carers and other care staff. Staff are deployed throughout the building to ensure appropriate ratios for service users in each section. In the absence of the home’s own nursing staff, cover is arranged through agencies. The home also employs staff for other key tasks, such as catering, cleaning, laundry and maintenance. An anonymous complainant to the CSCI in March 2007 raised concerns regarding the suitability of the staff team. These were not upheld by the home’s own investigation, or by the findings of our inspections. There is a mix of age, gender and ethnic origins amongst Miranda House’s employees. All Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 28 staff that we met have suitable English language skills, enabling them to communicate effectively with service users and colleagues. Four comments from relatives before this inspection again challenged the quality of carers, with some also mentioning concerns about the trustworthiness of some staff. However, four relatives made positive comments about staff, stating that they understand the needs of service users and give them lots of care and attention. A service user said that they find the staff nice, friendly and helpful. There has been increased staff turnover during 2007, with some employees deciding to leave following the change of ownership. The home was below its establishment level for care and cleaning staff at the time of this inspection. Efforts are ongoing to recruit for vacant posts. Cover is maintained by staff working additional hours, and some use of agency employees. Staff express concern about the pressures created by recent turnover. They report having fewer numbers on duty per shift, with an impact on their ability to respond to the needs of service users. This is heightened because so many service users need two staff for all interventions. Part of this inspection included two hours spent observing the care given to a group of service users in a first floor lounge. During this period there were up to 13 service users in the area. Some moved in and out, but most were present the whole time. Numbers of staff in the area varied between one and four. This included several different people as staff came and went. There was one brief period with no staff present, but for no more than a minute. The home is about to undertake a thorough review of its staffing levels across all departments, to ensure that these fit the needs of the service. Caring Homes has its own training company with a regional co-ordinator for the area including Wiltshire. A member of staff within Miranda House will also be allocated the role of co-ordinator for the home itself. This in-house training company provides a range of services. These include monitoring of training in each home; providing sessions on statutory topics; ‘train the trainer’ courses on subjects such as moving and handling, which enable staff to cascade learning to others; booking trainers for specialist courses; and analysing local factors such as suitable venues and specific training needs for individual homes. At the moment most of the training organised by Caring Homes does not take place locally. However, the company owns another home in Chippenham, so links can be made between Miranda House and that service. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 29 There is a training matrix which shows what each staff member has done and what they still need to complete. Progress on training is monitored and reported on every month. Training records also show which staff are allocated leads on specific areas, such as moving and handling or fire safety. Care staff complete an induction programme in line with the national standards for social care workers. They then have the opportunity to go on to study for National Vocational Qualifications (NVQs). The percentage of care staff with NVQs at Level 2 or above has been affected by recent turnover, but remains at around 50 . More staff are currently working towards these awards. Training due to take place shortly includes health and safety, safeguarding vulnerable adults, palliative care, and equality and diversity. There will also be further training in dementia care awareness, with a particular focus on providing activities and engagement. The home has obtained some funding from the Skills For Care body which will help to access local courses. There are also company systems for individual supervision and appraisal of all staff. Senior staff of Miranda House are due to receive training so that they can implement these systems. Two relatives comment that they feel staff lack knowledge in some key areas. These concerns stem from a poor response received from staff when relatives ask questions or raise concerns. We checked three sets of staff records for people who have been recruited within the last six months. These all show that the required checks are carried out before staff begin working at the home. Caring Homes has its own recruitment policies and systems, which Miranda House is now using. The home advertises regularly in various local outlets. The company also has access to possible recruits from overseas through use of an agency. The home can offer some staff accommodation which may help to attract such applicants. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 30 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. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Service users are placed at risk by failure to maintain updated systems for recording management of their money. Service users are placed at risk by failure to manage all aspects of health and safety in the home effectively. EVIDENCE: Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 31 The home’s registered manager is Mrs Gill Gray. She was manager of the home under its previous ownership and has remained in post following the sale to Caring Homes Limited in June 2007. Mrs Gray is a qualified Registered Mental Nurse, with long experience caring for elderly people with mental health problems. She has also attained the Registered Managers Award. Around the time of this inspection she was attending various courses arranged by the home’s new provider. These included sessions on dementia awareness and the Mental Capacity Act. A deputy, senior nurses and senior carers support the manager in her role. Miranda House also employs an administrator. The home is now part of the Caring Homes Limited group. The area manager visits Miranda House on average once a week. This includes carrying out the monthly visits and reports on the conduct of the service which are required within Care Homes Regulations. She also provides supervision to the registered manager at least once a month. The company has various systems for auditing the home and for consulting about its quality. Audits are done at varying frequencies on a range of topics. Areas audited include health and safety, catering, medication, marketing, records and administration. Full scale audits of the home will take place at least twice a year, and more often if findings indicate this is necessary. Service users, relatives and staff are sent questionnaires to complete once or twice a year. The first such exercise has been carried out and the home was about to collate the results. Staff and relatives express anxiety about the impact for Miranda House of being taken over by a larger organisation than its previous owner. Both groups feel that, after some initial reassurances, they have not been kept sufficiently informed about developments and future plans. A common fear is that ‘economies’ will be made, to the detriment of the care of service users. Staff feel that they have good support from senior staff within the home, but at present are less confident about the wider organisation. Caring Homes’ area manager acknowledged that there is work to be done on addressing such anxieties. Meetings have been held with staff and relatives. More are due to take place. The company plans to have relatives’ meetings every month, and vary the time of these to give as many people as possible opportunities to attend. Staff Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 32 meetings will also be monthly for various groups, feeding into a ‘Heads of Department’ meeting which will discuss any issues arising from each area. Service users’ meetings also take place once a month, led by activities staff. There are about six service users who are able to engage with these sessions. Meetings are minuted so that people not able to attend can see what was discussed. Audits and meetings both lead to action plans on points arising. Progress on goals is monitored by the area manager through her supervisions with the registered manager. Miranda House also produced an Annual Quality Assurance Assessment (the AQAA) for us as part of this key inspection. This document sets out the home’s own assessment of how it is performing in all areas of service delivery. It identifies various areas for further improvement. These include reviewing all service users’ care records, providing more staff training and increasing the amount and variety of activities for service users. The home attempts to limit direct involvement in the management of service users’ money. Most people have their affairs managed by relatives or other representatives. If any amounts are held in safekeeping on site, there are secure arrangements for this. The transfer of service users’ money and records from the previous system is not complete. Some money has not yet been withdrawn and reallocated from an account operated by the former owner. Records were made in August 2007 about amounts carried forward, but have not been updated since. There are separate records about money due from service users’ personal allowances since that point, but these have not been cross-referenced to the main record. At the time of this inspection one part of the home’s roof was unsafe due to some loose tiles. The area around this was taped off to prevent access. Sometimes the home takes steps to prevent service users entering the bedrooms of others, especially when people are particularly frail. Advice was given at the previous inspection that, if this is assessed as being necessary, bedroom doors must be fitted with suitable locks. These must be of a type which enable people inside a room to exit safely without the use of a key. At our first visit we found a room where the handle had been fitted so that it opened by turning upwards, opposite to the usual direction. We advised that this method is not suitable, as it is likely to confuse people and may place them at risk if they are not able to work out how the door opens. The handle had been adjusted back to normal operation by our second visit. A number of service users have been assessed as needing bed rails to maintain their safety when they are in bed. Records relating to this practice have not Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 33 been kept up to date. In the files we saw, signed evidence of consent is in place, but often dates from around two years ago and has not been properly reviewed and updated since. This consent is not accompanied by a suitably detailed risk assessment, in line with available guidance. At our first visit we found examples of unsafe practice. One service user had a chair pushed up against the bed to try and prevent them from falling, with no bed rails in place. Another service user had got their leg trapped between the bed and bed rail in July 2007. When we checked this service user’s room we found that rails had been fitted to a normal divan style bed. There was still a large gap between the bed and the rail, presenting a serious risk of entrapment. The service user’s records were not complete in the documentation required to support the use of bed rails, and had not been reviewed or updated in response to the incident in July. At our second visit we saw that steps have been taken to provide more suitable equipment, making the situation safer for both these service users. However, the relevant records were still not updated. We saw some examples of potentially hazardous substances, such as cleaning materials, which were left unattended in areas accessible to service users. Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Each service user’s plan of care and associated records must set out the actions to be taken to meet all their needs, and must be updated to reflect changes. Timescale for action 31/10/07 2 OP8 12-1 14 15 13-2 17-1a Sch3-3m 13-2 Service users must have all 31/10/07 healthcare needs fully assessed, with suitable guidance to address any identified risks. There must be clear guidance on the criteria for administration of medication prescribed on an ‘as required’ basis. The GP and pharmacist must authorise each medication that is crushed or altered in any way before administration, to ensure its safety. Unusual or covert administration must be regularly reviewed and documented. (Timescale of 31/05/07 not met) Records must be kept of all complaints and the actions taken by the persons registered in response. Such records must be DS0000015930.V346979.R01.S.doc 3 OP9 31/10/07 4 OP9 31/10/07 5 OP16 17-2 Sch4-11 17-3b 08/10/07 Miranda House Nursing Home Version 5.2 Page 36 kept in the home and available for inspection at all times. 6 OP18 12-1 13-6,7,8 There must be clear, objective guidelines for staff management of potential disturbed behaviour from service users. This part of Regulations also applies to the above Requirement. The persons registered must establish suitable systems for the handling and recording of service users’ money. The persons registered must ensure that documented risk assessments, and written evidence of consent, are in place for any use of bed rails. Substances which may be hazardous to health must be stored securely at all times when not in use. 31/10/07 6 OP18 17-1a Sch3-3p,q 16-2l 30/11/07 7 OP35 30/11/07 8 OP38 12-1,2,3 13-7,8 31/10/07 9 OP38 13-4 08/10/07 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 2 Refer to Standard OP7 OP12 Good Practice Recommendations All service user records should be dated and signed, so that it is clear when they were made and who did so. The home should proceed with its planned developments in providing activities, to better meet the needs of service users and address the concerns of relatives. The spy holes in bedroom doors in the original part of the DS0000015930.V346979.R01.S.doc Version 5.2 Page 37 3 OP14 Miranda House Nursing Home building should be removed, to ensure greater privacy for service users. 4 OP15 Arrangements for mealtimes should be reviewed, so that all service users receive suitable and timely support in line with their assessed needs. Evidence of consent from relatives and other professionals should be renewed at suitable intervals, such as annually, to show that it remains relevant. The home should ensure that it refers to infection control guidance for care homes issued by the Department of Health in June 2006 and available via their website at www.dh.gov.uk. This should help to ensure that all personal care practices are suitable. The home should proceed with its proposed review of staffing levels, involving all staff in this consultation. The staff training programme should continue developing to include more topics relevant to the needs of the home’s service users. The new providers should ensure that they take all suitable steps for effective consultation with service users, relatives and staff. This will enable sharing of information and help to involve all relevant persons in the ongoing development of the home. Suitable locks should be obtained for service users wishing to have these on their bedroom doors. This will ensure an appropriate balance between privacy and safety. Risk assessments regarding use of bedrails should be in line with the advice in guidance issued by the Medicines and Healthcare Products Regulatory Agency (MHRA) in December 2006 and available via their website at www.mhra.gov.uk. 5 OP18 6 OP26 7 8 OP27 OP30 9 OP33 10 OP38 11 OP38 Miranda House Nursing Home DS0000015930.V346979.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Bristol Area Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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