Inspection on 09/07/08 for The Bakewells

This inspection was carried out on 9th July 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

The Bakewells 15/06/07

The Bakewells 08/12/05

The Bakewells 03/05/05

The Bakewells 02/11/04

The Bakewells 09/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE The Bakewells 102 Junction Road Deane Bolton Lancashire BL3 4NE Lead Inspector Grace Tarney Unannounced Inspection 9th July 2008 09:30 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 The Bakewells DS0000009282.V368140.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. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Bakewells Address 102 Junction Road Deane Bolton Lancashire BL3 4NE 01204 655772 F/P 01204 655772 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) Mrs Helen Bailey Morgan Mr Andrew Philip Morgan Mrs Helen Bailey Morgan Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number (25), the home can provide care and accommodation for up to 25 Older People (OP) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 15th June 2007 Date of last inspection Brief Description of the Service: The Bakewells provides personal care and support for up to 25 older people both male and female. One of the owners is also the manager. It is a large, extended detached house set in beautiful gardens. It is situated in a residential area, approximately 2 miles from the centre of Bolton. The home is accessible by public transport and is close to local amenities. There are two floors, with a lift to the first floor. The home has 21 single bedrooms, 10 of which have an en-suite toilet, and 2 double rooms. There are 2 dining rooms and 3 lounges on the ground floor. Toilets and bathrooms are provided on each floor. A copy of the latest inspection report is displayed in the entrance hall. The current weekly fees are £412.00 per week regardless of the room occupied. The home provides basic toiletries for the residents and additional charges are made for hairdressing, private chiropody services, personal magazines and newspapers and trips out of the home. This information was received on the 9th of July 2008. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The home was not told that this inspection was to take place although many weeks before the inspection, questionnaires (comment cards) were sent out to the residents, their relatives and the staff. The questionnaires asked what people thought about the care and quality of the service provided. 3 were received from relatives, 2 from residents and 4 from staff members. What they felt about the care and services provided is written in different sections throughout this report. Also before the inspection we (The Commission) asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they did at present, what they felt they did well and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we do. We spent 8 hours at the home and during this time we examined care and medicine records to make sure that the health and care needs of the residents were being met. We also looked all around the building to check if it was clean, warm, safe and well decorated. We also looked what the residents had for their meals. We also checked how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. How management check that the care and services that they provide is what the residents and their relatives want or expect and how the home manages the residents’ spending money was also looked at. In order to get further information about the home we also spent time talking to 3 residents, 2 visitor and 3 staff members. What the service does well: The manager makes sure that the staff only care for those people whose needs they feel they can meet. Relatives and residents feel that they are well looked after and they made the following comments: • I am very pleased with the care. • Residents are extremely well cared for. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 6 • • • If I ever had to go into care, the Bakewells is the one place I would choose. I am very happy with The Bakewells. The atmosphere in the home is light and airy encouraging; a home from home. The meals provided are varied and nutritious and the residents have a good choice of menu. People visiting the home are made welcome and can visit at any reasonable time. In order to protect the residents from harm, management make sure that they check people out properly and safely before offering them a job. Management make sure that the staff are given training so that they have the knowledge and skills they need to protect and meet the needs of the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 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. 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. People are assessed before they are admitted to the home and this gives an assurance to everybody, that a person is only admitted if the staff feel they can meet their needs. EVIDENCE: Before any resident was admitted to the home a senior member of staff from the home undertook an assessment of their needs. The assessment looks at what help and support the prospective resident needs in all aspects of daily life. The 3 assessments that we looked at gave enough information to show what the residents needs were. 2 residents told us that they had received enough information about the home to decide if it was right for them. Standard 6 does not apply. The home does not provide Intermediate Care. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 9 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. The care plans do not contain enough information to show how the residents are to be cared for. This puts the residents’ health and well being at risk. The system for handling medicines is not as safe as it should be. This puts the residents at risk of not receiving their medicines safely and correctly. EVIDENCE: Individual resident care records, (called care plans) were in place for each resident. The care plans of 4 of the residents were looked at. The care plans were not detailed and did not give clear instruction and guidance on how the care needs of the residents were to be met. The care plans that we looked at only identified some of the problems that the residents had. They did not show what the residents were able to do for themselves, thereby promoting their independence. The care plans for each resident were kept together in one clear plastic wallet and not easily available to read. They had to be taken out to read them. This led us to believe that they were not a true “working document”. Also the daily reports on the residents showing how they had spent their day/night were The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 10 recorded in a separate book and none of the report comments made any reference to the care plans. We found the system for reviewing the care plans confusing. There were instructions on the front of each care plan about how often they were to be reviewed but these instructions were not always followed. Reviewing care plans regularly and in detail is important so that any change to the residents’ care can be made known and acted upon. We also had concerns about the fact that staff were told by management that the last date of a care plan review had to be written in pencil and then rubbed out when the next review was done. This means that records of previous reviews are being destroyed. This is not good practice, as it does not show a true record of whether or when a care plan has been reviewed. The staff did not look at whether there was any risk or not in relation to the residents developing pressure sores. 1 resident was admitted to the home with pressure relieving equipment that was in use but there was nothing in her care plan to show if she was at risk and nothing to state why she had the equipment. The staff did write down how a resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. 1 of these risk assessments for moving and handling was done with the involvement of the residents’ daughter. That is good practice. Staff did comment that they would like to have more hoists and possibly a stand aid to help people who need a lot of assistance with moving around. We did not see a risk assessment document for assessing whether a resident was at risk due to problems with their diet or fluid intake. We discussed this with the manager who told us that she was in the process of introducing a new risk assessment form for nutrition. A standard statement on the care plan front sheets states that residents are to be weighed at least 6 monthly unless their condition needs it more often. There was nothing specific in the care plans that we looked at to show how often the residents were to be weighed. 1 resident was being weighed regularly every 2 months apart from 1 occasion when it was monthly and 1 when it was 3 monthly. There was nothing in the care plan to show us why this was happening and the staff member we spoke to could not explain the reason why. We discussed the issues of concern with the manager when she returned from her leave. She told us that she was aware that the care plans did need improving and that it was something that she was beginning to change. Whilst we were at the home we were shown the new documentation that the staff were going to use. The documents looked like they would be able to provide more detailed information about the residents’ needs and also what they could do for themselves. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 11 Inspection of the care files showed that the residents had access to health care professionals, such as dentists, opticians, district nurses and chiropodists. The following were some of the comments made by residents and relatives: • The residents are kept very clean. • I am very happy with the care. • They are all very nice. • They are very understanding and helpful. • I always receive the medical support I need. The way that the medicines were handled was not as safe as it should be. The home does not have a separate medicine room, however medicines are stored in locked cupboards on a corridor and the medicine trolley is secured to the wall when not in use. The keys were kept securely and identification photographs of each resident are kept with the medication administration records. Only staff trained in medication management deal with the medicines. Controlled drugs were being stored safely but not in a proper Controlled Drugs Cupboard. New legislation has been issued that now requires all Residential Care Homes to have a Controlled Drugs Cupboard. Previously this was only a requirement for Care Homes with Nursing. The manager told us that she would arrange for a Controlled Drug Cupboard to be installed. The following areas need putting right: • We saw a senior carer giving out a controlled drug without following the proper procedure. This could result in drug mistakes being made. 2 staff members must check the prescription together, check the drug, both go to the resident to see that it is administered to the correct person and then both sign the register. The carer giving out the drug must then also sign the drug sheet. • Handwritten instructions for medicines (Transcriptions) were not checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. • The homes’ staff had changed the prescription of 1of the medicines to an “as required” prescription. Staff must not change a prescription. They must refer the issue back to the prescribing GP. • Staff had handwritten a prescription that was incomplete. It did not state how much of the medicine was to be given. • The stocks of medicines in the top and bottom cupboards were not in any order. This is not good practice and could result in drug errors. • There were also large amounts of medicines that had been overstocked. Medicines were not being given in the date order that they had been dispensed from the pharmacy. This could result in out of date medicines being given. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 12 Staff were discreet when providing assistance to the residents. They spoke to the residents in a quiet and respectful way. Staff confirmed that the importance of ensuring privacy, respect and dignity is part of their initial training. The residents looked clean and comfortable and were suitably dressed. Comments made were: • Yes they do knock on my door but I may not always hear them. • They are all lovely. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 7 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice and control over their lives as far as they are able and enjoy the activities available to them. Residents are given a choice of well-balanced and nutritional meals. EVIDENCE: The residents that we spoke to told us that they can, more or less do as they please and that they are not made to do anything that they do not want to. The care plans however did not give enough information to show how the residents like to spend their day. 1 resident told us that she prefers to stay in her room for her meals and for most of the day. Whilst we were talking to her she had 2 visitors who came to her room. A part time activities person is employed at the home. We were told that she visits every 4 weeks and leaves enough activities for the residents to do for the following 3 weeks. Whilst we were at the home we saw the residents busy making paper windmills. They seemed to be enjoying themselves. What the resident has taken part in is written down in the activities folder. Activities include reminiscence sessions that are often trips down memory lane. The residents also have movement to music exercises every fortnight and a lady comes in every week to give aromatherapy sessions. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 14 A list of events showing what is “going on” is displayed in the reception hall. The home also regularly produces a newsletter that gives news items about the home, the staff and the residents. It also contains items of general interest. The hairdresser was at the home during our visit and we were told that she visits every week. Staff told us that visiting clergy of different faiths visit the home and are always welcome. Comments received about the activities were: • There are usually activities that I can take part in. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were personalised with pictures, photographs and ornaments. Some had brought in their own furniture. We spoke to 2 visiting relatives who told us that they are always made welcome and are able to visit at any reasonable time. They were visiting their mother in the privacy of her room. Other visitors were seen in the lounge area. We saw 2 visitors taking their relative out for the day. We did not eat with the residents but saw what they were having for lunch. There is a very pleasant separate dining room that overlooks the front of the house and a smaller dining room off the lounge. The tables were nicely set with tablecloths, napkins and cruets. The meal served was home cooked, plenty of it, and it looked appetising and nutritious. The residents have a choice of food at breakfast, lunch and teatime. They have the main meal at lunchtime and the lighter meal in the evening. Inspection of the menus showed that there is always a choice of menu. Fresh fruit was available and hot and cold drinks were served throughout the day. We were told that none of the residents in the home needed any special diets for religious or cultural reasons. Comments from relatives and residents were: • They provide a varied menu. • The residents are very well fed. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel able and know how to complain, and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents. EVIDENCE: A complaints procedure was in place and was displayed in the reception area. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. No complaints have been made to us or to the home since the last inspection. Training in the protection of vulnerable adults has been undertaken by most of the staff and is ongoing. The manager also confirmed this in the AQAA form that was sent to us. Records of training were kept on the training file and in the individual personnel files. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in suitably adapted, clean, comfortable and very pleasant surroundings EVIDENCE: The home is a large detached and extended property set in beautiful gardens. Accommodation is provided on two floors and can be reached either by a lift or stairs. Downstairs there are 3 lounges and 2 dining rooms. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were close by to bedrooms and lounge areas and had aids and adaptations to assist the residents. Some of the bedrooms also have en-suite toilets. We found that a hazardous caustic substance had been left out in one of the bathrooms. The senior care assistant removed the caustic substance immediately. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 17 We looked at most of the bedrooms. They were clean and warm and were decorated and furnished to good standard. We saw that the handyman was in the process of decorating some bedrooms. We saw that some of the bedrooms were without locks on the doors. We discussed this issue with a senior carer who told us that most of the residents did not want one. We saw that 1 of the upstairs windows had a broken window restrictor. This puts the residents at risk of harm. Management agreed to fix a new restrictor on as a matter of urgency and we received confirmation that this had been done within the week. Most of the radiators throughout the home were suitably covered except for a small radiator in the lounge. To reduce the risk of residents being harmed by hot radiators they need to be protected. The home was clean and free from offensive odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. This is to reduce the spread of infection. When asked if the home was fresh and clean comments from residents were: • Always. • No smell of urine. The laundry is situated in the basement. It had enough equipment to provide an efficient laundry service. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by experienced staff that are suitably trained and safely recruited. EVIDENCE: Inspection of the duty rotas and a discussion with the staff and residents showed that overall there was enough staff on duty over a 24-hour period to meet the needs of the residents living at the home. Comments from some staff did show however that they felt at some busy times they could do with extra help. Some staff felt that the cook should work longer hours so that the care staff did not have to deal with the serving and sometimes cooking of the evening meal. These comments were discussed with the manager who told us that staffing is always kept under review. Residents and relatives told us: • The staff are very understanding and helpful. • No requests seem too much trouble. The information from the AQAA document sent to us, and the information that we looked at in the training file showed that 60 of the staff had obtained their NVQ level 2 or above in care. This is very good progress. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 19 The personnel files of 2 staff members were inspected to check how they were recruited. All were in order and these staff had been properly and safely employed. Induction training is provided for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. The information received from the AQAA document also told us about the training that the staff received. From a discussion with the deputy manager and inspection of the records we saw that a wide range of appropriate and ongoing training in moving and handling, dementia care, basic food hygiene, fire safety, health and safety, medicine management and other relevant topics are provided to staff at the home. Staff commented that they felt the induction programme covered everything they needed to know to do their job. They also felt that they received enough training. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good management team in place. They are continuing to look at ways to improve the care provided so that the residents’ welfare is protected. EVIDENCE: The Registered Manager of the home is a qualified nurse and has several years experience in the NHS as well as working in the field of caring for older people. She is a co owner of the home and has a management qualification. She keeps herself regularly updated with training, both in management and care issues. Staff told us. • On the whole I am happy with the way things are run at my place of work. • The manager gives good care and support to the residents. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 21 • • She is approachable and puts things right. A relative told us: All the staff and the management are the best in Bolton. Management have developed their own quality assurance system within the home so that they can regularly check on the care and facilities they provide. The manager is responsible for checking on lots of things within the home. Management also send out survey forms every year to the residents and relatives asking what they think of the services and facilities that they provide. The system for the safekeeping of residents’ money was good. Management only handle any “spending money” brought in by relatives. Individual records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any money for their relative. Information received from the AQAA sent to us showed that the homes’ fixtures, fitting and equipment are properly maintained and regularly serviced. We saw that regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Issues of concern in relation to the health and safety of the residents were in relation to the broken window restrictor and the hazardous, caustic substance that was left out in one of the bathrooms. The senior care assistant removed the caustic substance immediately. Management assured us that the window restrictor would be fixed as a matter of urgency and we were informed within the week that it had been replaced. The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 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 3 17 x 18 3 3 3 3 x x 3 2 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 3 x x 2 The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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(1) Requirement Every resident must have a detailed care plan. The care plan must detail how the residents’ needs in respect of health and welfare are to be met. Staff must make sure that any risk to the health and safety of the residents is identified and action to reduce or stop any identified hazard is then taken. Therefore risk assessments for nutrition and pressure sores must be in place. To ensure the safe storage of Controlled Drugs, a Controlled Drug Cupboard must be provided. To prevent any drug mistakes being made, the giving out of controlled drugs must be done correctly. To ensure the safety of the residents, staff must not change a prescription. They must refer the issue back to the prescribing GP. Staff must also ensure that if they do have to hand write a prescription that it is done DS0000009282.V368140.R01.S.doc Timescale for action 31/08/08 2 OP8 13(4)(c) 31/08/08 3 OP9 13(2) 31/10/08 4 OP9 13(2) 09/07/08 5 OP9 13(2) 09/07/08 The Bakewells Version 5.2 Page 24 6 OP25 13(4)(a) accurately in accordance with the GPs’ requirements and is checked with another staff member. To protect the health and safety 31/08/08 of the residents, management must make sure that the radiator in the lounge is guarded 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 OP8 Good Practice Recommendations Entries in care records should not be written in pencil that is later erased. Erasing an entry does not show a true record of whether or when a care plan has been reviewed. The care plans should show a clear instruction of how often a resident should be weighed. Nutritional screening on a regular basis should determine how often a resident is to be weighed. To ensure the accuracy of a handwritten transcription they should be checked with another member of staff, signed and countersigned. There should not be an overstocking of medications. This could result in out of date medicines being given. To prevent the possibility of drug errors stocks of medicines should be kept in some sort of separated order. 3 4 5 OP9 OP9 OP9 The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Bakewells DS0000009282.V368140.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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