Inspection on 07/11/05 for Warrens Hall Nursing Home

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Warrens Hall Nursing Home 23/05/09

Warrens Hall Nursing Home 20/08/08

Warrens Hall Nursing Home 11/06/07

Warrens Hall Nursing Home 05/06/06

Warrens Hall Nursing Home 09/05/05

Warrens Hall Nursing Home 10/01/05

Warrens Hall Nursing Home 14/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Warrens Hall Nursing Home 218 Oakham Road Tividale West Midlands B69 1PY Lead Inspector Mrs Cathy Moore/ Mrs Jean Edwards Unannounced Inspection 7th November 2005 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 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. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Warrens Hall Nursing Home Address 218 Oakham Road Tividale West Midlands B69 1PY 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) 01384 455202 01384 240068 Bupa Care Homes (AKW) Ltd, Central and West Mids Regional Office Pauline Starrs Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 29.7.04 may be accommodated in the category PD(E). This will remain until such time that the service users placement is terminated. 09/05/05 Date of last inspection Brief Description of the Service: Warrens Hall Nursing Home is part purpose built. The Original part of the home that served as the original care home is the converted farmhouse. This has been added to and converted to provide a 56 bedded home registered to provide nursing care. The home since the last inspection has been purchased and taken over by ‘BUPA’. The official ‘ handing over ‘ process from the former organisation ANS to BUPA took place early in November 2005. Warrens Hall is close to a golf course and adjacent to riding stables. There are pleasant views from the back of the home of open fields. Accommodation is spread over three floors (Including the bedrooms on Rowley) and has three distinct units known as Rowley, Malvern and Clent. The home offers 40 single single en-suite rooms, 4 single rooms without en-suite facilities and 6 double rooms. The home provides three lounges and two dining rooms. The home has two passenger lifts enabling residents’ access to all floors. The manager and a number of staff have worked at the home for a considerable number of years. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day between 08.00 and 14.25 hours. The inspection was carried out by two inspectors’. The inspection was carried out as the second of the homes’ two statutory inspections for this year. During the course of the inspection four resident files were examined, this included looking at their assessment of need documentation, care plans, food consumption and fluid charts. Eight residents’ and three staff were spoken to. The premises were partially assessed this included; the courtyard, lounges, dining areas, three toilets, two bathrooms, two bedrooms on the ground floor and four on Rowley unit. Medication systems and administration were observed and assessed. Health and safety and service documents were examined. Since the last inspection enforcement notices were served on the manager and former organisation. It is very pleasing that requirements contained within the notices have been met. Further, considerable improvements have been made to reduce requirements made following previous inspections. The home should be congratulated on their efforts and improvements made. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the last report dated 9 May 2005. What the service does well: The home since the last inspection has been sold and taken over by a new organisation- BUPA. This is a large organisation with home’ nationwide but also local offering a support network. The home is located in a pleasant residential area, which offers panoramic views to the rear. The manager and a number of care staff have been employed at the home for a number of years providing consistency of care. The manager and staff have worked hard to address outstanding requirements and make the necessary improvements in the home which demonstrates commitment and motivation. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 6 The home has a high rate of care staff who have achieved N.V.Q level 2 or above in care. The home itself is a large detached property. It is homely and welcoming. Several staff were heard singing whilst undertaking their duties which enhanced the atmosphere further. Staff were observed giving the residents’ choices an example being what they wanted for lunch and tea. A number of staff and residents’ were spoken to during the inspection. Many positive comments were made about the home. One resident said, “ The staff are kind”. One relative commented, “ This home is so very nice – always warm- staff are welcoming and friendly”. One resident said, “ When they brought me here and I saw my room I thought this is it, very nice. I thought to myself I am going to enjoy it here and I do”. The home actively encourages residents’ to have contact with their family and friends. Visitors are welcomed and made to feel comfortable. What has improved since the last inspection? The home since the last inspection has been purchased and taken over by BUPA a large national organisation. ANS the former owner had over forty other homes but none very local to Warrens Hall, their head office was in London. BUPA is also a large national organisation but has numerous other homes in local areas. The manager and staff will now have local support networks. Enforcement improvement notices due to record keeping were issued to the manager and ANS since the last inspection. It is extremely positive that the Commission for Social Care Inspection were able to confirm that the requirements included in the notices were met in August 2005. The manager and staff have worked extremely hard since the last inspection and the issuing of the notices, this confirmed by the number of requirement from last inspections being met. Record keeping, care planning and quality of general documentation has improved considerably. The former owner invested in substantial training for nurses and care staff in order for this to be addressed. The general environment has improved since the last inspection. The courtyard Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 7 has been re-paved. The windows in Rowley unit lounge have been replaced. Bathroom lights have been replaced with more effective ones. Infection control processes have also improved considerably. The laundry flooring has received the required attention, hand wash signs are now available in all high risk areas and as is protective clothing. Monitoring processes have improved considerably this directly having a positive effect on all areas within the home examples being; care delivery, care planning, record keeping and the general day to day running of the home. 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. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5. Each residents’ file viewed held a statement of terms and conditions or contract of residency. Residents’ moving into the home have had their needs assessed. Written confirmation that the home could meet their needs was included on all files viewed. Prospective residents and their representatives have the opportunity to visit the home prior to admission to assess the services provided by the home. EVIDENCE: Although standard 1 was not assessed the manager confirmed that due to the change of the homes’ ownership the statement of purpose and service user guide are to be revised, reprinted and issued to residents’. There was documentary evidence on the files that were assessed to demonstrate that the residents’ had been issued with a terms or conditions or Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 10 contract of residency. It was pleasing that these documents detailed the applicable room number and weekly fee pertaining to these residents’. It is positive that assessment of need documentation was available on the resident files assessed. However, these documents had not been signed or dated by the resident or their representative. It is pleasing that written confirmation was seen on the files assessed to demonstrate that they had been given written confirmation by the home that their needs can be met. Three residents’ spoken to confirmed that they or their chosen representative had visited the home prior to their admission. One resident said, “ My wife and son came to look at the home. They liked the people especially the head one. They jumped at the chance of me coming here, they knew this was the one!”. Another resident said, “ My sister came and looked at the home for me”. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents’ files viewed held a care plan which captured their health, personal and social needs. Residents; health care needs are being met. Medication systems require further development to ensure that they are adequate and safe. Residents’ feel they are treated with respect and their privacy is upheld. EVIDENCE: It is extremely positive that care plans/ care plan content/ care plan instruction and review has improved considerably since the last inspection. Care plans viewed contained instruction example of which are; personal care, pressure sore treatment and activity provision. There was written evidence to confirm that each resident or their relative had been involved or consulted about the care plans. There was ample evidence available to demonstrate that residents’ weights are being checked on admission and regularly thereafter. That nutrition and tissue viability assessment are being carried out regularly and that where risks have been identified these are reflected in the care plans. Risk assessments in Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 12 respect of falls and other concerns are also being carried out and are reflected in the care plans. It is very positive that nurses are monitoring residents’ after falls more diligently. There was good evidence of fluid input/ output monitoring, and recordings of change of position for residents’ who are at risk of tissue breakdown It is also positive that nurses are now asking for a second opinion from doctors where they are not confident with the first doctors assessment /diagnosis. This happened recently where a doctor was called to see a resident who prescribed antibiotics. The nurse was not happy with the residents’ condition and requested another doctor to visit the same day who sent the resident to hospital. Medication systems have improved but work is still needed in a number of areas for instance; it was noted that some medication records are handwritten there was no evidence however, that the information from the medication container had been verified as correct by two staff. One resident (ED) complained of a headache yet the nurse administering the medications did not offer her any pain relief although she was prescribed this on a ‘ when required ‘ basis. An eye preparation that had expired was still available within the home as were controlled drugs no longer needed. Money was seen to be stored in the controlled drug cupboard. Good practice in respect of medications was also observed. The nurses administering the medications had a good knowledge of the medication. Medication trolleys were not left unattended. Medication tots were available to measure liquids and there were no initial/ signature gaps on the medication records. Staff were observed during the inspection talking to residents’ in a manner that showed respect. Positive interactions were observed between staff and residents’. Toilet and bathroom doors were closed when in use. Records revealed that the preferred form of address had been determined in respect of each resident on admission. Review notes in respect of one new resident stated, “ ..Is very pleased with the care.. is receiving and the kindness and attitude of the staff”. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 Residents’ are actively encouraged to maintain contact with family and friends. Residents’ are helped to exercise choice and control over their lives. EVIDENCE: A visiting policy is available within the home. Visiting times are open and flexible. One resident said, “ My sister visits me quite often”. A number of visitors were seen and spoken to during the inspection. They confirmed that the staff always made them feel welcome. Advocacy information was available within the home. Residents bedrooms viewed held a number and range of personal belongings. One resident said, “ I have brought some pictures into the home and my radio”. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents’ and their relatives’ can be confident that their complaints will be listened to and taken seriously. EVIDENCE: The home has a written complaints procedure which is available within the home. The existing complaints procedure however, will be replaced with that of the new organisations’. The complaints procedure has not been produced in other formats which may be more suitable to the needs of some residents’. The Commission for Social Care Inspection received an anonymous complaint which was forwarded to the new provider to investigate. This was addressed thoroughly within 28 days. A complaint was received by the home which also was responded to within 28 days. The complainant it appears is satisfied with how the investigation was undertaken. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26. Residents’ live in a safe, homely environment. Assisted bathing and toileting facilities are available within the home but are lacking on Rowley unit. Improvements have been made regarding infection control measures within the home however, further development is required in respect of the laundry. EVIDENCE: The home felt warm welcoming and friendly. Much work has been addressed in relation to the premises in the last 12 months. One area improved is the courtyard located in the centre of the home, which has been repaved. The paving is now even, clean and attractive enhancing this area considerably. The bedrooms off the courtyard have lowered slopes and the home has a portable ramp to aid access out of and into the home. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 16 The manager said that the new organisation intends to redecorate lounges and attend to the decorating and re-carpeting needs in the corridors. Clent lounge has been enhanced by the replacement of the bay window. The views from this window on a clear day are spectacular across open countryside. The manager suggested that Rowley unit may be put back into use in the near future. The concern regarding this, is the inadequate assisted bathing and toileting facilities in this area. Additionally, apart from the passenger lift the only access to the bedrooms in this unit is a staircase made of metal which does not generate a homely feel. Window frames in Rowley unit require some attention which would involve repainting, or replacement. It was pleasing to see that the laundry cleaning schedules are in use and are being completed. Hand wash signs are on display in bathrooms and toilets and that the laundry floor has received the required attention. Protective clothing was seen to be available in high risks areas examples of which being; the bathrooms, toilets and laundry. Concern was highlighted in that laundry bags containing dirty washing were seen stored directly on the floor outside of the laundry. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30. Generally residents’ needs are met by the numbers and skill mix of staff. Nurse cover however, will have to be increased when Rowley unit reopens. Residents’ are in safe hands. Generally staff are trained to do their jobs. EVIDENCE: Generally staffing levels are satisfactory. Staff rota’s were viewed and revealed the following staffing levels; Am 4 care plus an RGN on both floors. PM 3 care plus an RGN on both floors. Nights 5 care plus one RGN. Sufficient cleaning, catering and laundry staff are provided in addition to the staffing detailed above. The home also has a handyperson. Rowley unit has not been used for some time. An additional RGN will be required at night when it does. The home since the last inspection is using the ‘ Bartel’ dependency rating tool. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 18 All but six of the care staff to date have achieved N.V.Q level 2 or above. This is a considerable achievement. The manager has a training matrix but has confirmed that it is not adequate in it’s present format and will be revised. There was evidence of in-house induction given to new staff. The new organisation BUPA has it’s own induction packages. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Residents’ live in a home which is run and managed by a suitable person. Generally the home is run in the best interests of the residents. Fine tuning is required to ensure that the financial interests of the residents’ are safeguarded. Work is needed to ensure that the health, safety and welfare of staff and residents’ are promoted and protected. EVIDENCE: The manager has been in post for a number of years and is approved by the Commission for Social Care Inspection as a suitable person to be in charge of the home. The manager is a first level nurse who has years of experience of caring for elderly people in a nursing environment. The manager has achieved N.V.Q level 4 in management. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 20 The home has processes in place to gain the views of residents’ and relatives’ in respect of standards and services provided by the home. The previous organisation as a whole was accredited with ISO9002. The manager carries out regular audits of the home concentrating on different areas each time. This identifies conformance or non- conformance with policy, procedures and practice. The manager confirmed that BUPA would be implementing their own quality monitoring processes. A random audit of residents’ money held in safekeeping was carried out. Money against balances was correct. However, there were not always two signatures to verify each transaction. Inventories pertaining to furniture/ clothing and other items brought into the home were not available for all residents’. Records relating to health and safety and maintenance were assessed and revealed that the hoisting equipment and passenger lift had been serviced within the last 6 months. The five year fixed electrical wiring check had been carried out in 2004 however, records relating to this were not documented on the usual form. It was not possible to determine if any recommendations had been made. Bedrails and hoist slings are checked monthly. A gas landlords certificate was available dated 9/05. The homes water system had been tested for bacteria which was found to be negative in August 2005. The new organisation has it’s own health and safety section and has undertaken an audit of the premises, requirements have been made following this which will be addressed. The manager was due to go on health and safety training the week following this inspection. Requirements have been made in respect of the fire alarm system. In that it needs to be replaced. It was identified that Pat testing records stated that many items would need to be retested in September 2005 yet there was no evidence that this has been done. At least two bedroom doors on the ground floor were propped open with a wedge non- conforming with fire safety. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x 2 x x x x 2 STAFFING Standard No Score 27 3 28 4 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14(1)(c ) Requirement The registered person and manager must ensure that it is evidenced that prospective residents’ are involved in their assessment of need process. Where they are not able to sign and have no representative to act on their behalf then this must be detailed on the assessment of need documentation. Timescale for action 01/12/05 2 OP9 13(2) 3 OP9 13(2) (Timescale of 09.05.05 not met). The registered manager must 01/12/05 request a copy of the medication policy from the new organisation. The registered provider and 25/11/05 manager must ensure that when there is a choice of dosage e.g. 1 or 2 tablets that the number of tablets administered is recorded. (Timescale of 01/06/05 not fully met). This mainly applied to Paracetamol and Senna tablets. Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 23 4 OP9 13(2) 5 OP9 13(2) 6 OP9 13(2) The registered provider and manager must purchase thermometers for the medication fridge that record maximum and minimum temperatures. The registered provider and manager must ensure that where medication records are handwritten two staff members witness that information from the medication container being transferred to the medication record is correct and that they both sign to verify this. The registered provider and manager must ensure that; Where pain relief and other medications is prescribed as ‘ when required’ that these medications are always offered to the resident. Where dispersible medications (example being Aspirin) are prescribed that they are administered as such not given dry. All short life preparations (example; eye drops) are disposed of on their expiry date. No money or other extraneous items are stored in controlled drug cupboards. The registered provider and manager must ensure that nursing staff date the opening of all containers. They must also ensure that balances from previous cycles are carried over. 01/12/05 01/12/05 25/11/05 7 OP9 13(2) 01/12/05 Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 24 8 OP9 13(2) The registered provider and manager must devise and implement a policy for the handover of medication keys between shifts. These key handovers must be verified by staff signatures. 01/12/05 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP9 13(2) 14 OP16 22(2) The registered provider must ensure that medication reviews are arranged where residents’ refuse their medication for longer than 4 days. (This of course depending on the medication in question). A lesser time may be required. The registered provider and manager must ensure that all unwanted controlled medication is disposed of at the first opportunity. The registered provider and manager must carry out an audit/ assessment to determine the suitability of the medication storage room on the first floor. The registered provider and manager must ensure that the controlled drug cupboards are sufficient in size to store all items and example being the liquid Oramorph. The registered provider and manager must request quarterly audits from the homes’ dispensing pharmacist. The registered provider and manager must ensure that the complaints procedure is appropriate to the needs of all residents’. 01/12/05 01/12/05 10/01/06 01/12/05 10/01/06 10/01/06 Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 25 15 OP19 23(2)(d) 16 OP19 23(2)(d) The new organisation must provide a timescale for the redecoration of the ground floor corridors. The new organisation must inform the CSCI in writing of their plans to enhance window frames on Rowley unit. The new organisation must ensure that all bathrooms and toilets throughout the home (This applies to Rowley Unit) are in suitable working order and are provided with the required equipment. The new organisation must carryout an assessment of the suitability of the staircase on Rowley unit and inform the CSCI of the outcome of this and any actions they intend to take The registered provider and manager must ensure that all wardrobes are suitably secured to prevent accident or injury. (Timescale of 01/06/05 not met). This applies to wardrobes in first floor bedrooms. The new organisation must forward to the CSCI their views on the present laundry and any plans they may have to improve this facility. 10/01/06 10/01/06 17 OP21 23(2) 10/01/06 18 OP19 23(2) 10/01/06 19 OP24 13(4) 01/12/05 20 OP26 13(3) 16(2) 10/01/06 Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 26 21 OP26 13(3) The registered provider and manager must ensure that laundry bags containing dirty laundry are not stored directly on the floor. The registered provider and manager must ensure that a second RGN is provided each night shift when Rowley unit reopens. If the unit opens before the timescale given is reached then the second nurse must be provided from this date. 01/12/05 22 OP27 18(1)(a) 10/01/06 23 OP29 17(2) The registered provider and manager must ensure that; All written references are authentic, with the referees full name and position detailed. Interview questions and answers in respect of all prospective staff are recorded. (Timescale of 09/05/05 not fully met 01/12/05 24 OP35 16(2)(l) 13(6) The registered provider and manager must ensure that two signatures verify any transaction in respect of resident money held in safekeeping. 01/12/05 Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 27 25 OP35 17(2) Sch 49,10 26 OP38 23(4) 27 OP38 23(4) 28 OP38 23(4) 29 OP38 23(4) The registered provider and manager must ensure that all items brought into the home by residents’ (This to include furniture and electrical items) are recorded on a personal inventory. The registered provider and manager must provide a timescale to the CSCI of when the new fire alarm panel will be installed. The registered provider and manager must ensure that all portable electrical items are tested at least annually. The registered provider and manager must confirm that there were no requirements or recommendations made following the 5 year check of the fixed electrical wiring. The registered provider and manager must cease propping bedroom doors open with wedges. They must seek advice from the Fire Service and purchase automatic closures to be installed on bedroom doors. 23/12/05 01/12/05 15/12/05 20/12/05 20/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Warrens Hall Nursing Home DS0000004853.V263883.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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