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Inspection on 18/11/05 for Pals Residential Home

Also see our care home review for Pals Residential Home for more information

This inspection was carried out on 18th November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was clean, tidy and comfortably furnished. It had a homely feel about it. All bedrooms seen were personalised by the resident residing within that room. Residents seen spoke highly of the care provided and of the staff employed. Carers seen were friendly to residents and afforded necessary privacy while carrying out care tasks. The registered manager ensures that a suitable assessment is undertaken prior to an admission. This assessment demonstrates that the home believes that they are able to meet identified care needs. The number of care staff on duty was sufficient to meet the needs of residents. The percentage of staff who have achieved an NVQ (National Vocational Qualification) is commendable. Activities are provided. Appropriate assistance was given during a mealtime. Information available within the home included details of a local advocacy service. The fire logbook was in order. The majority of staff have received the required mandatory training.

What has improved since the last inspection?

Each long stay resident has a copy of the homes statement of terms and conditions held on their individual file. The registered provider continues to carry out improvements around the home to ensure the environment is pleasant and homely. Evidence of a residents questionnaire was available. This information needs to be collated.

What the care home could do better:

The necessary amendments identified during the last inspection to the statement of purpose and service users guide have not taken place. Although monthly reviews of care plans are taking place improvements are needed. Care plans must be an up to date reflection of each residents care needs and follow up action must be recorded. As previously highlighted risk assessments throughout the home are lacking and need to be carried out, these are especially required to safeguard residents and staff. The lack of a lockable space within bedrooms needs addressing. Medication systems need to be improved. The need for suitable procedures regarding medication remains unmet. Both of these medication issues are required to ensure that residents are fully safeguarded. A complaints procedure is on display in the hall, however this fails to meet the required standard and continues to need amending. Staff recruitment procedures failed to meet the necessary standard in that the level of checks and disclosures required were not in place. Formal staff supervision is not taking place.Some health and safety matters gave cause for concern. The hoist over the bath has not been serviced as required and must be done without delay. Records regarding hot water temperature are not undertaken. The gas safety certificate was out of date.

CARE HOMES FOR OLDER PEOPLE Pals Residential Home 79 Ombersley Road Worcester Worcestershire WR3 7BT Lead Inspector Andrew Spearing-Brown Unannounced Inspection 18th November 2005 11:15 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 Pals Residential Home DS0000018669.V266357.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. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pals Residential Home Address 79 Ombersley Road Worcester Worcestershire WR3 7BT 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) 01905 612439 Mr Sharanjit Singh Purewal Mrs Eileen Nellie Jeynes Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age of places (14) Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 2005 Brief Description of the Service: The home is registered to provide board, accommodation and personal care for a maximum of fourteen older people who may also have physical disabilities. The home is an extended Victorian house situated close to Worcester City centre, and within close proximity to local services and resources. Accommodation is provided on two floors, which can be reached by a central passenger lift and two staircases. There are 12 single bedrooms and 1 double. Five bedrooms have en-suite facilities. Communal facilities consist of a large lounge and a dining room. Mr Purewal is the registered provider while Mrs Jeynes is the registered manager. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of two days and was undertaken by a regulation inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The first day was unannounced the second day was announced having been arranged at the end of the first day. The inspection lasted a total of 7 ½ hours. The last inspection at Pals took place during May 2005 making this inspection the second statutory visit during the 2005 – 2006 inspection year. Part of this inspection was to assess the progress made in relation to the requirements from the previous inspection. Throughout the inspection the registered manager was on duty. Consultation with a number of residents took place. Many parts of the home were seen. These areas included communal areas as well as a small number of bedrooms. The care records regarding a sample number of residents were viewed. Other documents seen included medication records and fire records. What the service does well: The home was clean, tidy and comfortably furnished. It had a homely feel about it. All bedrooms seen were personalised by the resident residing within that room. Residents seen spoke highly of the care provided and of the staff employed. Carers seen were friendly to residents and afforded necessary privacy while carrying out care tasks. The registered manager ensures that a suitable assessment is undertaken prior to an admission. This assessment demonstrates that the home believes that they are able to meet identified care needs. The number of care staff on duty was sufficient to meet the needs of residents. The percentage of staff who have achieved an NVQ (National Vocational Qualification) is commendable. Activities are provided. Appropriate assistance was given during a mealtime. Information available within the home included details of a local advocacy service. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 6 The fire logbook was in order. The majority of staff have received the required mandatory training. What has improved since the last inspection? What they could do better: The necessary amendments identified during the last inspection to the statement of purpose and service users guide have not taken place. Although monthly reviews of care plans are taking place improvements are needed. Care plans must be an up to date reflection of each residents care needs and follow up action must be recorded. As previously highlighted risk assessments throughout the home are lacking and need to be carried out, these are especially required to safeguard residents and staff. The lack of a lockable space within bedrooms needs addressing. Medication systems need to be improved. The need for suitable procedures regarding medication remains unmet. Both of these medication issues are required to ensure that residents are fully safeguarded. A complaints procedure is on display in the hall, however this fails to meet the required standard and continues to need amending. Staff recruitment procedures failed to meet the necessary standard in that the level of checks and disclosures required were not in place. Formal staff supervision is not taking place. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 7 Some health and safety matters gave cause for concern. The hoist over the bath has not been serviced as required and must be done without delay. Records regarding hot water temperature are not undertaken. The gas safety certificate was out of date. 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. Pals Residential Home DS0000018669.V266357.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 Pals Residential Home DS0000018669.V266357.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): 1,2 and 3. Standard 6 is not applicable to Pals Potential residents are assessed by the home to ensure that care needs can be met. Improvements are needed regarding the service users guide and statement of purpose. EVIDENCE: The previous inspection report acknowledged the considerable amount of time placed by the registered persons in to preparing both a Statement of Purpose and Service Users Guide. A number of amendments or additions necessary to these documents were highlighted within the last inspection report. A copy of both these documents was freely available within the entrance hall. On re assessing them it was evident that none of the amendments have taken place and therefore the requirements remain outstanding. Once these changes have occurred a copy of both documents must be sent to the Worcester office of the CSCI. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 10 A signed statement of terms and conditions was seen on one residents file. The registered manager confirmed that a similar document was held on each residents file with the exception of a resident who was still on an initial trial period. A pre admission assessment was viewed for a resident who was admitted into the home recently. The initial assessment contained basic information however it was sufficient in its detail regarding individual care needs to ensure that an initial care plan could be implemented. This information then needs to be built upon as the care plan develops ensuring that all identified care needs are suitably covered. A trial period is available before residents make a decision about becoming long stay. The registered manager would not admitted any emergency admission without a suitable assessment having taken place. Intermediate care is not offered at Pals and the home has no plans to provide such a service. Pals Residential Home DS0000018669.V266357.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 and 10 Limited progress has been made on improving care plans. However improvement is necessary to ensure that care plans and risk assessments are suitable detailed and up to date to ensure safe working practices. In addition the management of medication requires improvement to safeguard residents. EVIDENCE: Monthly reviews of care plans are taking place. Care plans need to be up dated more frequently if necessary to reflect the changing care needs of residents. These need to be a full account of recent changes to care details. The care plan, daily records and monthly reviews of one resident were assessed in detail. The terminology used upon daily notes was generally satisfactory however they failed to appropriately follow up on concerns in wellbeing. No evidence of residents involvement in the drawing up and reviewing of care plans was seen in the files viewed. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 12 The monthly reviews seen did not accurately summarise events, which had taken place during the previous few weeks. One monthly review stated ‘unsteady on her feet’. However the daily records showed two falls and stated ‘refused to stand and walk. Later records stated ‘ refused to walk’ ‘ mobility wasn’t too good’ ‘ mobility very poor’ ‘ difficult to walk’ and ‘ very difficult to walk.’ None of this information was transferred to the care plan. Risk assessments were either insufficient in details or not in place regarding moving and handling, fall prevention, skin viability and nutritional screening. The management of medication has improved over recent inspections; further improvements are however needed in order to fully meet the National Minimum Standard. The Manrex MDS (Medication Dosage System) blister packs are held in a lockable cupboard however as highlighted within previous inspection reports this cupboard is unsuitable. Since the previous inspection a nominated person holds the keys to the medication. As part of the inspection the current months Medication Administration Record (MAR) sheets were viewed. The morning medication of one resident were not signed for when the sheet was viewed at 11.50 a.m. Medication records must be checked and signed at the point of administration. Creams and ointments are not signed as applied by carers. The MAR sheets indicated that some residents self-administered some of their own medication. When self administering risk assessments need to be in place; in some incidents they were while others they were not. One risk assessment was undertaken in 2003 and concluded with a box stating that a review should take place in 3 months. No review was recorded since it was originally compiled. The recording of known allergies on the MAR sheets is now taking place. Furthermore hand written MAR sheets were double-checked and signed by two staff, which is good practice. One MAR sheet from a previous month showed a course of antibiotic medication. An audit of the number of signatures balanced with the number of tablets prescribed. There was no current up to date list of medication available in the residents’ individual care plan. Accredited training for staff who are involved in the ordering and administering of medication has not taken place. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 13 The homes medication policy remains scant. This point was highlighted within the last 4 inspection reports. A copy of the guidance issued by the Royal Pharmaceutical Society of Great Britain was left with the registered manager. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 14 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): 12, 14 and 15 Activities are provided to stimulate and interest people living in the home. EVIDENCE: The daily records of a sample number of residents showed a range of activities undertaken over recent weeks including singsongs, exercises, skittles, making cards and bingo. Information regarding activities was displayed in the lounge. Residents are able to bring personal possessions in to Pals. Information regarding a local advocacy service was contained within the Statement of Purpose, which was available in the entrance hall. The mid day meal on the second day of the inspection was seen. It consisted of gammon, mashed potatoes, carrots and sprouts. For sweet residents where due to be offered sticky toffee pudding. Residents consulted were happy with the meals provided. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 15 Lunch is plated up for residents in the dining room. One resident had lunch in her bedroom, the tray was suitably set out and a table provided. A member of staff was seen to be assisting a resident with her meal; this was carried out in a sensitive and discrete manner. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 16 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, 17 and 18 The current complaints procedure needs amending to fully safeguard the interests of residents. EVIDENCE: The complaints procedure displayed in the hallway does not meet the National Minimum Standard in that no timescale is given. The fact that complaints may be referred to the CSCI at any stage is not clear. These amendments need to take place in order to meet the standard. A copy of the Department of Health documents No Secrets and Protection of Vulnerable Adults (POVA) Guidelines were available. In addition copies of the guidance booklet regarding the reporting of abuse and mistreatment of vulnerable adults issued by Worcestershire County Council were also available; the registered manager stated that all staff were given a personal copy. A policy and procedure document issued by the County Council could not be found. The registered person must ensure that the in house policy is in line with local guidance and information regarding the introduction of POVA. It was noted that information regarding the availability of a local advocacy service was available. The registered manager confirmed that residents are on the electoral roll and received postal votes during the last general election. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 17 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, 20,23, 24, 25 and 26 The home is homely, clean and comfortable. Some requirements remain unmet, which could be detrimental to residents right to privacy and their safety. EVIDENCE: There is a lounge and a dining room on the ground floor, both of which are suitable decorated and furnished comfortably. Lighting in communal areas is domestic in style. The home was seen to be clean, tidy and free of any offensive odours. A small representative sample of bedrooms were viewed they were all personalised demonstrating individuality. Five bedrooms have en-suite facilities. The registered provider was decorating an upstairs bedroom on the first day of this inspection. One other bedroom has been decorated and recarpeted since the last inspection. No programme of routine maintenance and renewal of fabric was sought on this occasion. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 18 The double bedroom on the ground floor does not have a lock fitted to the door. The previous inspection reported highlighted the need to discuss the lack of a lock with relevant individuals as well as for it to be risk assessed and recorded. This has not taken place. At such time that a lock is fitted this needs to be in line with recognised guidance issued by Hereford and Worcester Combined Fire Authority. Bedrooms can be personalised by residents. No lockable facilities are provided. At the time of the previous inspection the registered provider had purchased a number of cash tins. It is now planned to fit a suitable lock to a drawer in each bedroom; progress on providing this facility will be assessed as part of a future inspection. An Environmental Health Officer visited Pals two days before this inspection. The handwritten report left at the conclusion of the visit recorded two minor recommendations. During the previous inspection the registered manager confirmed that thermostatic valves are fitted to baths. The previous inspection highlighted that water temperatures were not taken to check that valves are in working order. The registered provider stated that a contractor has recently visited to carry out a legionella risk assessment, although the documentation from this had not yet arrived. As part of this assessment sheets are expected to record bath temperatures. While awaiting this documentation interim measures of recording bath temperatures need to be introduced. The vast majority of radiators are covered in order to prevent the risk of scalding. The registered provider confirmed that any uncovered radiators are not used. The paper towel dispenser was checked in 2 bathrooms, both were empty. Neither location had liquid soap dispensers although these were put in place during the course of the inspection. It was not established whether the washing machine located in the laundry meets the Water Supply (Water Fittings) Regulations 1999. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 19 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, 29 and 30 Procedures for the recruitment of staff are not sufficiently robust to ensure the protection of residents however the deployment and number of staff available is sufficient to meet the needs of residents. EVIDENCE: Residents made very positive comments about carers and the registered manager throughout the inspection describing them as hardworking, kind and attentive. The current weeks rota was viewed. This confirmed that 3 carers including the registered manager cover the morning shift. The afternoon shift consists of 2 carers. Nights are covered by 2 wakeful members of staff. Since the last inspection a domestic member of staff has been appointed who works 4 hours per day Monday to Friday. Out of the current care team 75 are qualified to NVQ (National Vocational Qualification) level 2. An additional carer is due to commence NVQ training. This level of qualified staff is in excess of the National Minimum Standard and is commendable. Information relating to a recently appointed member of the care team was viewed. On the date when the person commenced duties only one written reference would have been in place. No Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) check was carried out prior to Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 20 appointment. The registered provider confirmed that an application for a CRB disclosure had now been made. The induction training documentation remains the same as noted within earlier inspection reports and does not meet the National Training Organisation Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 21 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, 34, 36, 37 and 38 Quality assurance systems need to be developed and the lack of formal staff supervision needs to be addressed. Some progress has taken place regarding health and safety however the lack of risk assessments and some health and safety checks leave residents at potential risk. EVIDENCE: The registered manager has many years experience in caring for older people and is able to demonstrate knowledge of conditions associated with aging. Although the manager attended training in the past it was not in line with the qualifications as listed within the National Minimum Standards. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 22 Quality survey questionnaires were noted on individual residents files. The results of the questionnaires have not been analysed. The results following analysis need to be included within the service users guide and shared with other interested parties including the local office of the CSCI. No other quality assurance or quality monitoring systems are in place; these now need to be developed. A certificate showing that the required level of public liability insurance is in place was available. The certificate of registration was displayed in the hallway. No formal supervision in line with the National Minimum Standards – Older People is taking place. The registered provider confirmed that since the last inspection the electrical hard wiring has been checked to British Standard 7671. As no documentary evidence was available this should be sent to the Worcester office of the CSCI. A file detailing the most recent testing of portable electrical equipment was seen. The certificate forming the front cover had expired as the testing had taken place in excess of 12 months ago. Following the above test the examiner had failed 3 items; although assurance was given that these items were disposed of, this information was not recorded. The certificate regarding the last landlord gas safety check was also in excess of 12 months old and therefore in need of renewal. A contractor recently inspected the passenger lift. Following the last inspection at Pals by the CSCI the registered provider was required to have the hoist over the bath inspected under the Lifting Operations and Lifting Equipment Regulations 1998. Under these regulations all personal lifting equipment needs to be thoroughly examined every six months. When the contractor last visited to service the lift in August 2005 the bath hoist was not examined. Therefore this equipment remains un-serviced some 6 months after this requirement was made and 4 months after the timescale given by the CSCI. This equipment must be serviced without further delay. Three wheelchairs were stowed in a corridor area near to the lounge. One chair was noted to be without footrests in place. The fire log is completed on a regular basis; the weekly testing of the alarm system is carried out in sequential order as necessary. The annual inspection of fire extinguishers took place in July 2005. The fire risk assessment was not sought on this occasion. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 23 The new style accident book, which conforms to data protection legislation, is in place to record accidents to residents. A number of sheets remained within the book, which need to be transfer to the relevant residents personal file. The accident book used for employees remains to be the older style and therefore needs to be changed. It was noted that a recent event involving a member of staff was not recorded within the accident book. Mandatory staff training was discussed. The registered manager stated that all staff undertook basic food hygiene during March 2005 and moving and handling during February 2005. A number of staff have undertaken first aid training therefore at least one trained member of staff is on during each shift. Staff receive fire training from the registered manager. Environmental risk assessments are seriously lacking and in need of urgent attention. A ladder stowed near the office needs to be chained to the wall to prevent it accidentally falling. Hazard data sheets were available for some cleaning materials although some items used within the home were without any such documentation. A risk assessment based on the data sheet, where the item is used, for what purpose and who may be harmed is required. Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 24 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 X X X 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 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 3 X X 3 2 2 2 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 X 2 2 1 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 25 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 OP1 Regulation 4 (1) Requirement The Statement of Purpose must be an accurate reflection of the service provided within the home. (Previous timescale of 31/12/04 and 31/07/05 part met) 2. OP1 5 (1) A Service Users Guide, which includes all the information detailed in Regulation 5 and Standard 1, must be available in the home, and copies must be given to all current, and any prospective service users. (Previous timescale of 31/12/04 and 31/07/05 part met) 31/01/06 Timescale for action 31/01/06 3. OP1 4 (2) 5 (2) A copy of both the revised Statement of Purpose and Service Users Guide must be supplied to the local office of the CSCI. 31/01/06 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 26 4. OP7 15 Residents care plans must be recorded in a style accessible to the individual residents, agreed and signed by the resident whenever possible and/or representative (if any). (wording in this requirement slightly amended) (Previous timescale of 31/12/04 and 31/07/05 not met) 31/12/05 5. OP7 15 (2) (a) Care plans must be reviewed on 18/11/05 a monthly basis or more frequently to reflect the changing care needs of service users. Up dates to care plans must be an accurate record of changes which have occurred. A risk assessment must be carried out in respect of every resident, in respect of all aspects of their lives, and with particular attention to prevention of falls. (Previous timescale of 30/11/04 and immediate and on going following the inspection on 26/05/05 not met) 18/11/05 6. OP7 13 7. OP8 13 (1) (b) The registered manager must ensure that necessary follow up action is taken and recorded in relation to service users welfare and needs. Nutritional screening must be undertaken on admission, and subsequently on a periodic basis. (Previous timescale of 30/11/04 and immediate and on going following the inspection on 26/05/05 not met) 18/11/05 8. OP8 14 17(1) (a) 3 (o) 18/11/05 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 27 9. OP9 13 (2) The registered manager must ensure that medication administration records are correctly compiled and are completed at the time of administration. (Previous timescale of immediate and on going not met). 18/11/05 10. OP9 13 Medication training undertaken by carers must be accredited. (Previous timescale of 30/06/05 not met – new time scale given.) 31/01/06 11. OP9 13 A policy and procedure for the receipt, recording, storage, handling, administration and disposal of medication must be drawn up and implemented. (Previous timescale of 30/11/04 and 30/06/05 not met – new timescale given which must be met) 31/12/05 12. OP9 13 Risk assessments must be compiled and reviewed regarding residents who wish to selfadminister any medication. The registered manager must ensure that residents current medication details are documented within individual care plans. The registered person must ensure that the complaints procedure seen displayed is in line with the required standard. (Previous timescale of 30/11/04 and 30/06/05 not met – new timescale given.) 18/11/05 13. OP9 13 14/12/05 14. OP16 22 31/12/05 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 28 15 OP18 13 (6) The registered persons must ensure that the in house adult protection procedures are in line with local and national procedures. 31/12/05 16. OP24 12 (4) Service user must have access to 31/01/06 a suitable lockable space within their own bedroom. (Previous timescale of 31/01/05 and 31/08/05 not met – new timescale given) 17. OP24 13 (4) A risk assessment must be compiled in relation to the need for a suitable lock to be fitted to the downstairs double bedroom. (Previous timescale of 31/07/05 not met – new timescale given) 31/01/06 18. OP25 13 (3) (4) Water temperatures must be recorded in relation to bath water and random checks to ensure that thermostatic valves are functioning correctly. (Previous timescale of immediate and on going not met. This must now be met) 18/11/05 19. OP25 13 (3) (4) A Legionella risk assessment must be completed, and remedial action must be undertaken to address any identified risk. (Previous timescale of 31/12/04 and 30/06/05 not met- new timescale given) 31/01/06 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 29 20. OP26 16 (2) (j) Suitable arrangements must be 30/11/05 taken to prevent the risk of cross infection including the provision of hand washing facilities. (Previous timescale of 30/11/04 and 30/06/05 part met) The registered manager must ensure that two references and a response from the Criminal Records Bureau are received before a candidate is offered a post and the commencement of employment. 21. OP29 19 18/11/05 22. OP30 18 (1) (c) (i) (Previous timescale of immediate and on going not met) A staff-training programme, 31/01/06 which meets National Training Organisation workforce targets, must be in place. (This standard was not fully assessed as part of the inspection carried out on 18th and 24th November 2005. New time scale given) 23. OP33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 28/02/05 and 31/07/05 not fully met – extended timescale given) Care staff must receive formal supervision at least six times a year. The supervision of care staff must include all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale of 31/01/05 and 31/07/05 not met – new timescale given – new timescale given) 31/01/06 24. OP36 18 31/01/06 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 30 25. OP38 13 The registered person must ensure that suitable procedures are in place to maintain portable electrical appliances. The registered provider must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage. (Previous timescale of 30/11/04 and immediate and on going following the inspection on 26/05/05 not met) 31/12/05 26. OP38 23 (4) 25/11/05 27. OP38 13 The registered manager must ensure that the Control of Substances Hazardous to Health risk assessments are reviewed. (Previous timescale of 30/11/04 and 30/06/05 not met) 25/11/05 28. OP38 13 The registered manager must ensure that wheelchairs are well maintained and that footrests are in place at all times. The hoist in the ground floor bathroom must be examined every 6 month. (Previous timescale of 30/06/05 not met. Immediate action must be taken to comply) 25/11/05 29. OP38 13 18/11/05 30. OP38 13 The registered person must comply with the Management of Health and Safety Regulations in respect of appointing a competent and suitably trained person to oversee Health and Safety within the home. 31/07/05 Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 31 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. Refer to Standard OP8 Good Practice Recommendations A record of each individuals dietary intake should be recorded on a daily basis. (This recommendation was made within a previous report) 2. 3. OP9 OP26 It is strongly recommended that the storage cupboard for medication be changed to one more suitable for purpose. Consideration should be given to updating the homes infection control policy. (This recommendation was made within a previous report and was not viewed on this occasion) 4. OP29 All reference request letters should be photocopied prior to despatch, and should be amended to include the provision to include any additional information. (This recommendation was made within a previous report) 5. OP30 The homes training and development programme should be formally recorded. (This recommendation was made within a previous report and was not sought on this occasion) Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pals Residential Home DS0000018669.V266357.R01.S.doc Version 5.0 Page 33 - 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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