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Inspection on 26/05/05 for Pals Residential Home

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

This inspection was carried out on 26th May 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. Residents were confident that any complaints or concerns would be listened to. Those consulted were happy with the menu available to them.

What has improved since the last inspection?

Although requiring further improvement considerable effort has gone into producing the statement of purpose and service users guide. Since the last inspection the number of staff with a level 2 NVQ (National Vocational Qualification) has increased, for which staff should be commended. Other necessary training in areas such as fire safety and moving and handling has taken place.

What the care home could do better:

Risk assessments throughout the home are lacking and need to be carried out, these are especially required to safeguard residents and staff. Assessments and care planning must improve to ensure that staff know what to do for each resident. Medication systems as well as policies and procedures need to be improved further to ensure that residents are fully safeguarded. Quality assurance and staff supervision are in need of further development. Staff recruitment procedures are lacking safeguards. Staffing numbers were found to be inadequate at certain times during the week when the inspection took place. Some areas of health and safety need improvement to ensure that the home is safe to live and work in.

CARE HOMES FOR OLDER PEOPLE Pals Residential Home 79 Ombersley Road Worcester WR3 7BT Lead Inspector Andrew Spearing-Brown FINAL - Unannounced 26 May 2005 10:05 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pals Residential Home Address 79 Ombersley Road Worcester WR3 7BT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01905 612439 Mr Sharanjit Singh Purewal Mrs Eileen Nellie Jeynes CRH 14 Old age Physical Disability - over 65 14 14 Category(ies) of OP registration, with number PD(E) of places Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: It was noted that the homes Statement of Purpose made reference to Pals have the category Dementia - over 65 DE(E) as well as those detailed above. The inspector is currently investigating whether this category should still be in place. Date of last inspection 8 November 2004 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 Purewel is the registered provider while Mrs Jeynes is the registered manager. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out during the morning and early afternoon of a weekday towards the end of May 2005. A brief return visit took place by arrangement 5 days after the initial inspection to give feedback on some documents. A main focus of this inspection was discussing and assessing the progress made in relation to the requirements from the last inspection which took place during November 2004 During this inspection a total of four residents, one relative, one carer, a cook and both registered persons were consulted. Several areas of the home were viewed including all communal areas, bathrooms and toilets as well as a high percentage of bedrooms. The care records of a representative sample of residents were seen, as were some staff files. Other documents seen included medication records, fire records, accident reports, complaint records and some policies and procedures. 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. Residents were confident that any complaints or concerns would be listened to. Those consulted were happy with the menu available to them. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 6 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. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 3. Standard 6 is not applicable to Pals Information was available to assist potential residents and their families in making a choice of home; however the documentation needs to be amended further in order to be of the required standard. The documents were however a significant improvement from the last inspection. EVIDENCE: A copy of both the Statement of Purpose and Service Users Guide was obtained during this inspection. It was evident that the registered persons have spent a considerable amount of time since the previous inspection in drawing these documents together. Copies of these documents were on display in the entrance hall as was a copy of the last inspection report. The Service Users Guide is written in plain English however some additional information as follows needs to be included in order that the National Minimum Standard is met. • • Details of the registered provider Details of training (other than NVQ) undertaken by staff E52 S18669 PALS V223025 260505.doc Version 1.30 Page 9 Pals Residential Home • • • Details of the last inspection report The complaints procedure Residents comments Other information is inaccurate such as the percentage of NVQ staff, the statement that ‘all the residents will have single rooms with safety locks’ – Pals has one double bedroom, which is without a door lock. Reference to ‘nurse call’ system needs changing as no nurses work at the home and therefore this could be misleading; the system is an emergency call system. Other information needs to be accurate and needs to be able to be demonstratable. The Statement of Purpose also needs amending. It makes numerous references to day care (day care is not provided at Pals and would need to be discussed with the Commission for Social Care Inspection prior to any future introduction). As indicated above information needs to be accurate and able to be demonstrated such as reference to ‘specialist equipment’ ‘ established catering standards’ ‘ locked in their personal bedside drawer’ ‘ activities organisers’. Some additional information is required such as the room sizes in the home including communal areas. A blank copy of the homes terms and conditions was seen; however these were not seen on residents’ files. It became apparent that one resident had moved from an upstairs single to a downstairs double bedroom. Although the resident concerned stated she was happy with her bedroom and got on well with the other resident no indication that the purchasing authority were aware of this change was evident and no signed terms and conditions were available. Individual records are kept for each resident; the records for one recently admitted resident were seen. A initial care plan was written on a sheet entitle ‘assessment’, this was satisfactory as an initial care plan however it was evident that this was not undertaken before the resident was admitted as it was dated 3½ weeks after the date of admission. No pre admission assessment compiled by a person from the home was seen. A relative of a recently admitted resident believed that his wife had settled into Pals well. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 Risk assessments are not in place to ensure safe working practices, which include moving and handling. Furthermore suitable policies and procedures regarding medication are not in place. The lack of these assessments places both residents and staff at risk. Further attention needs to be given to the development of care plans including nutritional screening. EVIDENCE: Representative samples of care plans were viewed as part of the inspection; those seen showed little progress from the initial improvement seen during the last inspection. There was no evidence of either residents’ involvements or agreement in the care plan; none were signed by either the individual resident or a representative. The requirements from the previous inspection report, which ensure that all aspects of care are fully met, remain outstanding. This was particularly evident in the case of one resident who fell fracturing her pelvis. Comments such as ‘to have complete rest (no weight bearing)’ and ‘xx can now take some weight’ were seen however no risk assessment in relation to moving and handling was undertaken. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 11 In addition conflicting information was noted on a monthly review, within the daily notes and upon an undated physical assessment in relation to dietary intake. No nutritional assessments are in place but this was partially relevant to this resident who lost weight over the same period of time as the conflicting recording took place. The resident concerned was seen and appeared both well and content she voiced no concerns about any aspect of the care provided at Pals. Care plans lacked detail in certain aspects such as dental care. The lack of instruction and guidance relies on staff memory and verbal communication, which can result in either inconsistency or tasks getting overlooked. One care plan had not received a monthly review while others had care plans which had repeated reviews and therefore require a new care plan to be drawn up taking into account the changed care needs. Evidence was seen of residents receiving annual optical check up. The overall lack of suitable recording and necessary renewing of care plans does not reflect the good quality care, which was mentioned by residents. The registered manager has addressed some further areas of concerned noted within the previous two inspection reports regarding medication. Medication was receipted into the home as required. Items such as eye drops had the date of opening recorded upon them. No sticky labels or liquid paper were noted as during the last inspection. The Manrex MDS (monitored dosage system) blister packs are held in a lockable cupboard however this remains unsuitable. A nominated responsible person did not hold the keys for the medication cupboard. The majority of MAR (Medication Administration Record) sheets were completed satisfactorily. It was noted that some sheets contained hand written entries or amendments, the recommendation within the last report to have such entries checked by a second member of staff should be adopted. The section on each MAR sheet to record any known allergies was blank. It was discovered within the notes of one resident that an allergy to penicillin was known; the emission of this information on the MAR sheet could be potentially dangerous in the event of a medic only viewing this sheet. In the event of no known allergies this is to be entered on the MAR sheet. This was a requirement within the previous inspection report. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 12 One MAR sheet had two gaps when no signature was in place; the drugs were not within the MDS pack. Additionally a drug prescribed to be given at 6.00 p.m on the day of the inspection was signed as given when the MAR sheet was examined before 12.00 mid day. Audit checks upon the signing for some antibiotics were all correct. The MAR sheet for one resident stated that one drug needed to be given ½ -1 hour before food. This drug was given along with all other medication as part of the lunchtime routine and therefore was not given in line with the given instructions. It was discovered that some medication, which would be dispensed from the supplying pharmacist in their original packaging, are transferred into a monitored dosage system at Pals. This practice constitutes secondary dispensing and brings with it an increased likelihood of mistakes. The registered manager who last received training as a trainer in excess of 15 years ago undertakes staff training in medication. The medication policy and associated procedures remain scant and in need of development. Guidance issued by the Royal Pharmaceutical Society of Great Britain was not available. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 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 standard(s) None of the standards in this section were assessed in any detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Pals. EVIDENCE: Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Residents consulted were confident that any complaints or concerns would be listened to; there is still a need to update the complaints procedure. EVIDENCE: A number of varying documents were seen making reference to complaints including one displayed in the hall. None however were in line with the National Minimum Standard. One document referred to former legislation and the former County Inspectorate while another made no reference to timescales or the Commission for Social Care Inspection. There were no recent complaints recorded within the complaints log. The Commission for Social Care Inspection has not received any complaints since the last inspection. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 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 standard(s) 19, 21, 24, 25 and 26 The home presents as a homely place to live, which is clean and comfortable. Some outstanding matters remain which could be detrimental to residents’ safety. EVIDENCE: There is a lounge and a dining room on the ground floor, both of which are suitable decorated and furnished comfortably. The home was seen to be clean, tidy and free of any offensive odours. Residents confirmed that the home is kept clean. Lighting throughout the communal areas is domestic in style, it was noted that 3 out of the 8 bulbs in the ceiling light in the dining room were not working. The bedrooms seen had been personalised demonstrating individuality. Five bedrooms have en-suite facilities. The bath panel in bedroom B is split as noted within the previous report and remains in need of replacing. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 16 Bedrooms seen did not have lockable facilities. The Statement of Purpose indicated that valuables could be locked in bedside drawers. Cash tins are now available although not yet placed in residents bedrooms; these need to be bolted to the draw to ensure security. The double bedroom on the ground floor does not have a lock fitted to the door. The lack of a lock needs to be discussed with relevant individuals, risk assessed and recorded. 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. The latest report from the Environmental Health Officer was not available for inspection. The registered manager stated that it contained no outstanding matters. Water temperatures were not taken; the registered manager confirmed that thermostatic valves are fitted to baths. No records exist of any tests taking place checking that the valves are in working order. The vast majority of radiators are covered in order to prevent the risk of scalding. Radiators remaining uncovered were said to be not used. A copy of the Herefordshire and Worcestershire Local Health Protection Unit guidance in relation to infection control was not available. A copy will be forwarded to the registered manager. It was noted that a comb, toothbrush and a used disposable razor was within a communal bathroom. Although liquid soap is available within staff areas no such item is provided in the communal areas. It was not established whether the washing machine located in the laundry meets the Water Supply (Water Fittings) Regulations 1999. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The procedures for recruitment have not improved since the last inspection, this could leave residents at risk. The level of staff at certain times of day are not sufficient to meet the needs of residents. EVIDENCE: Current staffing rotas did not confirm reported staffing levels of three carers on duty throughout the working day. The rota for Sunday 22nd May indicated that only two carers were on duty. As carers are also required to undertake cleaning and laundry tasks this level of staff is not sufficient. This shortfall was explained as occurring while new staff receive induction. The rota for weekdays showed a higher level of staffing; however the rotas showed the registered owner to be present in the home when he was not. Information relating to some new members of staff was not available. Documentation regarding a member of staff recently employed indicated that the registered persons had not undertaken all the necessary recruitment checks to ensure protection of residents. Only one reference was obtained and this was dated after the date on which the employee had commenced duties. No Criminal Records Bureau (CRB), which includes a check against the Protection Of Vulnerable Adult (POVA) list, was available. Furthermore no POVA first check had taken place. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 18 Out of the 9 carers employed a total of 5 (55.5 ) are qualified to NVQ level 2, this is in excess of the National Minimum Standard. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 and 38 Effective and appropriate quality monitoring and staff supervision needs to be developed. Some areas connected with the health, safety and welfare of residents and staff need to be improved or developed in order to protect individuals and ensure safe working practices. Limited progress has been made since the previous inspection. EVIDENCE: The Statement of Purpose makes reference to the maintaining of ‘a quality service . . . through quality assurance questionnaires’. No results or findings of such an exercise are available at the time of writing this report. No minutes exist following residents meetings. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 20 Improvement was noted in relation to the maintaining of records of residents money held in safekeeping. Some up dating was necessary on some records. Formal supervision, which is recorded, is not taking place in line with the National Minimum Standard. The registered persons are reviewing policies and procedures using a commercially produced manual. These need to be made specific to Pals and refer to the correct legislation and current good practice guidance. Some fire doors were held open by means of wedges. The kitchen door, the door leading into the hallway and the door into the dining room were all propped open on the morning of the first visit of this inspection. The fire log was completed on a regular basis; the weekly testing of the alarm system was carried out in sequential order as necessary. The majority of the fire signage are pictorial, all signage needs to meet this standard. The fire risk assessment was dated July 2004; this document needs to be reviewed as necessary and prior to the end of July 2005. It was noted that the fire extinguisher in the hall was partially block by a vacuum cleaner. Since the last inspection the registered manager has under the Control of Substances Hazardous to Health Regulations acquired data sheets from manufactures. Following obtaining this information it is now necessary to carry out risk assessments regarding these items as well as assessing the risk to employees of exposure and providing the necessary instruction and training. The registered provider stated that wheelchairs are checked and that three new wheelchairs were recently obtained for named individuals. Wheelchairs no longer required are going to be returned to stores / disposed of. Currently all wheelchairs are stored under the ‘back staircase’ the over spilling could cause a potential blocking of easy of access to the fire escape. One wheelchair was noted to have a flat tyre. It was noted that one resident was transferred in a wheelchair without footrests in place, this is potentially hazardous practice. Despite previous inspection reports it was noted that carers continue to be wearing certain amounts of jewellery. The ground floor bath has a portable hoist within it. Although this piece of equipment has a hand charger that will not allow the seat to descend if there is not enough power to raise the lift and the person this is only one component and therefore examinations are required. Under the Lifting Operations and Lifting Equipment Regulations 1998 personal lifting equipment need to be Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 21 thoroughly examined every six months. No other hoists are provided. A report on the passenger lift dated 17/05/05 contained no recommendations. Records seen demonstrated that electrical testing of portable appliances (PAT) had taken place; labels seen on appliances checked could also verify the test. It was noted that a small number of items had failed this test, although the registered person stated that these items were disposed of / removed from the premise the sheets indicating failure did not confirm that this action had taken place. The most recent report upon the hard wiring to British Standard 7671 is dated March 1997. The 1992 Requirements for electrical insulations or the Institution of Electrical Engineers (IEE) Wiring Regulations recommend that testing should take place every 5 years. Gas appliances were examined in November 2004. The new style accident book, which conforms to data protection legislation, is in place. The registered manager is aware of the need to notify the Commission for Social Care Inspection of certain event. It was noted that the information upon the accident form was not consistent with the information sent to Commission for Social Care Inspection. This demonstrated the need to ensure that recording on legal documentation is accurate. The majority of staff have undertaken training over the last four months in: • • • Fire safety Moving and Handling Basic food hygiene Storage cupboards were all locked and the cellar was free from combustible materials. Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x 2 x x 2 2 2 STAFFING Standard No Score 27 2 28 4 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 2 x 2 2 2 1 Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 (1) Requirement The Statement of Purpose must be an accurate reflection of the service provided within the home. 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 part met.) 3. 2 5 (1) (b) A copy of the homes terms and conditions must be provided to each resident. A written assessment must be completed before the admission of any service user, and in accordance with the requirements of Regulation 14 and Standard 3.3 Unless it is impractical, service users or their representatives must be involved in drawing up their individual plans. 30/06/05 Timescale for action 31/07/05 2. 1 5 (1) 31/07/05 4. 3 14 10/06/05 5. 7 15 (1) 31/07/05 Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 24 6. 7 15 (Previous timescale of 31/12/04 not met). Service user plans must be recorded in a style accessible to the service user, agreed and signed by the service user whenever capable and/or representative (if any). (Previous timescale of 31/12/04 not met). 31/07/05 7. 7 13 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 not met). immediate and on going 8. 8 14 17 (1) (a) Schedule 3 (o) Nutritional screening must be undertaken on admission, and subsequently on a periodic basis. (Previous timescale of 30/11/04 not met). Service users care plans must include specific details in order to ensure that carers are able to maintain oral hygiene needs. The registered manager must ensure that the keys to medication are held by an identified person at all times immediate and on going 9. 8 12 (1) 10/07/05 10. 9 13 (2) immediate and on going 11. 9 13 (2) Medication Administration Record immediate (MAR) sheets must show all and on known allergies. In the event of going ‘none known’ the MAR sheet must reflect this information. (Previous timescale of 30/11/04 not met). Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 25 12. 9 13 (2) The registered manager must ensure that medication administration records are correctly compiled and are completed at the time of administration. The registered manager must ensure that secondary dispensing does not take place. Current practice must cease immediatley. Medication training undertaken by carers must be accrediated. 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 not met). immediate and on going 13. 9 13 (2) immediate and on going 14. 15. 9 9 13 13 30/06/05 30/06/05 16. 16 22 The registered person must ensure that the complaints procedure seen displayed is in line with the required standard. (Previous timescale of 30/11/04 not met). 30/06/05 17. 21 23 (2) (b) The registered provider must ensure that the damaged bath panel is replaced. 30/06/05 18. 24 12 (4) Service user must have access to 31/08/05 a suitable lockable space within their own bedroom. (Previous timescale of 31/01/05 not met). 19. 24 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. 31/07/05 Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 26 20. 25 13 (3) (4) Water temperatures must be recorded in relation to bath water and random checks to ensure that thermostatic valves are functioning correctly. A Legionella risk assessment must be completed, and remedial action must be undertaken to address any identified risk. immediate and on going 21. 25 13 (3) (4) 30/06/05 22. 26 16 (2) (j) (Previous timescale of 31/12/04 not met). Suitable arrangements must be 30/06/05 taken to prevent the risk of cross infection including the provision of hand washing facilities. (Previous timescale of 30/11/04 not met). Adequate staffing levels must be maintained at all times. Staffing levels must not fall below the minimum requirement. 23. 27 18 (1) immediate and on going 24. 29 19 (Previous timescale of 20/11/04 not met). Recruitment procedures must be immediate developed in accordance with the and on requirements of Regulation 19 going and Schedule 2 of The Care Homes Regulations 2001, and Standard 29. (Previous timescale of 22/11/04 not met). All application forms must be scrutinised to ensure that there are no unexplained gaps in employment history, and all reasons for employment breaks must be recorded. (This standard was not assessed as part of the inspection carried out on 26th May 2005. The timeframe previously set 25. 29 19 Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 27 remains - this requirement will therefore be re- assessed as part of a future inspection.) 26. 29 19 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. (Previous timescale of immediate not met). 27. 30 18 (1) (c) (i) A staff training programme which meets National Training Organisation workforce targets must be in place. (This standard was not assessed as part of the inspection carried out on 12th May 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection.) 28. 33 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 not met). Records appertaining service user monies must be kept up to date. 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 Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 28 immediate and on going 31/07/05 29. 35 Schedule 4 (9) 17 (2) 18 30/06/05 30. 36 31/07/05 not met). 31. 37 17 (1) The registered persons must ensure that records specified in Schedule 3 of the Care Home Regulations 2001 are reviewed. (Previous timescale of 31/12/04 not met). The registered persons must ensure that records specified in Schedule 4 of the Care Home Regulations 2001 are reviewed. (Previous timescale of 31/12/04 not met). 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 not met). The registered manager must ensure that the Control of Substances Hazardous to Health risk assessments are reviewed. (Previous timescale of 30/11/04 not met). The registered manager must ensure that wheelchairs are well maintained and suitable to the individual need of service users for whom they are used. (Previous timescale of 31/12/04 not met). The registered manager must review the use of jewellery amongst staff in line with the health, safety and welfare of service users. (Previous timescale of 31/12/04 not met). Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 29 31/07/05 32. 37 17 (2) 31/07/05 33. 38 23 (4) immediate and on going 34. 38 13 30/06/05 35. 38 13 immediate and on going 36. 38 13 (4) (c) immediate and on going 37. 38 13 The hoist in the ground floor bathroom must be examined every 6 month. The hard wiring must be checked every 5 years. 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. 30/06/05 38. 39. 38 38 13 13 31/08/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 8 Good Practice Recommendations A record of each individual’s dietary intake should be recorded on a daily basis. (This recommendation was made within the previous report) 2. 9 Any handwritten entries on the MAR sheets should be checked and signed by a second member of staff. (This recommendation was made within the previous report) 3. 26 Consideration should be given to updating the home’s infection control policy. (This recommendation was made within the previous report) 4. 29 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 the previous Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 30 report) 5. 30 The homes training and development programme should be formally recorded. (This recommendation was made within the previous report) 6. 30 Induction records should be developed to ensure that the section pertaining to “personal care” is expanded to cover the exact topics covered within induction (This recommendation was made within the previous report) Pals Residential Home E52 S18669 PALS V223025 260505.doc Version 1.30 Page 31 Commission for Social Care Inspection The Coach House 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 E52 S18669 PALS V223025 260505.doc Version 1.30 Page 32 - 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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