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Inspection on 28/06/06 for Pals Residential Home

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

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Relatives and residents spoken to were complimentary about the care provided by the service and it`s staff. The service maintains a homely feel and individuals spoken to were appreciative of the home. Many residents living in the home have lived there for some time and were very settled. The home promoted open visiting and staff were very courteous to visitors on the day of inspection.

What has improved since the last inspection?

Since the time of the previous inspection, a new bath hoist has been acquired and a deputy manager has been appointed into post.

What the care home could do better:

Health and safety must be improved, along with care records, staff recruitment, staff training, staff supervision, food delivery, quality assurance,home management and social, occupational and recreational activities. Failure to do so could place residents at risk.

CARE HOMES FOR OLDER PEOPLE Pals Residential Home 79 Ombersley Road Worcester Worcestershire WR3 7BT Lead Inspector N Richards Unannounced Inspection 28th June 2006 12:45 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.V301934.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 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.V301934.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 November 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. The fees range from £365 per week to £415 per week, and do not include private healthcare or items such as toiletries and newspapers. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over an afternoon period, and focused on key National Minimum Standards. Opportunity was taken to interview staff, residents and relatives during the inspection process, along with an opportunity to observe care practice. Care records, staff records, and environmental records were examined in conjunction with a detailed examination of the home’s physical environment. Within the past 12-month period, the CSCI has received one complaint from the relative of a former resident. The complaint related to service delivery and resulted in immediate requirements being issued in relation to care plans, preadmission assessments and categories of registration. The response from the provider has been disappointing as the issues identified within the complaint investigation have not been addressed and rectified by the registered provider and registered manager. Many of the National Minimum Standards assessed during this inspection have not been complied with. What the service does well: What has improved since the last inspection? What they could do better: Health and safety must be improved, along with care records, staff recruitment, staff training, staff supervision, food delivery, quality assurance, Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 6 home management and social, occupational and recreational activities. Failure to do so could place residents at risk. 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.V301934.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 6, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although information is available for prospective residents, the information presented is not always accurate. Pre-admission assessments require development to ensure that the needs of prospective residents are effectively assessed prior to any decision being made about residency within the home. EVIDENCE: Both the Statement of Purpose and the Service User Guide were examined during the inspection. While the information contained within the documents was comprehensive, some data was inaccurate and required updating. The two previous inspection reports acknowledge the considerable amount of time placed by the registered person in 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 reports. 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 Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 9 occurred a copy of both documents must be sent to the Worcester office of the CSCI. The Statement of Purpose says, “Each resident will have an individual Care Plan drawn up in consultation with them which addresses their requirements”. All care files examined on the day of inspection failed to contain a preadmission assessment and care plan. Immediate requirements had previously been issued to the home to ensure that pre-admission assessments are undertaken prior to any prospective resident taking up residency within the home, and care plans are formulated following admission to the home. Immediate requirements had not been complied with. The Statement of Purpose also claimed that vegetarian options are available on the menu. The menu, when examined, failed to demonstrate any alternative option to the main (only) course offered. All files examined contained a contract. The home does not contract to provide intermediate care. Therefore Standard 6 is not applicable to the home. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. Appropriate systems are not in place for care planning and health care screening. As such, there is no assurance that the health and social care needs of residents will be appropriately met. EVIDENCE: A random sample of residents’ files was examined. None of the files contained a plan of care. This is a serious, fundamental and potentially dangerous flaw. A plan of care is the end point of the assessment of the individual, and care must be delivered in accordance with a plan for each individual resident within the service. As such, the plan becomes the yardstick for judging whether appropriate care is delivered to the individual resident. Care plans are dynamic documents that will change as regular assessment of the resident reveals changing needs. The absence of care plans highlights a fundamental problem with the service provided by the home, and the manner in which the home is managed. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 11 Immediate requirements have been issued historically to the home in direct relation to care planning. These have not been complied with. An immediate requirement was again issued to the home on the day of inspection regarding the home’s failure to develop and implement care plans. Failure to comply with the immediate requirement will result in the CSCI considering enforcement action against the home. Residents interviewed were confident that staff respected their privacy and dignity. Medication records were examined at the time of the inspection. The home’s newly-appointed deputy has developed a list of all medicines prescribed for residents, the reason for the medication having been prescribed and has placed the list amongst each individual resident’s MAR (Medication Administration Record) chart. A copy of the Royal Pharmaceutical Society of Great Britain’s “The Administration and Control of Medicines in Care Homes and Children’s Services” has been acquired by the home, and is to be used as the home’s operational policy for medication – particularly as the home’s current policy consists of just one single page, and is too vague in terms of content, instruction and direction. As the Royal Pharmaceutical Society’s policy is a generic policy, the home must ensure that the policy is streamlined to reflect the medication system used/operated by and within the home. The overall standard of medication management within the home has improved, but there are still inadequacies noted in staff recording onto the preprinted MAR charts – which could place residents at risk. Examples of poor recording include; (1) Medication not having been signed for on MAR charts (daily records showed that although the MAR chart had not been signed, the prescribed medication had actually been given to the resident at a later time). Another resident’s MAR chart had not been signed, but when the medication was actually examined, the tablet was not in the blister pack. The audit was unable to establish whether the resident had (a) been given the medication and the staff member had forgotten to sign the MAR chart, or (b) the resident had refused the prescribed medication and the staff member had forgotten to enter a corresponding code onto the MAR chart and MAR charts manually altered with no corresponding countersignatories to confirm authenticity of the manual alteration(s). (2) The registered manager was providing medication training to care staff. There was no documentary evidence available to confirm that the registered manager was competent to provide medication training. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 12 It was noted, when medication stock was checked, that a resident was receiving Temazepam 20mg. This was not being managed in accordance with Controlled Drug (CD) procedure (given the actual dose prescribed and recorded evidence of Temazepam abuse within residential care settings). Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. Whilst residents can freely receive visitors, the social, occupational, recreational and leisure opportunities within the home require improvement to ensure residents are actively occupied with meaningful activities. Food provision requires further development to ensure residents are provided with quality food and offered a choice and variety in their daily activities. EVIDENCE: The daily records of a sample number of residents showed a range of activities undertaken over recent weeks. Information regarding activities was displayed in the lounge. Residents are able to bring personal possessions into the home. Information regarding a local advocacy service was contained within the Statement of Purpose, which was available in the entrance hall. The menu was examined during the inspection. The menu was not available to residents in so much as it was not circulated to individual residents. The menu was based on a three-week cycle, and failed to offer a choice or variety of meals. Typically, the food offered for the main meal of the day consisted of (for Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 14 example) roast lamb, followed by rice pudding or jelly and ice-cream. The evening meal routinely consisted of “a selection of sandwiches, salads, fresh fruit or a selection of sweets and yoghurts”. The menu failed to offer flexibility. Opportunity was taken to examine the kitchen area. All meals are provided from a central kitchen. The food stock was examined. Bags of potatoes were located on the floor by the kitchen sink. The potatoes were sprouting roots, and when prompted, staff removed the potatoes for disposal. The refrigerator contained a range of foods including bottled items – many of which had no date of opening. One food item had passed its expiry date. On prompting, staff removed the expired product and undated products for disposal. Catering staff require training to enhance their knowledge and awareness of safe food storage. The deputy manager estimated that 12 out of the 14 residents living in the home possessed short-term memory problems. On arrival in the lounge, it was noted that many residents were sat in chairs without any method of engagement from staff. A television was on, but very few residents were actually engaged by the television. One resident was seen with her next-of-kin in attendance. Opportunity was taken to interview the resident and her nextof-kin, who all expressed their appreciation of the service provided within and by the home and its staff team. One criticism expressed was the view that social, occupational, recreational and leisure opportunities were limited. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. The current complaints procedure needs slight amendment, but systems are in place to ensure residents know how to, and whom to complain should the need arise. EVIDENCE: During the inspection, a copy of the home’s complaints procedure was clearly visible on display. The procedure was open and transparent – thereby enabling people to understand how, when and to whom complaints should be made. The procedure required minor amendment to ensure the correct details of the regulatory authority are accurately displayed. Residents and their visiting relatives said they knew who to raise concerns with, should the need arise. A copy of Worcestershire’s vulnerable adults procedure was available within the home. Residents interviewed said that they felt safe within the home. Within the past 12-month period, the CSCI has received one complaint from the relative of a former resident. The complaint related to service delivery and resulted in immediate requirements being issued in relation to care plans, preadmission assessments and categories of registration. The response from the provider has been disappointing as the issues identified within the complaint investigation have not been addressed and rectified by the registered provider and registered manager. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. While many environmental issues within the home are satisfactory, health and safety measures and controls are at times inadequate and potentially place residents at risk. 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. All bedrooms were examined during the inspection. Many had been personalised demonstrating individuality and autonomy. Five bedrooms have en-suite facilities. No programme of routine maintenance and renewal of the fabric of the building was available within the home. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 17 Several bedroom doors possessed locking devices that could only be activated outside of the bedroom(s) – meaning that; (a) residents are unable to promote and maximise their privacy whilst they are within their bedrooms, and (b) residents are at risk of being accidentally or deliberately locked in their rooms without any over-ride facility – representing a clear, potential health and safety risk to residents. Several bedroom windows located above ground level lacked window-opening restrictors – which represented a clear health, safety and security risk to residents – from residents sustaining injury through accidental (or deliberate) falls from the windows, and from persons potentially gaining unauthorised access to the home from outside. The layout of some bedrooms requires reviewing to ensure that residents’ independence is promoted. For example, a wardrobe in one bedroom had been positioned directly in front of a light switch – resulting in the resident who occupied the room experiencing extreme difficulty turning the overhead light on and off. While most communal bathrooms and toilets possessed a pull cord to turn the light on and off, one toilet possessed a push-switch. This represents a clear and potential risk to residents as someone may attempt to switch the light off, having used the toilet facilities, with a wet or damp hand – resulting in possible electrocution. Opportunity was taken to examine the linen storage cupboards. There appeared to be sufficient linen for residents’ usage. However, one storage cupboard contained hot water pipes that had not been insulated (representing potential for someone to sustain accidental injury through contact burns), failed to contain an overhead mains operated smoke detector (as there was a source of heat and combustible materials within the cupboard) – but possessed a notice on the door which read “Keep locked. Fire Hazard”. The door was not locked. The ground-floor bathroom was examined. The door failed to possess an internal lock. A locking device was fitted to the outside of the door (see note above), and towels were being stored in the bathroom area (which contravenes infection control principles). The home benefits from a large ground-floor communal lounge area. The lounge is, however, long and thin with an outlook into the car park. Opportunity needs to be taken to review the lounge to see how the area can be best used for the residents who have memory loss problems (12 out of 14 people reportedly possessed memory loss problems, and those who were seated within the lounge at the time of inspection were not being actively engaged in meaningful activities). Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 18 Although most areas within the home were visually clean and tidy, several areas (noticeably some bedrooms) possessed some bad odours. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 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. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. The home’s management of staffing is poor, resulting in potentially dangerous recruitment procedures being undertaken, and significant failings in undertaking basic pre-employment checks. Staff training is poor with little evidence of staff having received robust training pertinent to the care needs of the residents the home has been entrusted to look after. This potentially places residents at risk of deliberate or accidental harm. EVIDENCE: Staff employment procedures, supervision and training within the home are critically poor, and borders on negligent and dangerous practice. Basic safeguards are routinely not being undertaken. 30 of staff files were examined at the time of inspection. Although all possessed an application form, one third of those examined were incomplete. The member of staff had not cited an employment history prior to September 2005 and there was no education history or details on file. These are dangerous omissions given that care staff are working in positions of trust with very vulnerable people. One file contained just one written reference, and the information on the reference form used was of very little use. There was no ability to comment on Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 20 the applicant’s work performance, questions were basic, and generally consisted of a “yes/no” response i.e. “Would you re-employ?” The recruitment process undertaken within the home was ineffective in terms of protecting residents. One person was interviewed 14 days before an application form was completed. This results in the interviewer not being able to explore the data supplied by an applicant on an application form during the interview, neither does it allow the home to scrutinise applicants before making a decision whether or not to shortlist for interview. The registered provider did explain that staff recruitment can sometimes be difficult. However, the employment processes being undertaken by the home sacrifices safety for convenience, and places residents at unacceptable risk. 66 of staff files examined failed to contain an up-to-date CRB (Criminal Records Bureau) check. No staff member whose file was examined had received any formal supervision, and there was no training and development programme. The training records available were basic and there was no evidence of anybody having received training specific to the assessed needs of the residents within the home. One member of staff interviewed confirmed that she had not received any training within the previous 12-month period. Staff interviewed confirmed that they had not received any training specific to the needs of people with memory loss problems (12 out of 14 residents reportedly possessed memory loss problems). Staff also explained that the registered manager had provided medication training. There was no evidence available to confirm that the registered manager was competent in the provision of training for medication management. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 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, 32, 33, 36, 37 and 38. The quality outcome for this area is poor. This judgement has been made using available evidence including a visit to this service. Management within the home is weak. This is clearly evidenced within the main body of this report, and demonstrated by the number of Standards that have been assessed and not complied with. A total of 24 out of 32 National Minimum Standards assessed have not been complied with (representing 75 non-compliance). EVIDENCE: Although the registered manager has many years experience in caring for older people, and has attended training in the past it is not in line with the qualifications as listed within the National Minimum Standards i.e. a level 4 NVQ (National Vocational Qualification) in management and care or equivalent. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 22 Quality assurance or quality monitoring systems are not in place, and must be developed in accordance with the specifications of National Minimum Standard (NMS) 33 (Care Homes for Older People). 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 NMS 36 is taking place. There was no evidence available to confirm that portable appliance testing had taken place. The certificate regarding the last landlord gas safety check was also in excess of 12 months old and therefore in need of renewal. Since the time of the previous inspection, the ground-floor bath hoist has been replaced. Water temperature checks in relation to total immersion, and checks to ensure that thermostatic valves are functioning correctly were not being undertaken. A Legionella risk assessment had not been undertaken, and the registered person had not complied 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 – which was dangerously lacking. Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 23 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 2 3 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 3 3 3 2 3 2 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X X 1 1 1 Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 24 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. (This requirement remains unaddressed from the previous inspection report) 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. (This requirement remains unaddressed from the previous inspection report) 3. OP3 15 A comprehensive pre-admission assessment that meets the specifications of NMS 3.3 must be undertaken for all prospective residents. A plan of care generated from a comprehensive assessment must DS0000018669.V301934.R01.S.doc Timescale for action 31/08/06 31/08/06 31/08/06 4. OP7 15 31/08/06 Pals Residential Home Version 5.2 Page 25 5. OP7 15 be drawn up with each resident, and must provide the basis for the care to be delivered. Plans of care must set out in 31/08/06 detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident are met. Care plans must be drawn up with the involvement of the resident, agreed and signed by the resident whenever capable and/or their representative (if any). 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). Care plans must be reviewed by care staff at a frequency of not less than once a month. 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. (This requirement remains unaddressed from the previous inspection report) 31/08/06 6. OP7 15 7. OP7 15 31/08/06 8. OP7 15 31/08/06 9. OP7 13 31/08/06 10. OP8 14, 17(1)(a), 17(3)(o) Nutritional screening must be undertaken on admission, and subsequently on a periodic basis. (This requirement remains unaddressed from the previous inspection report) 31/08/06 11. OP9 13 (2) The registered manager must DS0000018669.V301934.R01.S.doc 31/08/06 Page 26 Pals Residential Home Version 5.2 ensure that medication administration records are correctly compiled and are completed at the time of administration. (This requirement remains unaddressed from the previous inspection report) 12. OP9 13 Medication training undertaken by carers must be accredited. (This requirement remains unaddressed from the previous inspection reports) 13. OP9 13 A policy and procedure for the receipt, recording, storage, handling, administration and disposal of medication must be drawn up and implemented. (This requirement remains unaddressed from the previous inspection reports) 14. OP15 16(2)(i) Supply nutritious, varied, balanced and attractively presented meals. The menu must provide healthy eating or vegetarian options. Menus must be made available to residents to examine and make an informed choice. Residents must be given opportunities to express their preferences for food, and opportunity must be taken to comply with the preferences expressed. Catering staff must be provided with training in relation to the safe management and storage of food. DS0000018669.V301934.R01.S.doc 31/08/06 31/08/06 31/08/06 15. OP15 16(2)(i) 31/08/06 16. OP15 16(2)(i), 18(1) 31/08/06 Pals Residential Home Version 5.2 Page 27 17. OP15 16(2)(i) The menu must evidence the provision of five portions of fruit and vegetables each day (in line with healthy-eating guidelines). Staff must enable residents to take opportunities to maintain and develop meaningful social, occupational, recreational and leisure activities. The registered person must ensure that the complaints procedure seen displayed is in line with the required standard. (This requirement remains unaddressed from the previous inspection report) 31/08/06 18. OP12 12(2) 31/08/06 19. OP16 22 31/08/06 20. OP19 13(4)(a) All windows located above ground floor level must be restricted to an opening width not exceeding 100mm. (An immediate requirement was issued at the time of inspection to promote the health and safety of residents living within the home.) 31/08/06 21. OP19 12(1)(a) A programme of routine maintenance and renewal of the fabric of the building must be developed and implemented. All bedroom doors must be fitted with appropriate single-action locking devices that residents can operate, and which staff can over-ride with a master key in the event of an emergency. Bedroom layouts require reviewing to ensure that residents’ independence is promoted. DS0000018669.V301934.R01.S.doc 31/08/06 22. OP24 13(4)(a) 31/10/06 23. OP24 12(1)(a) 31/10/06 Pals Residential Home Version 5.2 Page 28 24. OP21 12(1)(a) Communal bathrooms and toilets must possess pull cords to activate and deactivate lighting. All hot water pipes must be insulated or boxed-in. Mains-operated smoke detectors must be fitted to any area where combustible materials are stored, and where a source of heat exists. All fire doors marked “keep locked” must be kept lock to contain fire should a fire occur. The ground-floor bathroom door must be fitted with a suitable locking device that can be activated and deactivated from inside the bathroom, and be over-ridden by staff from outside the room in the event of an emergency. The external door lock must be removed. Towels must not be stored in communal bathrooms. 30/09/06 25. 26. OP19 OP19 13(4)(a) 23(4)(c)(i ) 30/09/06 30/09/06 27. OP19 23(4)(c)(i ) 13(4)(a) 31/08/06 28. OP21 30/09/06 29. 30. OP26 OP22 16(2) 23(1)(a) 31/08/06 The communal lounge must be 30/09/06 reviewed to ensure that it is suitable for residents living within the home – with particular reference to the outlook from the lounge windows. All areas of the home must be kept free from offensive odours. All persons applying for employment within the home must submit a completed application form, which must be scrutinised prior to interview. Any gaps must be explored during the interview process. DS0000018669.V301934.R01.S.doc 31. 32. OP26 OP29 16(2)(k) 18(1)(a) 31/08/06 31/08/06 Pals Residential Home Version 5.2 Page 29 33. OP29 18(1)(a) At least two satisfactory written references must be received prior to any member of staff taking up employment within the home. (This requirement remains unaddressed from the previous inspection report) 31/08/06 34. OP29 18(1)(a) The home’s reference form must be reviewed to ensure that vital information such as previous employer’s observations about the individual’s work performance is recorded down. All staff must be in receipt of a clear, enhanced CRB check prior to taking up employment within the home. If this is not possible, a “Pova1st” check must be undertaken as a basic minimum requirement. (This requirement remains unaddressed from the previous inspection report) 30/09/06 35. OP29 18(1)(a) 31/08/06 36. OP30 18(1)(a) All staff must receive structured 31/08/06 induction undertaken by somebody appropriately qualified and competent to do so. All staff must be formally supervised in accordance with the specifications of Standard 36 at least six times each year. All staff must have an individual training and development programme based on the needs of the residents and the home’s Statement of Purpose. The stafftraining programme must meet National Training Organisation DS0000018669.V301934.R01.S.doc 37. OP36 18(1)(a) 31/08/06 38. OP30 18(1)(a) 30/09/06 Pals Residential Home Version 5.2 Page 30 specification. 39. OP30 18(1)(a) All staff must receive a minimum of three paid days training per year. 30/09/06 40. OP30 18(1)(a) Persons suitably competent, 31/08/06 skilled, experienced and qualified to do so must provide all training delivered. Water temperatures must be recorded in relation to bath water and random checks to ensure that thermostatic valves are functioning correctly. (This requirement remains unaddressed from the previous inspection report) 31/08/06 41. OP25 13 (3) (4) 42. OP25 13 (3) (4) A Legionella risk assessment must be completed, and remedial action must be undertaken to address any identified risk. (This requirement remains unaddressed from the previous inspection reports) 31/08/06 43. OP33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (This requirement remains unaddressed from the previous inspection report) 31/08/06 44. OP38 23 (4) 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. DS0000018669.V301934.R01.S.doc 31/08/06 Pals Residential Home Version 5.2 Page 31 (This requirement remains unaddressed from the previous inspection report) 45. OP38 13 The registered manager must ensure that the Control of Substances Hazardous to Health risk assessments are reviewed. (This requirement remains unaddressed from the previous inspection report) 46. 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. A copy of both the revised Statement of Purpose and Service Users Guide must be supplied to the local office of the CSCI. (This requirement remains unaddressed from the previous inspection report) 48. OP38 13 The registered person must ensure that suitable procedures are in place to maintain portable electrical appliances. (This requirement remains unaddressed from the previous inspection report) 31/08/06 30/09/06 30/09/06 47. OP1 4 (2)5 (2) 31/08/06 Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 32 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) Pals Residential Home DS0000018669.V301934.R01.S.doc Version 5.2 Page 33 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.V301934.R01.S.doc Version 5.2 Page 34 - 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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