Inspection on 17/01/07 for Pantiles Residential Care Home

This inspection was carried out on 17th January 2007.

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

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

Other inspections for this house

Pantiles Residential Care Home 20/09/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pantiles Residential Care Home 67 Harriots Lane Ashtead Surrey KT21 2QE Lead Inspector Joseph Croft Unannounced Inspection 17th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pantiles Residential Care Home DS0000067929.V325424.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. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pantiles Residential Care Home Address 67 Harriots Lane Ashtead Surrey KT21 2QE 01372 275310 01372 279201 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) The Pantiles Care Home Limited Paula M J Johnson Care Home 16 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (16) of places Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Pantiles care home is registered to provide care for 16 older people. The home is a large detached house set in a residential road, close to the village of Ashtead. The home offers fourteen single bedroom accommodations, and one double bedroom. Nine of the bedrooms have en-suite facilities and there are ample bathrooms, shower facilities and toilets throughout the property. There is a range of communal areas including a lounge, conservatory and dining room. The garden is well maintained and secure for all residents to use. Car parking is offered to the front of the house. The fees for this home range from £435 to £480 per week. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 17th January 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This inspection was conducted by Regulation Inspector Mr J Croft and was assisted throughout the site visit by the manager who was representing the establishment. The inspection took place over a period of 7 hours commencing at 10:00 and concluding at 17:30 hours. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments and staff recruitment files. Other documents sampled included the staff duty rota, menu, policies, medication and records of medicines. The Inspector had discussions with the responsible individual the manager and staff on duty. The Inspector also had discussions with several residents and he observed practice and staff interaction with residents during the inspection. The Inspector also had discussions with one relative who was present during this inspection. Feedback from residents was complimentary about the home and the standard of care they receive from the staff. Both residents and staff were complimentary about the new owners and the registered manager of the home, stating the quality of residents’ lives had improved. The pre-inspection questionnaire completed by the home has been used as a source of evidence in the findings of this report. Comment cards were received from residents, their relatives and other associated visiting professionals, and these have been used as a source of evidence in this report. The inspector would like to thank the manager, staff and residents for their cooperation during this inspection. Feedback was provided to the to the responsible individual and the manager at the end of the inspection. Eight requirements have been during this inspection. What the service does well: Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 6 Residents are provided with an up to date Statement of Purpose and service users guide. Care files sampled evidenced that prospective residents had a pre- admission assessment of their needs undertaken prior to moving into the home. All care plans had been reviewed and updated by the manager and staff. Residents are provided with opportunities to improve their lifestyle and are offered a healthy balanced diet. The home has a complaints procedure in place that gives clear procedures and guidance of how to make a complaint, who to complain to, timescale for responding and investigating complaints. The arrangements for management and administration ensure the home is run in the best interests of residents, and the safety of residents is promoted and safeguarded. What has improved since the last inspection? What they could do better: The Inspector noted that no risk assessments were written for all residents. A record of medicines received into the care home must be maintained. Risk assessments for residents who self-administer medication must be produced. The manager must ensure that another designated and appropriately trained member of staff witnesses the administration of Controlled Drugs. The leaks in the ceilings of the identified areas of the home must be repaired immediately. The Registered Person must forward to the Commission For Social Care Inspection Surrey Local Office, an action plan with timescales of how the identified issues in regard to the décor of the home is to be achieved. The Registered Person must carry out a review of staffing levels to ensure there sufficient staff on duty at all times to meet the assessed needs of Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 7 residents. Staff recruitment files must include reasons for gaps in employment recorded, POVA first checks and Criminal Record Bureau clearances. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 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 Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 1,2,3,6 were assessed. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with up-to-date information about the home to enable them to make an informed choice. The needs of residents have been assessed prior to their admission to the home. EVIDENCE: The home has a Statement of Purpose that is provided to prospective residents enquiring about the home. The discussions with residents and relatives present during the inspection informed the Inspector that they had received a copy of the home’s Statement of Purpose. Comment cards received prior to this inspection informed that residents living at the home had received enough information about the home to enable them to make the right decision about where to live. Each resident had a copy of the service user guide that included a copy of the home’s Complaints Policy and Procedure. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 10 The inspector sampled the care files of two recent admissions to the home. These evidenced that prospective residents had a pre- admission assessment of their needs undertaken by the manager and a senior carer prior to admission to the home. It included information in regard to personal care, mobility, communication and personal safety. This information was used to form the basis of the residents’ care plans, which identified the actions that carers should follow to assist an individual living at the home. The assessments sampled had been signed and dated by the person who undertook the assessment. Residents spoken to informed the inspector they visited the home for a day prior to moving in. The home has an Admissions Policy and Procedure in place that is currently being reviewed and updated. The home does not offer intermediate care. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Standards 7, 8, 9 and 10 were assessed. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are in place, however, risk assessments must be produced for all residents. Residents are supported in a dignified and respectful manner. Procedures in regard to the safe administration of medication must be reviewed to ensure the health and safety of residents. EVIDENCE: On the day of the inspection two care plans were sampled as part of the case tracking process. Information in the care plans included personal care needs, nutrition, mobility, continence, orientation, health care and how the general care needs of individual residents are to be met. The care plans are generated from the pre-admission assessments, and had been by signed by residents and /or their representatives. There was evidence of monthly reviews having been carried out. The manager informed the inspector that care plans for all residents had been reviewed and updated since the new owners bought the home in September 2006. Care plans were detailed in regard to meeting the Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 12 assessed needs of residents. During discussions with the Inspector residents stated they were aware of the care plan. Members of staff were able to give an account of the contents of care plans for the residents with whom they key work, and were aware of the need to review care plans on a monthly basis. Staff stated they support residents to make choices about themselves, the activities they like to do and the food they would like to eat. Staff maintain daily records on each resident, which were evidenced for the residents who were part of the case tracking. Health care needs had been recorded in care plans, and evidence that residents are registered with the GP and have access to all NHS services was observed. Records of appointments are maintained in individual care files. Only one of the care files sampled evidenced risk assessments were in place. The manager stated not all risk assessments had been completed. A requirement in regard to this has been made. At the time of writing this report, the manager notified the inspector that all risk assessments have now been completed. Records of nutrition and monthly weights were observed in the care files sampled. The manager stated that training in regard to tissue viability is to be organised. The district nurse visits the home on a weekly basis, and advises on the areas of tissue viability. The home has a policy in place for the administration of medication. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. Medication recording charts sampled did not provide the total of medication received into the home. A requirement in regard to this has been made. Medication is appropriately stored in secure medical cabinets. Staff stated they had received training in regard to the administration of medication. The manager stated that some residents do self-administer medication, but risk assessments had not been put into place. A requirement in regard to this has been made. The storage of Controlled Drugs (CD) complies with the Misuse of Drugs (Safe Custody) Regulations, and a CD register is maintained. However, it was noted that a second member of staff does not witness the administration of Controlled Drugs. A requirement in regard to this has been made. The home has a contract in place for the disposal of medication. Records of medicines returned to pharmacy were maintained by the home. During discussions with the Inspector the residents stated they can see the GP when required, and that they receive the medical support they need. The manager and staff stated residents are able to see the GP in the privacy of their bedrooms when a home visit is required. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 13 On the day of the inspection staff on duty were observed interacting with residents in a supportive manner, and addressing residents by their preferred names. During discussions staff stated residents have access to a telephone in the home, and calls can be taken in private. Residents’ privacy and dignity is respected throughout by staffs knocking on bedroom doors, addressing each of the resident by their preferred names, helping residents to be independent and providing personal care in the privacy of resident’s bedrooms. This was confirmed during discussions with residents. Comment cards returned by residents informed that they always receive care and support when needed, that staff listen and act on what they say, and that staff are always available. This was reiterated during discussions with residents on the day of the inspection. Residents spoken to were complimentary about the staff working at the home. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 12, 13, 14 and 15 were assessed. This judgement has been made using available evidence including a visit to this service. Residents are provided with opportunities to improve their lifestyle and are offered a healthy balanced diet. EVIDENCE: Residents spoken to were complimentary about the home, the care they receive, their lifestyles within the community and the variety of meals provided. The home organises activities each day for residents to take part in if they wish to. The pre-inspection questionnaire completed by the manager informs that activities on offer include an extensive book collection, quiz time, extended exercises, visiting theatres and a small animal farm. Residents stated church leaders provide Holy Communion once a month. Residents spoken to state they choose which activities they join in with, and they can spend time in their bedrooms listening to music, watching television or reading. Residents stated they are made aware of what the activity is for the day as it is displayed on the notice board in the hallway. One resident spoken to has his own computer and access to the Internet, which the resident stated keeps him busy. Some residents stated they could visit the local shops. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 15 On the day of the inspection the activity was extended exercises. The majority of residents attended this activity. The inspector had discussions with the person delivering this activity, who informed the inspector that she attends every Wednesday to conduct this exercise. This person also informed the inspector that, in their view, the new manager and owners of the home have improved the quality of life for residents, and that the home is being managed to a high standard. Residents stated there are no restrictions on visitors to the home, and they can see their visitors in the privacy of their bedrooms. The relative of one resident visiting on the day of the inspection informed the inspector that they could visit within reasonable times and take their relative out. They also stated that the staff are always welcoming, their relative receives a good standard of care and that they are kept informed about the care of their relative. Residents spoken to state they make decisions about their lives, handle their own financial affairs, and are able to have their own personal possessions with them. The home uses a four-week rolling menu that is displayed on the notice board in the hallway. Menus submitted to the Commission For Social Care Inspection Surrey Local Office in the pre-inspection questionnaire provided evidence that balanced meals are offered to residents. Meals included meat, fish, fresh vegetables and fresh fruit. The inspector joined residents for lunch, which was a chicken casserole and rice. It was observed that residents who did not like the meal were offered an alternative. A member of the staff team was available in the dining room throughout the meal to offer assistance and support as and when required. The meal was observed to be a relaxed unhurried occasion with residents conversing with each other. Relaxing music was being played quietly in the background. During discussions residents stated the food was very good, and they can ask for an alternative meal. Breakfast is always a choice of cereals, toast and tea or coffee. Residents spoken to stated they could not eat a cooked breakfast, but would be provided with one if they requested it. The home does not employ a chef; therefore staff are responsible for cooking the food, existing staff had received training in food hygiene. The manager stated that training for new staff is in this area is to be delivered by an external training agency in February 2007. The manager stated that the menus would be discussed at the next resident meeting that is to be held on the 23rd January 2007. The food was appropriately stored in fridges and freezers, and daily records of temperatures were maintained. The manager stated that the storage of food is being reviewed, and that a new storage area is to be provided. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 16 The kitchen is in need of refurbishment as the cupboards are worn, the floor tiles are cracked and an extractor fan for the cooker needs to be installed. Requirements in regard to this have been made under the Environment section of this report. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 16 and 18 were assessed. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Staff having knowledge and understanding of adult protection issues protects residents. EVIDENCE: The home has a Complaints Policy and Procedure that includes time scales and the Commission For Social Care Inspection Surrey Local Office details. A copy of this is included in the Service Users Guide that is provided to all residents. Residents spoken to stated they would talk to the home’s manager if they needed to make a complaint. The manager stated there have not been any complaints since they took over in September 2006. Comment cards received from residents and other associated professionals stated they had a copy of the complaints procedure, had not made a complaint, and indicated that residents knew who to talk to if they needed to make a complaint. The manager stated the home has an inherited Protection of Vulnerable Adults Policy that is currently being reviewed and updated in line with the Surrey Multi-Agency Procedures of February 2005, which the home has a copy of. The manager attended the Surrey Multi-Agency Training in regard to the Protection Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 18 of Vulnerable Adults in November 2006. The manager stated that refresher training for all staff in this area is to be provided by an external training company on the 20th February 2007. During discussions with staffs they provided an accurate account of the procedures to be followed in the event of abuse or suspected abuse of residents. The home has a Whistle Blowing Policy and Procedure. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Standards 19, 24 and 26 were assessed. This judgement has been made using available evidence including a visit to this service. The general standard of the environment requires attention to ensure residents are provided with a safe, secure and homely place to live. EVIDENCE: A tour of the premises was undertaken, during which it was observed that the home had three separate leaks on the flat roofs, one in the bathroom, one in the conservatory and one in a corridor. The manager had closed the affected bathroom, and residents are able to use the other bathing facilities in the home. The manager stated the owners had been made aware of the leaks and that appropriate action was being taken to have them repaired. An immediate requirement has been made in regard to the leaking roof. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 20 Since the day of the inspection, the manager has informed the Commission for Social Care Inspection Surrey Local Office that quotes have now been received and that the repair to the leaking roof is to be undertaken. Bedrooms were appropriately furnished with chest of drawers, relaxing chair and lockable facilities. Residents had their own possessions and photographs in their bedrooms. Nine of the bedrooms have en-suite facilities. During discussions residents informed the inspector that their bedrooms were comfortable and contained all they need. Comment cards received from residents informed that the home is kept fresh and clean. It was observed that residents could access all communal parts of the home. The home has grab rails and adaptations such as bathing aids and a new stair lift. The new owners have replaced all call bells throughout the home, which are easily accessible to residents. The manager stated that new adapted baths and showers are to be provided in the home. Discussions took place with the manager and the responsible individual in regard to problems with the premises when the new owners purchased the home. The registered provider stated the owners are aware that the kitchen is in need of redecoration, and that some bedrooms require attention to the décor, that the fire escapes must be replace, and covers must be fitted to all radiators. A requirement has been made that the registered person must forward to the Commission for Social Care Inspection Surrey Local Office, an action plan with timescales of how the identified issues are to be achieved. The responsible individual and manager stated they are investigating ways of improving the environment, which will include replacing all windows with double glazing and the possibility of extending the rear of the premises that will include new laundry facilities and food storage areas. Some communal areas of the home have had new carpets, and the manager stated all carpets would be renewed throughout the home. The home has a large garden to the rear of the property that can be accessed by residents via a ramp from the conservatory. The home has an Infection Control policy, and as with all Policies and Procedures, the home is currently reviewing this. On the day of the inspection the home was found to be tidy and free from offensive odours. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Standards 27, 28, 29 and 30 were assessed. This judgement has been made using available evidence including a visit to this service. The staff team supports residents to ensure their needs are met, but staffing levels must to be reviewed to ensure the needs of residents can be met throughout the twenty-four hours. Training needs for staff is addressed. The home has a recruitment policy and procedure in place, however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. EVIDENCE: The staff duty rota for the month of the inspection was viewed. This provided evidence that there are three members of staff on duty during the early shift, with the manager as supernumerary, and two members of staff on duty during the late shift. The home has one waking night staff on duty each evening. The manager stated one of the care staff currently lives on site, and therefore covers the sleep in duties. It was noted that the home does not employ a chef or domestic staff, therefore the staffing for the late shift must be reviewed, as this could leave residents at risk if there is only one member of staff available whilst the other staff member was attending to the evening meal. The pre-inspection questionnaire forwarded to the Commission for Social Care Inspection Surrey Local Office informs that 43 of staff currently working at Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 22 the home holds the minimum of an NVQ level 2 and /or above. The manager stated that another three members of staff are due to commence NVQ training. The home has a Recruitment Policy and Procedure in place that has been reviewed by the home’s manager. Random sampling of recruitment files evidenced that one member of staff had commenced employment before the results of POVA first check or Criminal Record Bureau clearances had been received by the home; another recruitment file did not record reasons for gaps in employment. The manager stated that whilst reviewing the recruitment files of staff inherited from the previous owner, one recruitment file did not contain a Criminal Record Bureau clearance or two references. The registered person must take appropriate action to safe guard residents at all times, and ensure these persons do not work unsupervised until the appropriate clearances have been received. An immediate requirement has been made in regard to these. The manager has forwarded information of how these issues have been addressed. Each member of staff has a training file that contains records of supervision and training undertaken. The manager stated that new staff had undertaken an in-house induction, but not a’ Skills to Care’ programme of induction. These packs have been applied for each new member of staff recently employed at the home. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 31, 33, 35, 36 and 38 were assessed. This judgement has been made using available evidence including a visit to this service. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the residents. There is a strong ethos of being transparent and open in all areas of running the home. EVIDENCE: The manager was registered with the Commission for Social Care Inspection in September 2006 when she commenced her duties. The manager has a number of years experience working within residential care, the last ten years in senior positions, and is currently undertaking the NVQ level 4 Registered Managers Award (RMA). The manager informed the inspector that she has a job description and clear lines of accountability. The manager informed the Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 24 inspector that all Policies and Procedures relating to the care practices of the home are being reviewed. During discussions, staff stated the manager is very approachable, always available and has an open door approach to management. Staff feel they are supported and are receiving regular formal one to one supervision. Residents stated they feel the manager runs the home in an efficient and responsible manner. Quality assurance is undertaken by the home through questionnaires for residents, their relatives and other associated professionals. These had been sent on the 12th December 2006, and are gradually being returned to the home. The registered person stated she has visited the home on a weekly basis since September 2006, and will be conducting Regulation 26 visits in the future. Residents meetings have been arranged for January, May and September 2007. The manager informed the inspector that residents are responsible for their own finances. Staff had attending mandatory training, and dates for refresher courses had been set, which will ensure the health and safety for all residents is promoted. The pre- inspection questionnaire forwarded to the Commission for Social Care Inspection Surrey Local Office provided evidence that health and safety records are appropriately maintained and up to date. The new owners had a fire risk assessment undertaken by an external agency on the 16th November 2006. Remedial action had been identified in regard to fire risk; the registered person stated that these issues would be addressed within the given timescales stated in the report. Substances Hazardous to Health were appropriately stored in a secure locked cupboard. Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 25 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? New Service 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 2 Standard OP7 OP9 Regulation 13 (4) (c) 13(2) Requirement The Registered Person must ensure risk assessments are written for all residents. The Registered Person must ensure a record of medicines received into the care home is maintained. The Registered Person must ensure risk assessments for residents who self-administer medication are written. The Registered Person must ensure that another designated and appropriately trained member of staff witnesses the administration of Controlled Drugs. The Registered Person must ensure the leaks in the ceilings of the identified areas of the home are repaired. The Registered Person must forward to the Commission For Social Care Inspection Surrey Local Office, an action plan with timescales of how the identified issues in regard to the décor of the home is to be achieved. The Registered Person must DS0000067929.V325424.R01.S.doc Timescale for action 17/02/07 01/02/07 3 OP9 13 (4) (c) 01/02/07 4 OP9 13 (2) 18/01/07 5 OP19 23 (2) (b) 17/01/07 6 OP19 23 (2) (b) (d) 17/02/07 7 OP27 18 (1) (a) 07/02/07 Page 27 Pantiles Residential Care Home Version 5.2 8 OP29 19 (1) (a) (b) undertake a review of staffing levels. The Registered Person must 17/01/07 ensure staff recruitment files include reasons for gaps in employment recorded, POVA first checks and Criminal Record Bureau clearances. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pantiles Residential Care Home DS0000067929.V325424.R01.S.doc Version 5.2 Page 29 - 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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