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Inspection on 03/11/05 for Partridge House Nursing And Residential Care Home

Also see our care home review for Partridge House Nursing And Residential Care Home for more information

This inspection was carried out on 3rd November 2005.

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

Partridge House provides a specialist service for older people with mental health problems. The permanent staff have specialised in mental health needs and as such are able to provide care to meet the assessed needs of the residents. The home is purpose built and all levels are reached by lift. This gives residents large areas within the home and gardens where they can walk without need for constant supervision and a large conservatory allows the garden to be enjoyed by all residents. Catering within the home is good and fresh fruit is provided in the lounges. On previous visits residents have stated that the food was, on the whole, good and that they enjoyed their meals.

What has improved since the last inspection?

The standard of tidiness and maintenance within the home has been showing a great improvement over the past nine months, this had previously been a matter of concern. The home is now a pleasant place for residents to live in. Staff files and some staff training shows improvement and this should be maintained.

CARE HOMES FOR OLDER PEOPLE Partridge House Nursing And Residential Care Home Leybourne Road Off Heath Hill Avenue Bevendean Brighton East Sussex BN2 4LS Lead Inspector Elizabeth Dudley Unannounced Inspection 3rd November 2005 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 Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Partridge House Nursing And Residential Care Home Leybourne Road Off Heath Hill Avenue Bevendean Brighton East Sussex BN2 4LS 01273-674499 01273-693332 Address 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) Anchor Trust Vacant Care Home 38 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (38) of places Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirtyeight(38) Service users should be aged sixty (60) years or over on admission Date of last inspection Brief Description of the Service: Partridge House is a purpose built home that was developed in partnership between Anchor Trust, ARDIS and Brighton and Hove Social Services to provide care for 24 older service users with mental health problems. Fourteen new rooms were recently added bringing the number of service users able to be accomodated to 38. This will provide 30 nursing beds, 6 for residential care and 2 for respite care. A new conservatory has recently been added to the building. All of the accomodation provided is in single rooms which have en-suite facilities and the home is divided into four units. The gardens are well maintained and accessible to all service users, a shaft lift gives access to all parts of the building. Anchor Trust is a not for profit organisation and ARDIS is a local charity providing services for people with dementia. Partridge House is situated in a residential area, local transport links are poor, but there are good car parking facilities. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 3rd November 2005 and was undertaken as part of the investigations for concerns raised around adult protection. The inspection was facilitated by Mr Cliff Parker, the recently appointed manager and Ms S Helliwell, deputy manager. As this was an inspection, compliance with past requirements was also addressed. During this inspection residents were spoken with only briefly, some records pertinent to the case being investigated, or previous requirements were examined, and a tour of the home was undertaken. Care staff were not spoken with on this occasion. A pharmacy inspection by CSCI was also taking place on the same day, this was coincidental, and there was no involvement with the concerns raised. The report from the pharmacy inspector will be included in this report. Thanks are extended to residents , staff and management for their courtesy and hospitality during the inspection. What the service does well: What has improved since the last inspection? Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 6 The standard of tidiness and maintenance within the home has been showing a great improvement over the past nine months, this had previously been a matter of concern. The home is now a pleasant place for residents to live in. Staff files and some staff training shows improvement and this should be maintained. What they could do better: The failure of Anchor Trust to comply with immediate requirements is causing concern, likewise the inability to recruit and retain staff. Investigations as to why this is happening must be implemented as there is danger that residents may not receive the appropriate amount of skilled care needed in this highly specialised area. Care plans have found to be lacking, insomuch they are not identifying or addressing new needs of the residents. Likewise the standard of recording was found to be poor, with the accuracy of some of the information causing doubt. Although time and money has been invested by the company in training of staff in adult protection, the correct reporting procedures were still not being implemented, senior staff within the home must ensure that they familiarise themselves with this and cascade this to all levels of staff. There was a time lapse in a resident receiving correct medical treatment and as there are registered nurses employed, this is not acceptable. The pharmacy inspector found the need to make requirements around the storage and administration of medication. The manager must ensure that registered nurses take responsibility for their accountability and are observant and vigilant in the administration of medication. With the appointment of a manager, it is hoped that these outstanding and concerning issues will be rectified Please contact the provider for advice of actions taken in response to this Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The home provides sufficient documentation to ensure that prospective or existing residents are informed about the home. However this must be kept under review. The home must be robust, prior to admitting residents, in ensuring that they can meet their needs. EVIDENCE: The statement of purpose meets the requirements but requires reviewing in light of recent management changes within the home, this also applies to the service users guide. The complaints procedure is now in these documents but again needs reviewing to reflect changes. All prospective residents are assessed by the deputy manager or a delegated registered nurse, in the past staff have taken in residents whose needs they could not fully meet, partly because of the block contract held with the PCT. This must not happen and trained nursing personnel must feel able to make this decision. If the needs cannot be met, or only partially met, then the resident must not be admitted, this also applies to those residents with Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 10 physical needs that the staff are not trained to meet. Prospective residents or their representatives can visit the home, and all residents are admitted for a trial period. The statement of terms and conditions given to residents on their point of admission to the home does not meet the standard, requiring a breakdown of fee details to show who pays which portion of the fees. This has been a previous recommendation and in the past, a requirement. Assurances that this had been done were previously given, but it had not been added to the main part of the terms and conditions, therefore this is again made a requirement. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,The standard of care planning in reflecting the current needs of these residents was poor. Lack of attention to care plans puts residents at risk of not receiving appropriate care. A review of medication handling was undertaken by a CSCI pharmacist inspector. Storage of medicines was secure in all parts of the home. Documented evidence was on occasions incomplete. Procedures of the home on safe practice are not always adhered to. EVIDENCE: Only two care plans pertinent to the concerns being investigated where examined. There was evidence that reviews of these care plans had failed to be reviewed on two months of the past six, however the rest of the time these had been reviewed monthly. There was evidence that residents or their representatives are involved in the formation or review of the care plan. Care plans did not address the needs of the residents following the change in their physical needs relating to the concerns raised. No specific care plans had been drawn up to address these incidents, notes had only been made in the Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 12 daily care notes, which were difficult to find and any agency nurse not familiar with the resident would not think to look over back notes. Although both sets of injuries were ongoing, the daily care plans had been archived at the back of the care plan and no awareness given that these may reflect current needs. There was no awareness that either resident may have difficulty with diet, or that one may have difficulty with the physical act of getting food into their mouth. The daily notes also gave the wrong information for one resident, not giving the correct limb affected, and had not followed instructions given by the hospital relating to support of the affected limb. There was evidence that the correct action of sending the resident to hospital had not occurred until the following day. With the second resident the relative had reported finding the resident injured, this had not been noted by care staff. No care plan addressing the incident or its implications on nutrition was in place and there did not seem to be any awareness in the daily notes of the restrictions that the incident may place on the patients ability to eat. There was no evidence that this had been addressed or that there may be a need for a prosthetic application. There was no indication of whether the resident was able to eat the meal offered on their return from hospital, only that it was offered. The standard of care planning is poor, although the general care plans are good, this falls down when incidents happen and trained staff do not consider forming a new care plan. Although care plans are reviewed the manager must now assess whether the care plans relate to the residents current or changing needs or are the review dates being written in without full attention to the content of the care plan and whether this still reflects real condition of the resident. The medicine storage area temperature is monitored and remains around 28– 30°C. Medicines policies will need to be reviewed in the light of the change to a different supplier. There is a weekly audit in place to check MAR sheets are correctly filled in. Any externals when applied by care staff should be signed for by the trained member of staff who checks that this medicament has been administered. Photocopied MAR sheet from the previous supplier were seen for respite care service users. These are fine except they necessitated the use of correcting fluid! These are hand written and one item was recorded as ‘TDS’ i.e. to be given three times a day. This was in fact given once a day. This chart related to three weeks and not one nurse had queried this anomaly. Examples Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 13 were noted for a variable dose where the actual amount administered was not recorded. A verbal order for pain relief was not verified. The medication front sheet, which gives a short information profile on service users, was incorrect for one service user and indicated that medication administration ‘must be observed’ for another service user. It was difficult to work out when the next Injections for Vitamin and depot injection were due. Controlled drugs storage and records were good. From two service users used for case tracking there was a concern on each one. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 The standard of catering is good, providing a varied menu for residents. Provision of activities needs addressing in order that residents may lead as fulfilled a life as their condition permits. EVIDENCE: Although the provision of activities has improved and some care assistants have now received training in the provision of activities for this category of resident, the activities records still reflects poverty of both imagination and types of activities provided. This has to be addressed and it is still urged that the home employs an activities person who is skilled in this very important part of providing a balanced, fulfilled life for residents of this category. Past visits to the home have noted the improvements made to the menus and that fresh fruit is put in the lounges for residents. This improvement has been maintained, with the majority of cakes and puddings being homemade and resident’s choices of meals being identified. The member of staff who takes the menu around must sign the daily menu. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 15 The cook stated that she feels that some of the pureed food is still being mashed together when it arrives on the unit, although it leaves the kitchen with separate components identified. It is recommended that the home invests in the individual moulds available, which would also allow the resident to identify what they are eating. The cleanliness in the kitchen has been addressed. It should be emphasised that this was only made a requirement following one visit to the home, on previous occasions this has been good. On that occasion the home’s own cook was not working. All fridge, freezer and hot food temperatures had been recorded and where within recommended parameters. All staff working within the kitchen have their food hygiene course. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The knowledge about reporting adult protection issues is poor and this could lead to concerns around the safety of residents. EVIDENCE: This inspection was undertaken following concerns raised around the knowledge of the methods of reporting adult protection issues. This had been explained to senior staff several times over the past two years and also guidelines had been issued. The reporting criteria was not followed and therefore had the need for a police investigation been identified, this would have been impossible to commence due to the actions taken by the home. Records show that the majority of staff, including senior staff (with the exception of the recently appointed manager) have attended adult protection courses. Therefore it is particularly concerning that the correct procedure was not followed. It is thought that the concerns being investigated may fall within the adult protection category, however at the present time, further discussion and meetings are required and this will probably be unable to be confirmed either way. The manager must check that the policies in the home correctly address the reporting of adult protection. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The standard of cleanliness, tidiness and maintenance in the home is good, providing a pleasant home for residents. EVIDENCE: The home is looking very clean, tidy and well maintained. This improvement was noted on the last visit to the home and has been maintained. All curtains were seen to be on their hooks and window restrictors tested were in place. Continence pads had been left on window sills around the home and these were removed by the manager as he went around. He is asked to continue addressing this issue Some paving slabs in the garden which were identified as being a hazard have still not been removed and this was an immediate requirement at the last visit. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 18 This will be made an immediate requirement again and it will be expected that it is addressed. The company has not met the requirement made at the last inspection in that tiles in the kitchen required replacing and some regrouting was needed. It is appreciated that the company intends to replace this with stainless steel but the repairs should have been made pro tem, particularly as the requirement was supposed to have been complied with by September 30th 2005, no request for this date to be amended was received by CSCI. Due to the infection control hazard of cracked and broken tiles, this will now be made an immediate requirement. Although most of the home was in a clean condition, the bath in one of the communal bathrooms was found to be unclean, staff must check the condition of baths when they have finished in the bathrooms. In general the home is free from noxious odours, however attention should be paid to the ground floor lounge and conservatory where there is some odour apparent. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 EVIDENCE: The home has received requirements in the past around the lack of permanent staff employed, and although several recruitment drives have taken place, staff are still not being employed or retained. This is now a matter of concern as during the months of September and October 2005, the amount of shifts covered by agency staff were excessive. In September, 63 registered nurse shifts were covered by agency staff and 331 shifts were covered by care staff. In October 62 trained staff shifts and 230 care staff shifts were covered by agency ( these figures were provided by the deputy manager and checked by the manager at the inspector’s request on the day of inspection). Concerns relating to why staff are not being retained, why staff are unable to be employed and whether the needs of the residents are being met are raised. As these residents require care from staff who are trained in this speciality, and more importantly have chosen to specialise in what can be a very difficult category of illness, using agency staff from a general agency who have neither the skills or knowledge to care for these residents may result in their assessed needs not been met and residents not receiving the quality of care and understanding that they deserve. Anchor Trust must now address this issue as a priority, particularly as further Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 20 action has been taken on a previous occasion by the CSCI and by the Local Authority. Recruitment files examined were in order with documentation as required by Schedule 2, however there was some discrepancy regarding a residency permit and this must be addressed. Staff cannot be employed unless they have the appropriate documentation. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,38 Anew manager has been appointed which will give stability to residents, some health and safety issues need addressing to ensure residents safety EVIDENCE: A new manager, Mr Cliff Parker, has been recently appointed and has been in post since mid October 2005. He is an RGN but will be undertaking a specialist course in caring for the elderly person with mental health needs. He also intends to study for the registered manager’s award. He will be forwarding his application for registration with the CSCI following his probationary period with Anchor Trust. Mr Parker has previous experience of managing care homes in London for the past four years. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 22 The majority of the health and safety requirements from the last inspection were addressed, however, on the last inspection, the company was required to forward a copy of their electrical wiring certificate and recent fire risk assessment to the CSCI as this was not in place in the home. This was an immediate requirement and this has not been complied with. A further requirement will be made. Failure to comply with requirements, immediate or otherwise, could lead to the commission taking further action. Although residents in the home at present have their room doors closed, policies need to be put in place and an action plan formed to protect any resident that may wish to have their doors left open, in the event of fire within the home. This was a previous recommendation. Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 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 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 3 x x x x x x 2 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 2 Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 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 Reg 4&5 Requirement That the statement of purpose and service users guide contain amendments as identified in the main body of the report. That the statement of terms and condition includes a fee breakdown.( This was a previous recommendation) That no service user is admitted to the home unless their needs can be fully met, and where required additional training is given to enable staff to meet these needs.( This was a previous requirement and is ongoing) That all parts of the care plan are reviewed on a monthly basis. ( This was a previous requirement Sept 1st 2005) That the reviewed assessed needs of the service user are written in the main body of the care plans and that these reflect the current and changing needs of the service user, that reviews of care plans assess whether the care plan identifies needs that are current and still viable. DS0000014021.V262363.R01.S.doc Timescale for action 01/12/05 2 OP2 Reg 5 (1)(a) Reg 14 (a) 01/12/05 3 03/11/05 4 Reg 15 (2)(b) Reg 15(2) Reg 13(b) 01/12/05 5 01/12/05 Partridge House Nursing And Residential Care Home Version 5.0 Page 25 6 Reg 15 (2) 7 Reg 13(6) 8 Reg 13(6) 9 Reg 13(4) 10 11 12 Reg 12(4) Reg 13(3) Reg !8(1)(a) 13 14 Reg 18(1)(a) Reg 19 Shed 2 Reg 13(4) 15 16 Reg 23(4)(a) That care plans are accurate and reflect appreciation of changes of needs which may occur due to the sudden change in a service users’ condition. That senior staff within the home, consolidate their knowledge of adult protection reporting and cascade this to all levels of staff That the manager checks that the policies within the home are correct with relation to the adult protection reporting procedure. That those garden items that could pose a hazard to service users are removed.( This was a previous immediate requirement) That replacement continence equipment is not left around the home. That staff check the cleanliness of baths following service user use. Anchor trust to ensure that at all times suitably qualified , competent and experienced persons are working at the home and ensure that temporary workers will be able to meet service users needs. Recruitment to continue and reasons for non-retention of staff examined. The appropriate residency documentation to be checked and copies retained prior to employing staff. That the IEE certificate and risk assessment are completed and evidence sent to the CSCI(This was a previous immediate requirement) That a policy is formed to address the safety of any service users admitted to the home who wish to keep their room doors DS0000014021.V262363.R01.S.doc 03/11/05 03/11/05 20/11/05 03/11/05 03/11/05 03/11/05 03/11/05 03/11/05 03/11/05 03/11/05 01/12/05 Partridge House Nursing And Residential Care Home Version 5.0 Page 26 open (This was a previous recommendation) 17 OP9 Reg 13(2) 18 Reg 13(2) 19 20 Reg 13(2) Reg 13(2) Policies and procedures around medicine management to be reviewed to reflect current practice The records on MAR charts to reflect accountability, accuracy, legibility and avoid the use of correcting fluid To Keep profile sheets up-to date. Instigate a clear system for due dates for injections 01/02/06 10/11/05 10/11/05 10/11/05 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 OP15 Good Practice Recommendations That moulds for pureed food are provided to keep the components separate, to prevent the pureed food being mashed together and to allow service users to identify what they are eating. That staff taking around the daily menus, sign the menu on completion in order to confirm that they have seen all residents. 2 OP15 Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Partridge House Nursing And Residential Care Home DS0000014021.V262363.R01.S.doc Version 5.0 Page 28 - 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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