Inspection on 25/07/07 for Paulmay Dementia Care

This inspection was carried out on 25th July 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

Paulmay Dementia Care 04/04/06

Paulmay Dementia Care 01/11/05

Paulmay Dementia Care 13/04/05

Paulmay Dementia Care 28/09/04

Paulmay Dementia Care 08/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Paulmay Dementia Care 17 Dukes Avenue Finchley London N3 2DE Lead Inspector Jane Ray Key Unannounced Inspection 25th July 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Paulmay Dementia Care DS0000010508.V333378.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. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Paulmay Dementia Care Address 17 Dukes Avenue Finchley London N3 2DE 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) 020 8346 3642 020 8349 3424 Mr Kevin Gurry Mrs Marjorie L Gurry Mrs Marjorie L Gurry Care Home 8 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th April 2006 Brief Description of the Service: Paulmay is a large double fronted Edwardian semi-detached house situated in a quiet residential area of Finchley in North London. The home is registered to provide care for eight older people who have some form of dementia. The home has one single and one double room on the ground floor. There are three single rooms and one double room on the first floor. The home has a stair lift to the first floor. There is a large lounge/dining area on the ground floor leading to the well-maintained garden. The stated aim of the home is to provide professional and skilled care to residents. This is within a friendly, family atmosphere where freedom, choice and dignity are maintained. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The current scales of charges range from £357 to £415 per week. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 25 July 2007 and was unannounced. This inspection was the annual key inspection and all the core standards were inspected. The inspection also checked how the service was progressing in meeting the requirement from the previous inspection that had taken place on the 12 December 2006. The inspection took six hours to complete. The inspector looked around the home and spent time speaking to the people living in the service. In the afternoon the inspector was able to meet a relative who gave some feedback on the home. The inspector also spoke at length to the deputy manager and one carer as well as receiving information from the other four care staff who were working during the day. The manager and registered provider assisted with the inspection. The care records, staff records and health and safety records were also inspected. What the service does well: A couple of the people living in the home were able to speak positively about the care they receive in the home. One person said “the staff are very caring and gentle”. The home is very small and provides an environment where the staff are able to focus on each person. The atmosphere in the home is friendly, with the residents enjoying each others company and chatting with the staff. The care plans and risk assessments were up to date and reflected the needs of the service users. They also demonstrated close working with other healthcare professionals when this is needed by the resident. Visitors are made very welcome when they come to the home. The individual staff were observed to be providing a high standard of personal care for the people living in the home. Some of the people living in the homes have complex and at times aggressive behaviours, which the staff manage in a calm, patient and appropriate manner. The staff were very positive about their work and when they spoke to the residents they demonstrated a good knowledge of their individual needs and a caring approach. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 6 The home was tidy and homely throughout. The lunch that was served during the inspection was tasty and nutritious. The staff provide a range of activities to stimulate the people living in the home. The staff are supported to do their work through ongoing training and supervision. The people living in the home are protected by effective procedures for health and safety and management of personal finances. What has improved since the last inspection? What they could do better: Nine requirements have been made at this inspection. One requirement was made under the heading health and personal care to support the people living in the home to have a dental check. A requirement was made in the complaints and protection section to ensure that the manager obtains a copy of the Barnet adult protection procedures and links in the local training in order to update the homes internal procedure. Four requirements were made in the environment section. This is to dispose of the broken hoist, ensure equipment is provided to enable all the residents to bathe, to eradicate unpleasant odours on the first floor, and seek advice from the environmental health officer about laundry arrangements to maintain standards of infection control. In the section on staffing one requirement was made. This is to ensure all staff have a copy of their ID in their staff record. Two requirements were made in the section called management and administration of the home. Firstly to undertake a portable electrical appliance Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 7 check and secondly to ensure staff all have food hygiene and moving and handling training. 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. Paulmay Dementia Care DS0000010508.V333378.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 Paulmay Dementia Care DS0000010508.V333378.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): Standards 1,2,3,4 and 5 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can be assured that they will be assessed as part of their admission process to the home. They will receive information about the home to help them decide if the service is right for them. They will have their individual needs met by a staff team who have a good understanding of how to support people with dementia. EVIDENCE: I read the current statement of purpose and service user guide and both these documents are clear and comprehensive and provide useful information to prospective residents. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 10 I looked at the case notes for four people living in the home. Three of them had a signed contract between themselves and the home and the manager explained that the contract for the final person had been sent to the relatives to sign. These documents clearly state what the home will provide and what residents are expected to pay for themselves. The two case notes for the people most recently admitted to the home also showed that each person had a detailed assessment provided by an appropriate care professional such as a social worker. In addition the home uses an assessment checklist, which is very comprehensive and was completed for each person. The main need of the people living in the home relates to their dementia. The staff training records show that all the staff have received training on dementia which equips them to carry out their work appropriately. The staff were also observed to have a good understanding of the needs of people with dementia and were able to appropriately support them with complex behaviours. The service user guide says that prospective residents are welcome to visit the home with their relatives. The staff spoken to during the inspection said that most relatives choose to visit the home without the resident, although the resident is welcome to also visit. The service does not provide intermediate care and so standard 6 was not inspected. Paulmay Dementia Care DS0000010508.V333378.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): Standards 7,8,9 and 10 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are receiving an good standard of personal care. They are also being supported to have their healthcare needs met, although some residents have not had dental checks. Service users are protected by appropriate medication systems in the home. EVIDENCE: I inspected four care plans. The care plans are based on the identified needs from the assessments. They clearly record what support each service user needs from the care staff. The care plans are comprehensive and include physical health, personal care, dietary needs, communication skills, mobility, religion and culture and care needs at night. Each service user also has a risk assessment. They all have a moving and handling assessment and this is designed specifically for people with dementia. A nutritional assessment is also Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 12 available. Other risk assessments are also available if required. The care plans and risk assessments have been reviewed on a monthly basis. The manager explained that the care managers attend review meetings on an annual basis but will come to the home if the needs of the person changes. The resident case notes were well organised and easy to follow. Daily reports are also completed for each person living in the home. It was observed during the inspection that some of the people living in the home show aggressive confused behaviour linked to their dementia. The care plans contain guidance on how this should be managed and the staff were observed supporting people in a kind, patient and appropriate manner. The health care records were inspected for four people living in the home. There is a clear record, of the healthcare input received by each person and these reflected their individual needs and demonstrated close working with other care professionals. Everyone was having regular input from the GP and optician and could access the chiropodist privately if required. None of the residents had a record of seeing the dentist. The manager explained that the home no longer received input from a visiting dentist except in an emergency and most of the residents could not go to the dentist. It was suggested that this should be taken forward with the PCT. The manager explained that none of the people living in the home have a pressure sore and they work closely with the district nurse if anyone shows signs of developing a pressure sore. The resident’s records all show they have their weight checked on a weekly basis. One resident had a record of her weight falling and it was positive to see that this had been addressed promptly with the GP and that the family had also been informed and a care-plan was in place to address her nutritional needs. I looked at the medication system in the home. The home does not use a monitored dosage administration system. This was discussed with the manager who explained that they had an excellent service from the pharmacist who visits the home and provides training for the staff. This pharmacist does not provide an administration system but as the home is small the preference was to keep working with the same pharmacist. The home has medication administration charts. These include a photo of each resident. The medication received in the home is recorded on the MAR sheet and there is a separate book for medication returned to the pharmacy. An audit trail for the medication is available. The MAR sheets were completed correctly. The temperature in the medication room is recorded daily. The staff training records were inspected for four staff and they had all received medication training. Control drugs that are in the home are locked in a separate secure cupboard and signed for appropriately by two staff when they are administered. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 13 Throughout the inspection the staff were observed supporting the people living in the home with their personal care, meals and moving around the home. This was done in a manner that respects the residents’ privacy. People living in the home can see visitors in the lounge or in their own bedroom. Paulmay Dementia Care DS0000010508.V333378.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): Standards 12,13,14 and 15 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users will be supported to enjoy a healthy and nutritious diet that meets their individual needs. People living in the home will be offered stimulating activities and opportunities to see visitors who will be made welcome in the home. EVIDENCE: I was able to observe the staff supporting the people living in the home throughout the inspection. The residents are able to exercise choice in terms of when they want to get up and eat breakfast. They can also ask for a drink whenever they want, although drinks are offered throughout the day. On the day of the inspection a number of activities were offered including listening to music, drawing, tactile games and gentle exercise. I was pleased to see that the television remained off and other stimulation from the staff was provided. The home has a pet cat and he provides interest and pleasure for the Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 15 residents. One of the residents will shortly be celebrating her 90th birthday and the manager explained that they are planning a party and all the relatives will be invited. The manager explained that whilst none of the residents go to church, some do enjoy watching programmes such as songs of praise. She also said she is actively requesting a Catholic priest to visit for one of the people living in the home. The staff and residents explained that visitors are made welcome in the home and this was observed when one relative visited the home in the afternoon. This relative said he felt his mother was “safe” in the home and that “the staff were very nice”. I spoke to residents about food in the home. They said that they enjoyed the meals. I looked at the record of food provided in the home and this was traditional and nutritious. During the inspection lunch was served. The lunch took place in a relaxed manner. The needs of residents who required a finely chopped meal were appropriately met. A choice of meal is available as required. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are able to access an appropriate complaints procedure. The staff have been trained to understand the protection of vulnerable adults. EVIDENCE: The complaints procedure is available in the service user guide and includes details of who complainants can contact. I looked at the record of complaints and there had been no complaints since the previous inspection. I looked at the staff training records for four staff and they had all received inhouse training on the protection of vulnerable adults. I spoke to a member of staff who was able to describe how she would recognise abuse and showed an understanding of what action she would need to take if she thought someone was being abused. The manager explained that she did not have a copy of the Barnet Adult Protection policy and had not yet attended training provided by Barnet social services. The homes policy did not reflect current adult protection procedures and needs to be reviewed. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 17 The manager explained that the home only holds pocket money for a few of the residents and does not act as their appointee. I checked the pocket money for three of the residents and these included a clear record of expenditure and receipts as needed. Generally money was only spent on hairdressing and the chiropodist. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 18 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): Standards 19,20,21 and 26 were inspected. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home have access to an environment that is homely and comfortable. Further work is needed to maintain standards of cleanliness and to enable all the residents to use the bath. EVIDENCE: I did a tour of the premises that consists of a double fronted Edwardian semidetached house over two floors. The home is located in an area with restricted parking but there is limited off street parking at the front of the house. The home has an attractive and well Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 19 maintained garden at the rear, with a pleasant patio area with seating available. The communal area in the home consists of a lounge / dining room. This was able to comfortably seat all the people living in the home. The home is very close to all the local shops and other amenities in Finchley Central. The decoration in the home is very traditional and generally in good order, although some furniture is showing signs of becoming worn. The home is not suited for people with severe mobility problems. The downstairs toilet requires going down two steps. The access to the rear garden is by external steps. The one bathroom in the home is on the first floor and requires the use of the stair lift. The staff and manager explained that not all the residents can access the bath. Discussions with the manager showed that she was already considering how this can be addressed and felt an automated bath-seat that lowered into the bath would be the best solution. This needs to be implemented as a matter of urgency. I also saw that there was an old broken hoist in the bathroom and this needs to be removed. I noted that on the first floor landing and in one bedroom on the first floor that there was an odour of urine. The deputy manager explained that the steam carpet cleaner had broken down a few days previously and was being repaired. The laundry is located in a separate room off the kitchen. The washing machine and dryer are both domestic models and a number of the people living in the home have issues of incontinence. The laundry arrangements in the home and the adequacy of the equipment available needs to be discussed with the environmental health officer to ensure standards of infection controlled are maintained. The front door is kept locked and this lock is linked into the fire alarm and will release as needed. On the first floor the fire exit is through the bathroom and the bathroom door is kept locked to safeguard the residents but can be opened with a coin. The inspector could see that a visit from the fire officer had deemed fire safety arrangements in the home to be adequate. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29 and 30 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a small stable team of staff who work in sufficient numbers and are appropriately trained. EVIDENCE: The staffing structure in the home consists of the manager, deputy manager, two senior carers and a team of carers. There are eleven staff on the staff team, including the manager. The staff rota was inspected. This showed that during the day there are three care staff working in the home from 9am to 3pm and two staff from 3pm to 9pm. At night there is one waking and one sleep-in member of staff. The manager is supernumerary. The staff turnover is very low with one new member of staff starting in the last six months and no staff leaving. The manager explained that at the time of the inspection three of the care staff have completed their NVQ training and six are studying for the qualification, which is an appropriate number of staff. It was observed that the manager is very supportive to the staff in completing this training and during the Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 21 inspection two staff came into the home for assistance in completing some work. The recruitment records for the one new member of staff and four long-term staff were inspected. All the staff had completed the necessary recruitment checks including a CRB disclosure and two written references. One member of staff did not have ID in her staff record. All the staff had a copy of signed terms and conditions. The two most recently recruited staff had a record of completing a comprehensive induction checklist. The manager explained that the emphasis at the moment is on supporting staff to complete their NVQ training, but she also arranges other refresher training as required. The manager trains the staff on dementia. I looked at the training materials she uses and these were very comprehensive and include information from organisations such as the Alzheimer’s Society. The training covers work on appropriate approaches to manage the challenges presented in supporting people with dementia. I spoke to the staff who said they had found the training very useful. The staff spoken to explained that they have regular staff team meetings, usually once a month and that these keep the staff up to date on operational changes in the home. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 22 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): Standards 31,33,36 and 38 were inspected. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in this home benefit from stable management arrangements and are supported to have input into the quality assurance process. Health and safety measures are in place apart from a portable electrical appliance check. EVIDENCE: The manager is also one of the owners of the home. She has the appropriate skills and experience and has care and management qualifications. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 23 At the time of the inspection the annual quality assurance exercise seeking the views of the service users, relatives and other care professionals associated with the home was starting to take place. I looked at the questionnaires that were being sent out to relatives and care professionals and these were a good standard. I also looked at the summary of the previous years exercise that was comprehensive. The supervision records were inspected for four care staff and they all had a record of regular supervision during the last six months. The member of staff spoken to confirmed that she had been supervised and that she was able to discuss any concerns relating to the home. The supervision records indicated that staff are able to review their performance and agree objectives and training needs. An annual appraisal has also been completed for each person. The staff training records were inspected for four care staff to see if their health and safety training was up to date. All of the staff had completed fire safety and first aid training. One member of staff needed food hygiene and moving and handling training. The manager explained that she does not yet have dates for the staff to complete this outstanding health and safety training. The fire safety measures were in place. The fire alarm had been serviced and the fire extinguishers had a date arranged for a service. The fire alarm had been checked weekly and drills had taken place quarterly. A comprehensive emergency fire plan and fire safety risk assessment was in place. Certificates to confirm the electrical installations, gas, stair lift and water system had been checked were available. There was no evidence that the portable electrical appliances had been checked. Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 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 2 3 3 2 x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 3 x 2 Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP8 Regulation 13(1)(b) Requirement The registered person must contact the PCT to make arrangements for the people living in the home to have a dental check. The registered person must arrange for the manager to receive training on local adult protection procedures and obtain a copy of the local policy. The homes own policy must be amended to reflect these procedures. The registered person must remove the broken hoist from the bathroom. The registered person must make arrangements for the bath to be made accessible for all the people living in the home, or for alternative facilities to be available. The registered person must take the steps necessary to eradicate the unpleasant odour on the first floor. The registered person must contact the environmental health department to ensure that DS0000010508.V333378.R01.S.doc Timescale for action 30/09/07 2. OP18 13(6) 30/09/07 3. 4. OP21 OP21 13(4) 23(2)(n) 31/08/07 31/08/07 5. OP26 16(2)(k) 31/08/07 6. OP26 16(2)(j) 31/08/07 Paulmay Dementia Care Version 5.2 Page 26 7. OP29 17(2) 8. OP38 13(4) 9. OP38 13(3)(5) laundry arrangements in the home maintain adequate standards of infection control. The registered person must ensure that all the staff have a copy of their ID in their staff records. The registered person must ensure the portable electrical appliances have a maintenance check. The registered person must ensure that all the staff have completed food hygiene and moving and handling training. 31/08/07 31/08/07 30/09/07 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 Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Paulmay Dementia Care DS0000010508.V333378.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!