Inspection on 19/05/05 for Pavilion Residential Home (The)

This inspection was carried out on 19th May 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 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

Pavilion Residential Home (The) 24/05/07

Pavilion Residential Home (The) 25/05/06

Pavilion Residential Home (The) 28/09/04

Pavilion Residential Home (The) 19/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE PAVILION RESIDENTIAL HOME 36 ST JOHNS ROAD BUXTON DERBYSHIRE SK17 6XJ Lead Inspector MARIE BONYNGE Unannounced Inspection Thursday 19th May 2005 at 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pavilion Residential Home Address 36 St Johns Road Buxton Derbyshire SK17 6XJ 01298 71422 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Guardian Care Homes Ltd Vacant Care Home 32 Category(ies) of OP registration, with number of places PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 28th September 2004 Brief Description of the Service: The Pavilion Care Home is a Victorian building close to the centre of Buxton, local gardens and leisure facilites. The provides accommodation and personal care for up to 32 older people. The home comprises of 20 en-suite bedrooms and 6 bedrooms without en-suite facilites. These are on 3 floors accessed by a passenger lift. There are 2 lounge / dining areas, one on the ground floor and one on the first floor. The home is served by a central kitchen and laundry. Garden areas are provided although access is limited to the rear garden. Car parking space is provided. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in May 2005. The main focus of this inspection was to follow up the progress made regarding the implementation of the requirements and recommendations from previous inspection reports and the implementation of a programme of refurbishment and upgrading of the building. The registered manager had left since the inspection in September 2004 and temporary arrangements had been put in place. A manager has now been recruited and has been in post for 4 weeks. The plans for upgrading the environment had not been implemented and no progress had been made in implementing the requirements from the previous inspection. Due to the seriousness of the issues found some immediate requirements were left on the day of the inspection and a detailed letter of serious concern was sent to the Responsible Individual. An urgent meeting was arranged with the Provider to discuss the issues raised and this has now taken place. An action plan has been provided to address these issues and the CSCI continues to monitor the home. What the service does well: What has improved since the last inspection? Improvements have not been made since the last inspection as highlighted in the main body of the report, action has not been taken to implement the requirements and recommendations made at the last inspection. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The standards in this section were not inspected on this visit and the requirements and recommendations made at the last inspection have been carried forward. The Inspector was advised that limited progress had been made regarding the reviewing and development of care planning. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The standards in this section were not examined and the requirements and recommendations made at the last inspection have been carried forward. The Inspector was advised that limited progress had been made regarding the development of care plans. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The standards in this section were not inspected on this occasion. These standards will be inspected at the next inspection of the home. One requirement has been carried forward from the last inspection report in respect of standard 12. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure was not effective and the protection of vulnerable adults training had not been completed. This did not serve to wholly protect residents. EVIDENCE: A complaints procedure was in place and service users interviewed said that they would speak to the manager or a member of staff if they were not satisfied with any aspect of the home. A book was in place to record complaints and one complaint was recorded, however the inspector was advised that not all complaints had been recorded including minor complaints. The manager had referred one incident to social services under the protection of vulnerable adult procedures, the outcome of this had not been concluded. Staff had not attended training regarding Derbyshire’s multi agency adult protection procedures although the protocols had been followed in this instance. A requirement has been carried forward regarding staff training from previous inspection reports. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 No progress has been made regarding the programme of upgrading and refurbishment of the building, residents do not therefore benefit from a safe, well-maintained and comfortable environment. EVIDENCE: Plans had been submitted to the CSCI in 2004 outlining an extensive programme of upgrading and refurbishment to the building. This programme of works had not been commenced and parts of the building were in urgent need of repair and maintenance. Service users interviewed expressed general satisfaction with their accommodation. No progress had been made with regard to giving service users access to the garden. Some residents said that they would like to be able to sit out in the garden and would benefit from being able to do this. A requirement has been carried forward in respect of this. A number of issues were identified as being in need of repair and maintenance. These were as follows: PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 13 • • • • • • • • • • • • • • • There was extensive water damage to the ceiling of the third floor of the building, this had also leaked into the stairwell of the second floor. There are two lounges / dining rooms provided, one on the ground floor and one on the first floor. There were some areas of cracked plaster above the door in the lounge and to the wall in bedroom 9 (next to the lounge) and in the en-suite toilet of bedroom 25. Many of the towels and flannels provided by the home were thin, worn and were frayed. Two of the toilets had signs on them saying ‘sluice’. These were reported as being used for sluicing purposes. It was reported that there was a need for separate sluicing facilities given the needs of some of the residents. There had been a fault on the nurse call system and repair work had been carried out, however the battery was low on a number of the call points and it was reported that the system was in need of major repair or replacement. Two of the corridor carpets were not adequately fixed to the floor, were frayed in a number of areas and presented as a potential trip hazard. Immediate action was required and taken by the manager to ensure that the area was safe. An immediate requirement was left in respect of this. Some locks had been provided to bedroom doors, however some of these were of a ‘yale’ type that could be double locked and prevent access to the room. A programme of the installation of locks had not been progressed. One service user said that they had requested a lock for their door but it had not been fitted. Lockable storage had not been provided in all of service users bedrooms. Some of the bedrooms were dark and did not provide sufficient lighting to enable reading or other activities. Some windows could not be opened for ventilation purposes, residents spoken with reported that sometimes it felt ‘stuffy’. A number of radiators were not guarded and did not have guaranteed low temperature surfaces. A number of window restrictors were not fitted securely and one window did not have restrictors fitted, a risk assessment had not been completed for this window. There was a very strong odour of urine in one bedroom and the carpet had not been replaced as required at the previous inspection. The mattress cover was torn and the mattress was heavily stained with a strong foul odour coming from the bed. The mattress and cover were required to be replaced immediately and an immediate requirement was left in respect of this. Water temperatures had not been monitored and an up to date certificate regarding design solutions to control the risk of Legionella was not in place. The tumble dryer was not working and wet laundry was being dried on radiators or being taken to a laundrette. C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 14 PAVILION RESIDENTIAL HOME Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Residents were not being supported and protected by the home’s recruitment policy and practices. EVIDENCE: A sample of staffing rotas was examined that indicated that the home was being staffed according to previously set minimum staffing levels. However, the Residential Forum guidance regarding staffing levels and the level of dependency of residents had not been used. There were 23 residents accommodated on this visit, with 2 residents in hospital. A number of residents were known to have dementia and at least 2 residents had high dependency needs. There were some staff vacancies and concerns were raised regarding staffing levels during holiday periods and staff sickness. Training for NVQ level 2 had not been progressed although the manager advised that enquiries had been made for this to enable training to be completed. Two staff files were examined for a kitchen assistant and a care assistant who were overseas workers. The homes recruitment policies and procedures had not been followed in respect of Criminal Record Bureau Checks (CRB), two written references and employment history. Both these members of staff were residing in the home, one in a vacant bedroom and one in an upstairs room previously used for activities purposes. An immediate requirement was left in respect of these practices. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 and 38 The health, safety and welfare of service users was at potential risk due to the lack of maintenance of safe working practices. EVIDENCE: The Registered Manager has resigned since the last inspection in September 2004 and the home has been without a manager in the interim period. Temporary arrangements had been put in place. A manager has now been appointed and has been in post for 4 weeks. An application has not yet been made to the CSCI for the manager to undergo the fit person process. Visits to the home had been made under Regulation 26, however these had not been completed on a monthly basis and did not identify the issues found on this inspection. A quality assurance system was not in place resulting in the aims and objectives of the home not being achieved. Action had not progressed to implement requirements identified in previous inspection PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 16 reports. Staff supervision had not been implemented although the newly appointed manager had begun to initiate formal supervision sessions. Certificates of maintenance had not been forwarded to the CSCI as requested at the last inspection in respect of gas safety, electrical safety and hot water systems for Legionella. A report regarding the maintenance of electrical systems and electrical equipment was dated 20th September 2004 had concluded that the wiring was ‘unsatisfactory’ and a number of recommendations were made. These had not been carried out and an immediate requirement was left in respect of this. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 2 2 1 2 1 1 1 STAFFING Standard No Score 27 2 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 2 x 1 x x 1 1 1 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) Requirement The statement of purpose and service user guide must be updated to reflect the changes identifed in standard 1. From inspection report 28.09.04. Service users must be provided with a statement of terms and conditions at the point of moving into the home. From inspection report 28.09.04. The registered person must ensure that all of the care plans are updated to ensure that they meet with national minimum standards. From inspection report 28.09.04. Care plans must include longerterm outcomes for service users. From inspection report 28.09.04. Timescale for action Previous timescale 01.02.05. New timescale 01.09.05 Previous timescale 01.02.05. New timescale 01.09.05 Previous timescale 01.02.05. New timescale 01.09.05 Previous timescale 01.02.05. New timescale 01.09.05. Previous timescale 01.10.04. New timescale 01.07.05 Previous Page 19 2. OP2 5 (1) (c) 3. OP3 15 (1) 4. OP3 15 (1) 5. OP4 12 (1) (a) 14 (1) (a) The registered person must not admit service users outside the homes registration category of Older People (OP). From inspection report 28.09.04. The registered person must 6. OP4 18 (1) (a) PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 7. OP7 15 (1) ensure that staff have individually and collectively the skills and experience to deliver the services and care which the home offers to provide including training in dementia care and mouth care. From inspection report 19.04.04. Care plans must include the follow up action and or interventions identified from risk assessments. From inspection report 28.09.04. timescale 30.08.04. New timescale 01.08.05 8. OP7 15 (1) (2) (b) 9. OP7 15 (1) 10. OP9 13 (2) 11. OP9 13 (2) 12. OP9 13 (2) 13. OP9 13 (2) Previous timescale 01.12.04. New timescale 01.08.05 Care plans must be fully Previous completed. From inspection timescale report 16.09.03. 31.12.03. New timescale 01.09.05 The service user plan must set Previous out in detail the action needs to timescale 30.08.04. be taken by care staff to ensure that all aspects of the health New personal and social care needs of timescale the service user are met. From 19.04.04 inspection report 19.04.04. Hand written instructions for the Previous administration of medication timescale must be signed by the person 01.11.04. prescribing the medication where New possible. From inspection report timescale 28.09.04. 01.07.05 A list of homely remedies must Previous be in place. From inspection timescale report 28.09.04. 01.12.04. New timescale 01.07.05 Medicines that are required to be Previous refrigerated must be stored in a timescale suitable lockable refrigerator. 01.02.05. From inspection report 28.09.04. New timescale 01.09.05 A controlled drugs register must Previous be provided. From inspection timescale report 19.04.04. 31.12.03. Version 1.30 Page 20 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc 14. OP12 16 (2) (n) Activities must be developed for service users with dementia or other cognitive impairments. From inspection report 28.09.04. All complaints must be recorded including minor complaints, the action taken and outcome. Staff must undertake the Derbyshire multi-agency training on adult protection procedures. From inspection report 08.10.02 Access to the garden must be provided for service users. From inspection report 16.09.03. 15. 16. OP16 OP18 22 13 New timescale 01.08.05 Previous timescale 01.02.05. New timescale 01.08.05 01.08.05 Previous timescale 31.12.03. New timescale 01.09.05 Previous timescale 31.01.04. New timescale 01.09.05 01.09.05 17. OP19 23 (1) (a) 18. OP19 23 (2) (b) 19. OP19 23 (1) (a) 20. 21. OP19 OP20 23 (2) (b) 23 (2) (b) 22. 23. OP21 OP21 23 (2) (b) 23 (2) (b) 24. OP22 23, 13 The registered person must ensure that the premises are kept in a good state of repair externally and internally. The registered person must provide the CSCI with an action plan including timescales for completion regarding the programme of works required. The areas of water damage must be repaired and made good. The cause of the areas of cracked plaster must be established and the areas must be repaired and made good. All linen provided by the home must be of good quality, any that is worn must be replaced. Sluicing facilities must be provided and located separately from service users toilet and bathing facilites. The nurse call system must be Immediate requiremen t issued. 02.06.05 01.09.05 01.09.05 01.08.05 01.10.05 01.08.05 Page 21 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 25. 26. OP21 OP19 12 13, 23 repaired / replaced and be in good working order. A suitable lock must be fitted to the door of the toilet on the first floor. The registered person must ensure that the corridor carpets are made safe and replaced. Service users must be provided with suitable locks to their bedroom doors, which they may actively choose to use - and in consultation with them and in accordance with risk assessed needs subject to consultation with the Fire Officer. From inspection report 28.09.04. Lockable storage must be provided. Lighting in service users accommodation must meet recognised standards (lux 150). From inspection report 28.09.04. 01.07.05 Immediate requiremen t issued. 30.06.05 Previous timescale 01.02.05. New timescale 01.12.05 27. OP24 16 (2) (c) 28. 29. OP24 OP25 16 (2) (c) 23 (2) (p) 01.09.05 30. OP25 23 (2) (p) 31. OP25 13 (4) (a) (c) 32. OP25 13 (4) (a) (c) 33. OP25 23 (2) (p) Previous timescale 01.02.05. New timescale 01.08.05 Windows must be able to be Previous opened for ventilation purposes. timescale From inspection report 28.09.04. 01.12.04. New timescale 01.09.05 The remaining radiators must be Previous timescale guarded and risk assessments completed for those outstanding. 01.01.05. From inspection report 28.09.04. New timescale 01.09.05 Window restrictors must be fitted Previous and risk assessments completed timescale for those outstanding. From 01.12.04. inspection report 28.09.04. New timescale 01.07.05 The cords to sash windows must Previous be repaired / replaced. From timescale inspection report 28.09.04. 01.12.04. New Version 1.30 Page 22 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc 34. 35. 36. OP26 OP26 OP25 12, 23 12, 23 13, 23 37. OP26 23 38. OP27 18 39. 40. OP28 OP29 18 13, 19, Schedule 2 41. OP29 13, 19 42. OP29 13, 19 43. OP31 9 44. OP31 9, 18 The carpet in the identified bedroom must be replaced. The identified mattress and cover must be replaced. The registered person must ensure the regulation of water temperature and design solutions to control the risk of Legionella. All equipment inlcuding the tumble dryer must be kept in good working order and repaired / replaced when necessary. The registered person must ensure that staffing numbers and the skill mix of staff are appropriate for the assessed needs of the residents according to guidelines from the Residential Forum. A training programme for staff to complete NVQ level 2 must be commenced with timescales. The registered person must provide details of the arrangements for the accommodation and supervision of the two members of staff and ensure that this does not affect the safety and welfare of the residents accommodated. Criminal Record Bureau checks at the appropriate level and a POVA check must be completed for staff prior to their employment in the home. Two written references must be obtained before appoiinting a member of staff and any gaps in employment records explored. An application must be submitted to the CSCI for the manager to undergo the fit person process. The manager must enrol on a timescale 01.08.05 09.06.05 21.05.05 01.08.05 01.06.05 01.07.05 01.08.05 02.06.05 Immediate requiremen t left. 30.06.05 Immediate requiremen t left 30.06.05 immediate requiremen t left 01.08.05 01.08.05 Page 23 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 45. 46. 47. OP33 OP36 OP37 course to complete NVQ level 4 or equivalent in management and care. 24, 26 A quality assurance system must be put in place including provider visits. 18 Care staff must receive formal supervision at least 6 times a year. OP17 (1) All required records must be (a) (2) (3) developed, kept up to date and (a) accurate. From inspection report 16.09.03. 18 (1) (a) Staff files must be up to date. All of the information identifed in Schedule 2 must be kept. From inspection report 19.09.03. 01.09.05 01.09.05 Previous timescale 31.12.03. New timescale 01.09.05 Previous timescale 31.12.03. New timescale 01.08.05 Previous timescale 01.12.04. Immediate requiremen t left 30.06.05. 48. OP29 49. OP38 12, 13, 18 Certificates of maintenance must be forwarede to the CSCI as soon as they have been completed. From inspection report 28.09.04. 50. 51. 52. 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. 2. Refer to Standard OP3 OP3 Good Practice Recommendations The homes assessment documentation should be expanded to include a comments section. The home should expand the details of the needs to be met when confirming in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 24 PAVILION RESIDENTIAL HOME 3. 4. 5. 6. OP8 OP9 OP25 respect of their health and welfare. A loop system should be considered. Hand washing facilties should be provided in the proposed treatment room. Secondary screening to bedroom windows should be considered to maintian service users privacy. From inspection report 28.09.05. PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 PAVILION RESIDENTIAL HOME C52 CO2 S20069 Pavilion V228745 190505 Stage 4.doc Version 1.30 Page 26 - 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. 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