Inspection on 01/02/07 for Pear Tree Lodge

This inspection was carried out on 1st February 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

Pear Tree Lodge 26/01/09

Pear Tree Lodge 12/01/06

Pear Tree Lodge 30/09/05

Pear Tree Lodge 28/02/05

Pear Tree Lodge 23/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Pear Tree Lodge Shaw healthcare (Homes) Limited Pear Tree Lodge 340 Preston Road Kenton Middlesex HA3 0QH Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 1st February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pear Tree Lodge DS0000017483.V325616.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. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pear Tree Lodge Address Shaw healthcare (Homes) Limited Pear Tree Lodge 340 Preston Road Kenton Middlesex HA3 0QH 020 8385 1640 020 8385 1642 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) Shaw healthcare Limited Mr Manny Tagulinao Care Home 9 Category(ies) of Learning disability over 65 years of age (9) registration, with number of places Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Pear Tree Lodge belongs to Shaw Homes, a national provider of care services. The home is found on the Preston Road and is about two minutes walk from local shops and facilities. It is easily accessible by public transport. There is a good bus service along the Preston Road and the Underground station is about five minutes walk away. There is limited parking on the grounds of the home, but additional parking can be found on the nearby roads. The home benefits from a maintained garden at the back and some lawn areas in the front and on the side of the building. The home is a converted big house. Service users are accommodated in single bedrooms on two floors. There are four bedrooms on the ground floor and five bedrooms on the first floor. The main kitchen, dining/lounge area and the laundry are on the ground floor. The first floor also has a dining/lounge area and a kitchenette. The home provides personal care to nine elderly service users of mixed gender with learning disabilities. It was previously registered for ten service users, but one of the bedrooms has been converted into an office area. The home charges £948 weekly. At the time of the inspection there were nine service users in the home. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the findings of an unannounced key inspection which took place on the 1st of February from about 10:00 to 13:00 and on the 2nd February from 10:00 to about 12:30. During the course of the inspection a sample of care records, health and safety records, training records and personnel records were inspected. The inspector also spoke to the manager, deputy manager, five members of staff and five service users. He also toured some of the premises and observe care practices in the home. The inspector would like to thank the service users, the manager, the deputy manager and all members of staff for a kind welcome to the home and for their support and assistance during the course of the inspection. What the service does well: The home provides a range of information to prospective service users to enable them to make an informed decision about moving into the home. Although there has not been any new service user in the home since the last inspection, the manager and his staff have in the past demonstrated that prospective service users would have a comprehensive assessment of their needs before moving into the home. The care plans of service users have been drawn up from a person centred approach and comprehensively described the needs of the service users. It is mostly written in easy to read format and there was evidence that service users have agreed to the care plans. The home is commended for the progress achieved in this area. Meals are provided to service users according to their wishes and the dining areas are prepared in a congenial and inviting manner. The home continues to provide a very homely environment for service users. The bedrooms of service users are personalised to a high standard and are in a good decorative state. The standard of training that is provided to staff is very good. All staff were up to date with statutory training although a few have not had abuse training. The manager stated that he has arranged training for staff who have not had that training. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 6 The home has an effective quality system, based on a system of audits as well as satisfaction questionnaires. Service users are involved throughout the process. Health and safety issues are taken seriously and are appropriately managed for the safety of staff, service users and visitors to the home What has improved since the last inspection? What they could do better: While the assessment of needs and care plans were mostly comprehensive, it was noted that the two service users, whose care records were inspected, did not have plans of care for needs that have been identified and which staff were managing. It was noted that the dining area on the first floor did not have a board with photos of the meals from which service users could choose, as was available on the ground floor. It is recommended that such a board be also produced for the first floor. Dining areas were prepared in a congenial manner for service users to have their meals, but the use of blue aprons for the protection of service users’ clothes should be reviewed and appropriate serviettes must be provided for service users to use during meal times. The home was generally clean but the kitchenette on the first floor was not as clean as it should have been. The registered person must establish consent of service users or consult the representative, advocate or funding authority of service users in cases where the money of service users is used to purchase items that the home should be providing. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 7 The inspector recommends a review of the fire risk assessment as some of the information that it contains may not be right, such as all bedrooms having automatic fire release doors when this is not the case and furniture being fire resistant when some of the furniture was wooden. 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. Pear Tree Lodge DS0000017483.V325616.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 Pear Tree Lodge DS0000017483.V325616.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): 1-4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users or their representatives are provided with the appropriate information to decide if they want to move into the home and the service users’ needs are assessed comprehensively prior to them being offered a place in the home. EVIDENCE: The service users’ guide and the statement of purpose were available for inspection. They have both been updated and were available in big prints. The service users’ guide now also contains information about the range of fees which are charged by the home. Service users are also offered terms and conditions of the placement and signed copies were available in the files of service users. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 10 The home has not had any recent admission. In the past prospective service users’ needs were appropriately assessed by the manager or his deputy before the decision was made as to whether the home would be able to meet the needs and aspirations of the prospective service users. There was no evidence that the home would now change its practices. The environment and the calibre of staff that are employed in the home suggest that the home is able to meet the needs of the service users who are accommodated in the home. As service users get older and as their needs change there was evidence that the home involves the multidisciplinary team as necessary to ensure that the needs of the service users would continue to be met in the home. The manager stated that the option of transferring a service user with increased needs to a care home with nursing would also considered within the multidisciplinary team, if the need for this arises. Pear Tree Lodge DS0000017483.V325616.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): 7-11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans of service users are on the whole comprehensive but plans of care to address the changing needs of service users are not always in place. The healthcare needs of service users in the home are being met. Medicines in the home is managed appropriately to ensure the safety of service users. The end of life care of service users and arrangements for death are comprehensively documented. This provides the reassurance that when the time comes, staff would know how to manage the situation. EVIDENCE: The home has now introduced the person centred care approach to all care plans. The needs of service users were appropriately described. The care plans were also accessible to service users and were written in an easy to read format. There was signatures in place in most care plans as evidence that the service users have been involved in drawing up the care plans. In cases where they were unable to do so, a note was made to reflect this. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 12 A range of risk assessments was available in the care records and these were reviewed at least monthly. In cases where risks have been identified care plans were in place to manage the risks. It was noted that the care plans of two service users, which were inspected, did not contain plans of care to address needs that have been identified. One of the service users had a need with regard to managing incontinence and a related behaviour. The other service user had needs with regard to depression and fluctuating weight. Records were kept of visits by the GP and other healthcare professionals. There was also evidence that referrals were made to the relevant healthcare professionals when that was required. The GP had also carried out medicines, review and a review of the care of the service users. Health action plans were maintained in the home. This is good practice. Service users were weighed monthly and a nutritional assessment was used for the monitoring of the nutritional status of service users. It was however noted that the day when the weight was monitored was not always recorded to enable a comprehensive judgement to be made with regard to a weight change (if any) in relation to the time scale. All service users were dressed smartly and appeared clean. Male service users were appropriately shaved. It was noted that a number of service users clothes have been purchased from charity shops. Wearing clothes from charity shops is matter of preference and choice. While this may well be accepted by some people, others may object to this. It is recommended that the preferences of service users or of their representatives, in cases where service users are unable to consent, with regard to buying clothes from charity shop be established. With regard to this, consideration must be given to the fact that the manager and his staff were motivated to do something good for the service users. Medicines were recorded when received and when administered. There were no gaps in the medicines record charts and codes were used where appropriate. The medicines were stored in a small cupboard and appropriate records were being kept with regard to the temperature of that area. There was also evidence of audits by the chemist, which supply the home. Medicines are administered by the team leaders and are audited by the deputy manager on a regular basis. Information about the aspirations and wishes and instructions of service users or of their representatives with regards to end of life care and death were appropriate addressed in care plans. Members of staff were able to talk to service users or their representatives to get this information to record it and to plan accordingly. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home make every attempt to provide social and recreational activities for service users, but this may be limited because of their numbers and other responsibilities. Meals are provided according to the choices and tastes of service users. EVIDENCE: The needs’ assessment and the recreational needs of service users were appropriately assessed and recorded. There was good information on files about the backgrounds of service users and their life history. Plan of care to address the social and recreational needs of service users were then tailored around the needs of the service users. There was a programme of activities in the home and care staff were in the main responsible to implement the activities programme. The home does not employ an activities coordinator and an assistant physiotherapist visits once a week for one hour to carry out activities with the service users. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 14 On the two days of the inspection, the inspector noted little in the form of recreational activities being provided to service users. The home runs as two units: ground floor and first floor. As there are three members of staff in the home, this leaves one member of staff on each floor and the team leader to float between the two floors. There are other tasks in the home such as doing the laundry, updating care records, taking service users out for appointments and tidying the bedrooms of service users. There are also cases when service users have to be offered personal care. As a result it seems that members of staff have little time to carry out social activities. The inspector was informed that service users go for outings into the local community. For example they visit the local shops and go to the hairdresser who is based in the village. One service user regularly attends an evening club. The manager stated that holidays were also planned for the summer. He added that the minister from the local church regularly visits the home and service users are assisted to attend the church if they wish to. Lunch was observed being served in the home. There was cottage pie, sprouts and mashed potatoes. There was mixed tinned fruits or yogurts for desert. All service users spoken to stated that they enjoyed their lunch. The home had a board in the dining area of the ground floor with photos of the meals from which service users could pick their choices. A service user was seen choosing a meal for his supper. However there was no board on the first floor and as service users on the first floor tend to have their meals on that unit, it is recommended that a board with pictures of the meals is also produced for that floor. The inspector observed that two service users were provided with blue plastic aprons to protect their clothes during mealtimes. Paper towels, which are used to dry the hands, were being used as serviettes, when more appropriate serviettes, including cloth serviettes, were available for this purpose. The chef stated that he continues to arrange meetings with service users to discuss the meals to prepare for them and to draw up menus. There were individual records of the meals served to service users. This is good practice. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and his staff are aware of the procedure to follow in cases of complaints and allegations and suspicions of abuse. EVIDENCE: The home has not had any complaints since the last inspection. The complaints procedure was available in the service users’ guide, the notice board and in the bedrooms of service users. Service users said that they would approach a member of staff if they had an issue to discuss. Training records showed that some members of staff in the home have had training on abuse and on safeguarding adults. The manager stated that there are plans to send the rest of the staff on abuse and safeguarding adult training. Staff were aware that they have to inform the person in charge or the manager in cases where abuse is alleged or suspected. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a warm, homely and well maintained environment to accommodate service users. EVIDENCE: The grounds in the front, side and back of the home and the car park area were maintained to a good standard. The exterior of the building also looked maintained. The home was warm, airy and mostly free of odours except for a bedroom, where staff were managing an odour problem. Since the last inspection one of the bedrooms on the ground floor has been converted to an office. Previously there was only a small office area, where the manager could not even meet visitors. Now there is a large office, where the manager can talk to staff, service users and visitors in private and where some of the records are also kept. The previous small office is now used as a staff Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 17 room. However that has meant a reduction in the number of beds from ten to nine which has affected the profitability of the home and the need for the reallocation of resources. The corridors have been redecorated and the dining areas have also been renovated. The flooring in the dining areas has been replaced and new dining tables and chairs have been provided for the ground floor. There are now a number of new armchairs in the ground floor lounge. Bedrooms of service users were personalised to a good standard and service users were encouraged to buy items of decorations and other items to personalise their rooms. For example there was evidence that they have purchased curtains for their bedrooms. The manager and his staff were proud of their achievement and efforts that they have made to enhance the comfort of service users. It was noted that the home was on the whole clean, except for the kitchenette on the first floor where shelves were dusty and where the area behind the freezer needed to be cleaned. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 18 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from well-trained and dedicated members of staff. However at times the numbers of staff may need to be reviewed to ensure that the home is able to meet its stated aims and objectives. EVIDENCE: As the home now accommodates nine service users instead of ten, there has also been a readjustment of staffing levels. As mentioned in the section under Daily life and Social Activities, there are three members of staff on duty during the day and two at night. A care worker is allocated to each floor and the team leader floats between the two floors as required. The manager is supernumerary. There are some issues with regard to whether the care workers have the time to carry out social and recreational activities in view of the amount of work that they have to do. The fact that the home is run as two floors does not help, but staff justified the need for this because service users like to sit in small groups and enjoy each others’ company more in this way. Team leaders have additional responsibilities. For example the deputy manager who is a team leader is also responsible for the management of quality in the home and for the management of medicines. She does not have supernumerary hours except for 1.5 hours a week. She is also responsible for the supervision of some members of staff. As a result it seems that staff are Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 19 restricted with what they can do during their working hours. It is therefore recommended that staffing be reviewed with a view of allocating supernumerary hours for staff who have additional responsibilities and to consider the provision of extra hours for the provision of social and recreational activities. The home has nine of the fifteen members of staff qualified to at least NVQ level 2 in care. Some members of staff who were qualified in NVQ level 2 have left and as a result the percentage of staff qualified to at least NVQ level 2 has decreased from in excess of 75 during the last inspection to about 60 . However there was evidence that staff who did not have an NVQ qualification were enrolled on such a course. Two personnel files were inspected. All records as required by schedule 2 of the Care Homes Regulations 2001 were available for inspection in each personnel file, including evidence of CRB checks. It was however noted that one of the applicants did not have a reference from the last employer. There was a reference from a person who worked for that employer, but that person was not senior enough and did not seem to have completed the reference as a representative of the employer. There was evidence that all new employees were offered induction as per the company policy and have also completed the Common induction standards from Skills for Care. A training grid provided to the inspector showed that all staff were up to date with statutory training. The home had a monthly training plan which has been prepared until December 2007. It included a range of training for staff to benefit from. For example there was training in assertiveness, teamwork, person centred approach to dementia care, and challenging behaviour. The standard of training provided by the home is very good. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 20 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): 31,33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and fit to run the home. There is an effective quality control system in place to monitor the quality of the service. Management of the personal money of service users is generally good except that more clarity is required with regards to how consent was reached in relation to some expenses that were made with service users’ money. The home has good systems in place to manage health and safety. EVIDENCE: The manager is experienced and is aware of his responsibilities as the registered manager. He has managed Pear Tree Lodge for a number of years and is familiar with the needs of the service users that the home Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 21 accommodates. He is a trained nurse and also has a qualification in management. There was evidence to show that he has attended a number of training courses to keep himself up to date. He is assisted by his deputy manager. The home has a quality assurance procedure and a quality control system. The quality control system consists of self-assessment/audits and satisfaction surveys. Audits are carried out in a number of areas including care plans, medicines, food, environment and infection control quarterly by the home. There is also a health and safety audit and monthly health and safety checks by the health and safety coordinator. Residents’ meetings seem to be held every two months and minutes were available for inspection. An analysis of the satisfaction surveys was available for inspection. The management of personal money of service users was inspected. The manager manages the money of the service users. There are individual bank accounts and individual records of the money of service users. Checks of a sample of service users’ accounts showed that appropriate records were kept and that receipts were kept for service users’ expenditures. It was noted that there were records to show that some service users had purchased curtains with their personal money, from the charity shop. Regulation 16(2)(c) of the Care Homes Regulations 2001 states that it is the registered person’s responsibility to provide in rooms occupied by service users, adequate furniture, bedding and other furnishings, including curtains and floor coverings. The manager stated that Pear Tree Lodge provides curtains and bed linen to all service users, however some service users wish to purchase their own curtains and bed linen to personalise their bedrooms and to enhance their comfort. While some service users were able to make an informed decision about buying the curtains, and it is their right to buy what they wish to, it was not very clear how consent was obtained in other cases where service users were less able to give consent. Therefore before purchasing items that the home should be supplying for a service user’s bedroom, with the service user’s money, it is required that the registered person establish consent (with record kept) in cases where the service user is able to give consent, or consult the representative, advocate or funding authority of the service user in cases where he/she is unable to give consent. All safety certificates were available in the home, including, electrical wiring, gas safety, PAT testing, Legionella test and LOLER certificates for the hoists and the lift. Maintenance certificates of the equipment in the home were also available for inspection. A health and safety risk assessment has been carried out and a fire risk assessment and an emergency fire policy and procedure were available for inspection. The inspector was informed that the fire policy and procedure contained the Fire Emergency Plan. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 22 The inspector however recommends that a review of the fire risk assessment be conducted to look at some of its content. For example it mentions that ‘ all bedroom doors has automatic fire release door’ when this is not the case, and that ‘furniture is fire resistant’ when there are wardrobes, tables, bookcases and shelves which are wooden. Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 24 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 2 3 Standard OP7 OP26 OP29 Regulation 15(1) 23(2)(d) 19(1) Requirement There must be plans of care in place to address all the identified needs of service users. The registered person must ensure that the kitchenette is kept clean at all times. One of the two references of applicants who wish to work in the home must be from the last employer Before purchasing items that the home should be supplying for a service user’s bedroom with the service user’s money, it is required that the registered person establish consent (with record kept) in cases where the service user is able to give consent, or consult the representative, advocate or funding authority of the service user in cases where he/she is unable to give consent. Timescale for action 31/03/07 28/02/07 31/03/07 4 OP35 20 31/03/07 Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations It is recommended that the dates when the service users are weighed be recorded to enable a comprehensive judgement to be made with regard to a change in weight in relation to the timescale. It is recommended that the preferences of service users or of their representatives, in cases where service users are unable to consent, with regard to buying clothes from charity shop be established. The provision of social and recreational activities in the home should be reviewed in line with the availability of staff to carry out activities in the home. It is recommended that a board with photos be also provided for the dining area on the first floor and not only for the ground floor. It is recommended that the right tissues/serviettes are used for service users during meal times and that the use of blue aprons to protect the clothes of service users is done as a last resort after all other means of protecting service users’ clothes have failed. It is recommended that staffing be reviewed with a view of allocating supernumerary hours for staff who have additional responsibilities and to consider the provision of extra hours for the provision of social and recreational activities. It is recommended that the fire risk assessment be reviewed to ensure that the content reflects the actual state of the home (see text under Health and safety). 2 OP10 3 4 5 OP12 OP15 OP15 6 OP27 7 OP38 Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 26 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 Pear Tree Lodge DS0000017483.V325616.R01.S.doc Version 5.2 Page 27 - 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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