Inspection on 30/08/07 for Pear Tree Lodge

This inspection was carried out on 30th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pear Tree Lodge 08/12/06

Pear Tree Lodge 05/12/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Pear Tree Lodge 1-3 Beech Grove Hayling Island Hampshire PO11 9DP Lead Inspector Ian Craig Unannounced Inspection 30th August 2007 09:30 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 DS0000064204.V342782.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 DS0000064204.V342782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pear Tree Lodge Address 1-3 Beech Grove Hayling Island Hampshire PO11 9DP 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) 023 9246 2905 023 9263 7922 lynnmcgregor@aol.com Pear Tree Care Limited Mrs Marie Ann Abolins Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability (4), Physical disability over 65 years of age (4) Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users must be at least 60 years of age. No more than 4 service users in the PD and PD[E] categories in total may be accommodated at the home. 8th December 2006 Date of last inspection Brief Description of the Service: Pear Tree Lodge is a twenty-three bedded care home, located in a pleasant residential area of Hayling Island. The service is set up to provide accommodation and care for older people, a number of whom have dementia. The service also has service users with additional physical disabilities accommodated on the ground floor. Pear Tree Lodge may also accommodate up to four service users who have an age related mental health problem, if their care needs are similar to the needs of the existing service users. Pear Tree Lodge has six double bedrooms and eleven single bedrooms. The home has three bathrooms and a shower room. At the time of inspection building works have commenced to extend the home, which has resulted in two bedrooms being decommissioned and the garden dug up. Completion of the building work will result in an improvement of the facilities. There is parking area at the front of the home. Pear Tree Care Ltd is the owner of the home i.e. the registered person. Mrs Gillian Bryden is the Responsible Individual. The home weekly fees range from £395.00 to £410.00. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the building, examination of records, documents, policies and procedures, including residents’ case records. Several residents were spoken to and two were interviewed in private. A resident’s relative was also interviewed. Feedback was also received in the form of questionnaires sent by the Commission and returned by several residents, relatives and professionals connected to the home. Several staff were spoken to and discussions took place with the manager, and one of the owners of the home. The service completed a Commission questionnaire entitled, Annual Quality Assurance Assessment (AQAA), which was also used for evidence for the inspection. What the service does well: The residents have a range of activities that they can attend including games and musical entertainment that they can participate in. Several residents attend activities outside the home. Information is provided to those people considering a move into the home in the form of a Service Users’ Guide and a Statement of Purpose. Prospective residents and their relatives are invited to look around the home before they make a decision about whether or not to move in. Each person has a terms of conditions contract for living at the home. Residents, relatives and staff confirmed that the personal care needs of the people who live in the home are met. Residents and their representatives state that the care staff are kind and helpful. The following comments were made: • “All the staff are tremendous. They work extremely hard.” • “Everyone is kind and I like it here.” • “I have always found the staff are there when I need them.” • “The staff are polite and well turned out.” Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 6 Staff have access to a variety of training courses including an in house induction for newly appointed staff. Sufficient numbers of staff are deployed to meet the needs of the residents. What has improved since the last inspection? What they could do better: The home is in the process of extensive building works, which are causing considerable noise which residents referred to. Several residents have had to move bedrooms and there was a lack of written evidence to show that each person and/or their relative had been consulted about this. It was also identified that the home should involve residents and their relatives in the assessment and care planning. The process of assessing the needs of new residents needs to be improved so that the home always obtains copies of assessments by the referring social Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 7 services department and that the details of any arrangements under the Mental Health Act 1983 are known and recorded. Recruitment procedures need to improve so that residents are fully protected. Due to the building works the home has rearranged the fire escape routes and it was unclear if this met fire safety standards. A letter was sent to the home requiring that this is addressed as a matter of urgency. 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 DS0000064204.V342782.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 DS0000064204.V342782.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, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents and their representatives receive information about the home to help them decide if they wish to move in. The home carries out assessments of need for those referred for possible admission to ensure that it can meet the individual’ needs before agreeing to admit them. EVIDENCE: Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 10 The home’s Statement of Purpose is displayed in the entrance hall. Residents and their relatives confirmed that they are supplied with information about the home before moving in. The home’s management maintains a record and a copy of a letter sent to each new resident demonstrating that copies of the Service Users’ guide and Statement of Purpose have been provided. Each person has terms and conditions of residence. This was evidenced from copies held at the home and from residents and their relatives. Records show that each person’s needs are assessed before being admitted to the home. This includes the home obtaining details of specialist after care arrangements for those leaving psychiatric hospital. Social services’ care management assessments had not been obtained for practical reasons unrelated to the home in one instance. The inspector suggested that the home’s pre admission assessment pro forma includes a space for details to be included of any arrangements under the Mental Health Act 1983 as these had been recorded in the daily running records following admission. The home should also liaise with the relevant mental health services and record the guidance and expectations of the home regarding supervision arrangements. Pear Tree Lodge DS0000064204.V342782.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, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident’s health and personal care needs are met with details recorded in care plans. Residents’ privacy and dignity is upheld. EVIDENCE: Each resident has various documents, which assess health and personal care needs. Care plans have been devised setting out how staff are to provide care to each person. These documents include the following: • Personal care plan • Handling assessment Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 12 • • • • • • • Risk assessment form Moving and handling assessment Care plan. Plan of action. Review Hobby care plan Score matrix assessment Risk assessments Each person’s personal details are recorded and a photograph of the resident is held with the medication records. Care plans are reviewed and amended on a regular basis. Risk assessments detail how staff should deal with specific needs such as behaviour. The daily running records confirmed that staff are following these procedures. Records show that residents have access to health care and that the home liaises with the district nursing service, opticians, continence nurse and specialist health care professionals such as community psychiatric nursing teams. It was unclear how much the residents are involved in their own assessments of need and the drawing up of the care plans. The home’s manager stated that this takes place, but one resident was unaware that he has a care plan and there was no evidence, such as a signature of a resident or their representative, on the care plans acknowledging their agreement. Residents, relatives and the staff expressed the view that the care and medical needs of the residents are met. There was a comment from one relative that a resident is sometimes not put to bed properly, including one occasion when she was put to bed with her clothes on. The home medication procedures were examined. Staff receive training in medication procedures. This was confirmed from training records and from discussions with the staff and manager. The medication administration records showed that staff record a signature each time they administer medication to a resident. The medication containers show that medication is administered as prescribed. Medication is stored in suitable lockable cupboards. Procedures for the storage, administration and recording of controlled medication meets pharmaceutical guidelines. The home administers insulin to residents intravenously. The staff involved in this have been trained by the resident’s district nurse. The medication is stored in a fridge in different containers for each time of the day. A procedure needs to be recorded for the storage and administration of this medication. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 13 Residents and relatives described being treated with respect by the home’s staff and management. Screens are provided in shared rooms for privacy. Two residents have a key to their bedroom door. Residents are offered a key to their bedroom door. The inspector advised that the offer of a key is recorded, or any decision that a resident should not have a key based on a risk assessment. Feedback from a social worker states that the home involves residents in decision making. Pear Tree Lodge DS0000064204.V342782.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a variety of activities and stimulation. The home provides nutritious and wholesome food. EVIDENCE: Residents were observed sitting in the lounge; some were reading newspapers and others watching television. In the afternoon residents gathered in the lounge to take part in an organised activity provided by a visiting provider specialising in activities for those with dementia. This involved two people playing music to the residents who were then give a variety of percussion instruments to play. It was clear that the residents found this engaging. The activity was suited to those with a variety of needs including those with dementia. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 15 The home also employs a dedicated staff member to provide activities from 3 to 4 pm each day. A record of these activities is maintained showing that this includes bingo, horse racing games, a parachute game, music, cooking, reminiscence and singing. One relative stated that he/she felt that there is not enough staff to motivate the residents. The home’s management stated that the provision of a staff member for providing activities has been arranged following similar feedback in recent survey forms. Residents and relatives confirmed that there are a variety of activities on offer. One relative stated that the number of outings has decreased. This was discussed with the manager, who replied that there are occasional trips out such as staff taking a resident to the pub, and that several residents go out with their friends and family. One resident confirmed that he plays snooker at a local club with a friend most evenings and that he attends a day club as well. Residents commented that they like to join in with the activities or prefer the peace and quiet of their bedroom. Residents and relatives confirmed that religious services are provided by a visiting preacher. The home has a menu plan. A notice board gives details of the day’s meals. On the day of the visit the midday meal was roast pork with apple sauce served with roast potatoes, parsnips, swede, cauliflower, carrots and broccoli. Cottage pie was available as an alternative. Dessert was jelly with ice cream or jelly with custard. A birthday cake had been prepared for one resident. Residents and relatives described the food as good although one person stated that it could be more varied. One resident stated that the food is good, is well prepared and presented. Pear Tree Lodge DS0000064204.V342782.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are aware of how to complain. The home takes measures to protect residents from possible abuse although this is not always the case with the recruitment of staff. EVIDENCE: The home’s complaints procedure is contained in the Service Users’ Guide and Statement of Purpose, which is supplied to the residents and their relatives. Feedback for residents and relatives confirmed that they know hat to do if they have a complaint. The home has its own adult protection policy, which gives guidance for staff to refer any suspicions of abuse to social services for investigation. Staff sign a record to confirm that they have read the procedure. The home does not have a copy of the local authority adult protection procedure. This was discussed with the home’s manager who agreed that this would be obtained from Hampshire Social Services Department. Staff also receive training in protecting older persons from abuse. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 17 Care plans detail how staff should react and handle any identified aggression for individuals. Records show that some of the staff have received training in challenging behaviour and the inspector advised that this could be extended to all staff. The home’s recruitment procedures are referred to in the ‘Staffing’ section of this report. Pear Tree Lodge DS0000064204.V342782.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): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in the process of building additional bedrooms and communal space, which is having a detrimental effect on the residents, although bedrooms were found to be clean, tidy and personalised. EVIDENCE: The home is creating an additional 7 bedrooms, a lounge, activities room and landscaped rear garden. The creation of these extra facilities has resulted in the decommissioning of the rear garden, three residents having to change Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 19 bedrooms and daily disruption from noise from building site machinery immediately adjacent to residents’ living spaces. Several residents complained about the noise from pneumatic drills and heavy land clearance vehicles. This is unfortunate as the resulting plan will be for an improvement in the environment for the residents. The home’s management state that the 3 residents who had to move bedroom were consulted about the process. There was a record that this had been discussed with one of the three residents but no actual signed agreement for any of the three affected residents. In order to accommodate these three residents, a single room has been converted into a double and a small lounge into a double room on a temporary basis. It is anticipated that the building improvements will be completed 27 weeks from the date of this inspection. The home’s communal areas are unaffected other than that referred to above. Residents were observed using the lounge and dining areas for relaxing, reading, watching television and for taking part in activities. Bedrooms are personalised with residents’ belongings. Residents are able to choose where they would like to spend their time. One resident stated how he/she likes to spend time in his/her room whereas another person said how he/she enjoys making use of the communal areas. Bedroom doors have a number and name plate so that each person can identify his or her room. The home is clean and free from any unpleasant odours. Residents’ relatives confirmed that the home is always clean and fresh. Staff were observed following safe hygiene practices using aprons and gloves. The home has a stair lift. Pear Tree Lodge DS0000064204.V342782.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides sufficient numbers of well-trained staff to meet the needs of the residents. Recruitment procedures continue to be an area that the home needs to improve on to ensure that residents are not placed at risk. EVIDENCE: The home aims to provide 3 care staff from 8am to 10pm each day. It was confirmed that this was being achieved as evidenced by the staff rota and from observation. In addition to this, the home employs an activities coordinator for one hour a day for 5 days, cleaning staff, a cook and a kitchen assistant. Night time staffing consists of two ‘waking’ staff. A relative of a resident commented that staff have recently left the service due to the introduction of a system whereby staff are required to work 12 hour` Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 21 shifts with 1 hour break. The manager stated that the staff have agreed to work these hours. The inspector raised concern regarding the fact that one staff member was working four 12-hour shifts in 4 days, which may affect the staff member’s performance. This situation was said to be unusual with most staff working three 12-hour shifts in 7 days. The service has introduced a staff induction procedure and a staff appraisal system. Records of these were available. Staff have access to a variety of training courses both ‘in house’ and from external providers and include the following: • Health and safety • First aid • Moving and handling • Infection control • Challenging behaviour • Basic life support • Fire safety • COSHH • Dementia awareness • Food hygiene • Care skills • Medication • Confidentiality • Legislation The above training was confirmed from training records, certificates, and from staff themselves. The home has a total of 15 care staff. Five of these have NVQ level 2 or above and a further 6 are studying for the qualification. Residents and their relatives described the staff as helpful, kind and polite. A professional linked with the home viewed the staff communication skills to be good. The manager is to attend a training course, which will qualify her to train staff in working with older persons who have dementia. Staff confirmed that monthly staff meetings are held which was also supported by minutes of the meetings although the last minutes are for a meeting held in April 2007. Recruitment procedures were examined for 4 recently recruited staff. It was noted that one person had commenced her induction before references had been obtained and a Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVAfirst) checks had been obtained. The manager was Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 22 unclear about this and thought it was acceptable to start a staff induction without these checks being obtained. Once this was raised the matter was immediately addressed and further work at the home halted until the required checks are obtained. Satisfactory checks had been carried out for 2 of the 4 staff. For a fourth person, references had not been requested from the referees given on application form, and the home had employed the person on the information of two references supplied by the applicant addressed, ‘To Whom It May Concern.’ The risk of not carrying out reference checks via the referees given on the application form was highlighted. CRB and POVA checks had been obtained for this person. The completion of recruitment checks was highlighted in the last inspection report and is an area of the home’s management that needs to be addressed. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is motivated to improving the service for the benefit of the residents but needs additional support to ensure staff recruitment protects the residents. The home acts on information provided by staff, residents and their representatives to improve the service. Staff and resident’s health and safety is upheld although arrangements for fire safety need addressing. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has extensive experience of the role and is qualified at NVQ level 4 in care and has the Registered Manager’s Award. The manager has also attended other training courses to update her skills. Relatives described the communication with the home to be of a good standard, although one person stated that they had not been kept informed of specific incidents. The home’s management practices for staff recruitment needs to improve. This is the second successive inspection where a requirement has been made for this. The home has started to implement a quality assurance system. Surveys have been distributed and returned from residents, relatives and staff. The home has taken action to improve the provision of activities for the residents as a result of the survey results. A quality audit has been partly completed and an annual development plan will be devised. The home does not handle or hold any resident’s money or valuables for safekeeping. Staff have received training in the following health and safety matters: food hygiene, fore safety, infection control and moving and handling. Residents are protected from hot bathing water by temperature controls on baths. Covers have been installed on radiators to prevent any possible burns. Restrictors are in place on first floor windows to prevent possible falls. The home’s appliances are tested and serviced by qualified persons. The fire logbook shows that the fire safety equipment is tested and serviced according to fire safety regulations. Records show that staff receive regular instruction in fire safety. The home’s fire safety exit routes have been amended due to the building works. The inspector was informed that the changes have been approved via the building contractor and the fire service. It was unclear if this applied only to the eventual finished plans. The inspector was concerned that the amended fire exit routes for the interim period whilst the building works takes place may not meet fire safety standards. The fire escape route plan had been amended to reflect these temporary changes but the fire safety risk assessment had not. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 25 There was no evidence that these interim arrangements met fire safety standards. A letter was sent to the home requiring that this is addressed as a matter of urgency. Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 26 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 2 8 3 9 3 10 2 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 2 X 3 3 X 2 3 3 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 2 X 3 X 3 X X 2 Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The home must devise a written procedure for the storage, handling and administration of intravenous medication. Residents must be consulted, and a record maintained regarding the following: • Assessments of need and care plans • Changes to alternative bedrooms Staff must not commence work in the home until the following checks have been obtained: • POVA(first) • A CRB has been applied for • Two written references have been obtained from the person’s previous employer This is a partial repeat of a requirement made in the last inspection report. 4 OP38 23(4) The registered person must ensure that any changes to the DS0000064204.V342782.R01.S.doc Timescale for action 30/10/07 2 OP10 12 30/10/07 3 OP29 19 30/09/07 10/09/07 Pear Tree Lodge Version 5.2 Page 28 fire escape routes are approved by the fire and rescue service. This is a partial repeat of the requirement made in the previous report. 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 Pear Tree Lodge DS0000064204.V342782.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000064204.V342782.R01.S.doc Version 5.2 Page 30 - 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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