Inspection on 02/08/07 for Peartree House

This inspection was carried out on 2nd August 2007.

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

Peartree House 31/07/08

Peartree House 23/08/06

Peartree House 07/12/05

Peartree House 09/08/05

Peartree House 02/02/05

Peartree House 23/06/04

Peartree House 17/03/04

Peartree House 17/02/04

Peartree House 11/06/02

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

CARE HOMES FOR OLDER PEOPLE Peartree House 24 Gordon Road Chingford London E4 6BU Lead Inspector Rob Cole Unannounced Inspection 2nd August 2007 09:00 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 Peartree House DS0000007235.V347678.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. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peartree House Address 24 Gordon Road Chingford London E4 6BU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8524 7680 0208 529 9773 pear_tree.house@fshc.co.uk Tamaris (South East) Limited (a wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Brenda Roach Care Home 55 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Old age, not falling within any other category (0) Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Total number of beds to be used flexibly between categories. As agreed on 17th July 2006, one named service user over the age of 65 years, with a mental disorder, can be accommodated. The home must advise CSCI when the service user no longer resides at the home. 23rd August 2006 Date of last inspection Brief Description of the Service: Peartree House is registered to provide accommodation and personal care to 55 elders of either gender, aged over 65, who may have dementia. Peartree House is not registered to provide nursing care. The registered providers are Tamaris, part of the Four Seasons Health Care Group, an organisation that operates a number of residential care homes and nursing homes across the country. The home is situated in a quiet residential area of Chingford, in the London Borough of Waltham Forest. It is close to a shopping centre, and local bus and rail transport links to London and Essex. The home is divided into five areas, comprising 3 communal areas in the main building, and two separate units known as the House and Flats. There are 45 single bedrooms, 28 of which have ensuite facilities, and 5 double bedrooms. The current range of fees charged by the home is between £431 and £550 per service user per week. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 2/8/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present for most of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premises. During the course of the inspection the inspector had the opportunity of observing the care and support provided by the home, and the interaction between staff and service users, and this was also used as a source of evidence to support judgements made within this report. Prior to the inspection the home completed an Annual Quality Assurance Assessment at the request of the CSCI, and this was also used as part of the overall inspection process. What the service does well: What has improved since the last inspection? There have been improvements to the home since the previous inspection. This is reflected by the fact that the overall number of requirements has fallen from twenty at the previous inspection, to thirteen that have been made in this report. There have been improvements around the area of adult protection, the home now has an appropriate policy in place, and staff undertake training in adult protection issues. It was also positively noted that staff have now undertaken training in relevant health and safety issues. Quality assurance systems in the home have improved, and these now include seeking the views of service users and their relatives on the running of the home. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are provided with sufficient information to enable them to make an informed choice about the home. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has both a Statement of Purpose and a Service User Guide in place. Both documents are written in plain English. The Statement says “Our aim is to provide an atmosphere in which all people in our care, whatever their needs, shall be able to live their lives contentedly in a pleasant and safe environment.” The Statement includes details of the organisational structure, Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 9 the staff team and their qualifications and of the services and facilities provided by the home. Service users are provided with their own copy of the Service User Guide. This includes details of the homes complaints procedure and of the home’s philosophy of care, and is in line with National Minimum Standards. Both documents have been subject to regular review. Individual contracts/statements of terms and conditions are in place for service users who are both privately and publicly funded. Contracts have been signed by the service user (or their representative where appropriate) and a representative of the home. They include details of fees payable and of the services provided. The home has an admissions procedure, which states that pre admission assessments will be carried out, and that prospective service users and their family will have the opportunity of visiting the home prior to making a decision as to move in or not. Service users initially move into the home on a trial basis. Service users spoken to confirmed to the inspector that they were indeed given the opportunity of visiting the home before moving in. Pre admission assessments are carried out by the homes manager. These cover needs associated with mobility, medication and health issues, and are of a satisfactory standard. The home does not provide intermediate care. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 and 11. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet the personal care needs of service users, although more attention needs to be paid to the administration of medication to help ensure that health care needs are also been met as appropriate. EVIDENCE: Care plans are in place for all service users. These are subject to monthly review. Care plans contain detailed information around personal and health care issues, for example the support needed with bathing, dressing, medication etc. However, plans are of a variable quality with regard to equalities and diversity issues. Some equalities and diversity issues, noticeably around age and disability, are addressed in care plans, while others, such as Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 11 around ethnicticity or gender, are not sufficiently addressed. In order to help ensure that the home is able to meet all of service users needs, in a consistent manner, it is required that comprehensive individual care plans are in place, which cover all areas of need, including those needs associated with equalities and diversity issues. Risk assessments are in place for all service users, and these are of a satisfactory standard. Assessments identify any risks, for example around falling or wandering, and include strategies to manage and reduce these risks. All service users are registered with a GP, the manager informed the inspector that service users are able to retain the GP they had prior to admission, where this is practical. Clear records are maintained of medical appointments, including of any follow up action necessary. Records evidenced that service users have access to health care professionals as appropriate, including district nurses, opticians and dentists. Used continence products are disposed of appropriately. The home has a medication policy in place. This was inspected as part of the previous inspection and found to be satisfactory. Medications are stored in locked cabinets within a designated and locked medication room, or in a fridge within the medication room. The medication fridge temperature is checked daily. All staff undertake training before they are able to administer medications. No service users currently self medicate, or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Charts (MAR) are in place, and at the time of inspection the home was in the process of attaching a recent photograph of each service user to their own MAR chart to help ensure that medications are administered to the correct person. The MAR charts indicated that the morning tablets for one service user had been administered as appropriate on the 29/7/07. However, on examination of the blister pack that contained the medication, it was found that the medication was still in place for that morning. This medication consisted of LEVOTHYROXINE TABLETS 1 x 25mg, 1 x 50 mg and 1 x 100mg tablets and 1 x 0.5mg RISPERIDONE TABLET. This was brought to the attention of the homes manager, who was able to speak with relevant staff during the day of the inspection, and it was found that these medications had indeed not been administered. It is required that all medications are appropriately recorded and administered. By the time these medications were inspected, four further doses had been administered between the 30/7/07 and the 2/8/07 inclusive. It was evident that the tablets for the 29/7/07 were still in the blister pack, yet no staff had picked up on this or reported to the homes manager that a medication error may have occurred. It is required that systems are in place to ensure that any medication errors are identified in a prompt manner, so that appropriate action (including consulting relevant health professionals) can be taken. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 12 The manager informed the inspector that service users are able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. The home has sought and recorded the wishes of some service user (or their next of kin where appropriate) on the arrangements to be made in the event of their death, but this has not yet been done for all service users, and this must be addressed. Through observation and discussion there was evidence that the home takes steps to promote the privacy and dignity of service users. Service users have access to a telephone that they can use in private, and the home has a visitor’s room where service users can see visitors in private. Staff were seen to interact with service users in a respectful and friendly manner. Service users have been offered keys to their bedrooms, subject to the completion of satisfactory risk assessments. Peartree House DS0000007235.V347678.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): 12,13,14 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are supported to live valued and fulfilling lives. Food was of a satisfactory standard, and the home provides a varied activities programme. EVIDENCE: The home employs two designated activities coordinators, and there is a designated activities room. There is a weekly activities programme, this is advertised by posters around the home. The inspector attended part of the activity session on the day of inspection. This consisted of a quiz, and a reminiscence session about food and cooking. The session was well attended, service users were observed to be actively participating in the session, and those spoken to said that they enjoyed the activities programme. The two activities coordinators were seen to interact in an appropriate manner, making an effort to include all those present in the activities. A small shop is also run in the activities room, selling sweets, drinks, cards etc. Any monies made in Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 14 the shop are used to provide more activities. Depending on the weather, the activities programme is sometimes held in the garden, service users informed the inspector that they valued this. The home occasionally books professional entertainers to visit the home. Recently a keyboard player/singer has visited the home, performing songs appropriate to the age of service users, thus helping to meet their needs around equality and diversity issues. Another recent event was a presentation on the life and career of a florist. A Pearly King is booked to give a show in August of this year. A visiting priest visits the home, and spends time with individual service users. Service users are supported to visit local parks and cafes, and are able to access the community on their own, subject to the completion of a satisfactory risk assessment. Menus are maintained, these evidenced that service users are offered a varied, balanced and nutritious diet. Service users are offered three meals a day, including the choice of a cooked breakfast, and drinks and snacks are offered throughout the day. The main meal is served at lunchtime, and on the day of inspection there was a choice of fish in sauce or lamb stew. The inspector sampled the lamb stew meal, which appeared appetizing. One service user commented of the same meal “Lunch has been very good, cant complain about it.” While another said “Its alright.” Fresh fruit was available on the day of inspection. Records are maintained of fridge and freezer temperatures, and food was stored appropriately. However, the inspector was disappointed to note that the cracked kitchen floor identified at the previous inspection has not been addressed, and a repeat requirement has been made that this is replaced or repaired. Peartree House DS0000007235.V347678.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): 16,17 and 18. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home has taken appropriate steps to help ensure that service users are safeguarded from the risk of abuse, such as providing appropriate policies and procedures, and ensuring that staff have access to relevant training. EVIDENCE: The home has a complaints log. This evidenced that complaints received have been appropriately recorded and investigated. The home also has a complaints procedure. This included timescales for responding to any complaints received, along with contact details of the CSCI. All service users are provided with their own copy of the complaints procedure, and a copy was on display within the home. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. The inspector was pleased to note that this has been amended since the previous inspection, and is now in line with current legislation. All staff but the most recent member to join the team have undertaken training in adult protection issues, and staff spoken to Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 16 demonstrated a good understanding of the issues involved around adult protection. The inspector was satisfied that service users legal rights are protected, for example all service users are on the electoral register, and service users spoken to confirmed that they are able to vote in elections. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that a considerable amount of work needs to be done to the homes physical environment before it is in line with National Minimum Standards and the care Homes regulations 2001. EVIDENCE: The home is situated in the Chingford area of the London Borough of Waltham Forest, close to shops, transport networks and other local amenities. The home provides a number of communal lounges, and also a specific area for activities. In addition there are a number of places were service users can sit and meet with visitors. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 18 All areas of the home are adequately lit. There is a courtyard that is attractively maintained with flowers that service users can enjoy. There is a second courtyard at the rear of the building, which contains plants, flowers and seating, and is accessible to service users. The home has a spacious garden. Thirty-two of the fifty bedrooms are ensuite, and the remaining bedrooms all have hand basins. Toilets, bathrooms and shower rooms are situated throughout the home, in sufficient numbers to meet service users needs. One toilet on the ground floor was found to be in a very poor state. It was dirty, the toilet seat was cracked and stained, the radiator in the room had no protective covering and the lock on the door was broken. This was pointed out to the manager on the day of inspection, and it was positively noted that the seat and lock were replaced, and the radiator was fitted with a protective covering. However, it is required that the bathrooms and toilets in the home are kept clean and tidy. Bedrooms inspected were decorated to service users personal tastes, and service users were able to bring their personal belongings into the home. Rooms had furniture including wardrobes and chest of draws and chairs. Hand basins are provided in those rooms which are not ensuite. However, as with the rest of the home, several bedrooms are in need of redecorating, and several items of furniture were coming towards the end of their useful life, and this must be addressed to fully meet this standard. The inspector noted that several bedrooms had a strong offensive odour, and this must be addressed, and is a repeat requirement. It was also noted that some bedroom carpets were threadbare, and these must be replaced. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, and all heating appliances in bedrooms are appropriately boxed in. Bedrooms have adequate natural light and ventilation, and lighting was domestic in character. The home has a policy on infection control, and staff are provided with protective clothing such as aprons and latex gloves. Hand washing facilities are situated throughout the home, and records are kept of water temperatures. The home has a designated storage cupboard for COSHH products, and this was found to be securely locked on the day of inspection. The laundry room was well maintained, with appropriate clothes washing facilities for the home, and each service user has their own clothes basket in the laundry room to help ensure they always only wear their own clothing. Although there have been some improvements to the homes décor over the course of the past year, much still remains to be done, several bedrooms are in need of redecorating, as are some of the communal areas. It is required that the home is well maintained and appropriately decorated. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 19 Throughout the home, there were instances of rotting window frames, and floor coverings in bathrooms and toilets that were not all impermeable, and these issues must be addressed. During the course of the inspection it was noted that a service user was seated at a table in a communal area of the home smoking a cigarette, and that an ashtray had been provided for this purpose. This was brought to the attention of the homes manager, who informed the inspector that this service user regularly smoked in this communal area as a matter of routine. It is required that all internal communal areas of the home are designated as no smoking areas. The inspector noted that the homes own quality assurance systems have identified that work still needs to be done to improve the homes environment. Monthly Regulation 26 visits by senior managers within the organisation have highlighted issues around the physical environment, likewise an internal audit of the home also highlighted environmental issues that must be addressed, as have questionnaires issued to relatives of service users. Requirements have been made repeatedly over the past three years around the homes physical environment, and continued failure to meet these requirements may lead the CSCI to take enforcement action against the home. Peartree House DS0000007235.V347678.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota available, and this accurately reflected the staffing situation on the day of inspection, and highlighted who was in charge of the home at any given time. All staff have been provided with a copy of their job description, and through observation and discussion there was evidence that staff have a good understanding of the collective and individual needs of service users. Staff were seen to have built up good relations with individual service users, and were observed to interact with them in a friendly and respectful manner. For example, where support was provided at mealtimes, this was provided in a sensitive, relaxed and unhurried manner. Service users spoken to informed the Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 21 inspector that they are very happy with the staff support provided, one commented that “They are very good here, the staff are very nice people.” The home has various employment related policies in place, including recruitment and selection, equal opportunities and grievance and disciplinary issues. The inspector checked staff employment files. These were found to contain appropriate proof of ID and employment references. However, CRB checks were not in place for all staff. The manager informed the inspector that the home has obtained CRB’s for all staff, but that after a set period these are destroyed. However, it is required that CRB’s are retained by the home until they have been inspected by persons so authorised to do so, after this they may be destroyed. The inspector was however satisfied that that the home has carried out CRB checks for all staff, and CRB disclosure numbers are still held on file. The homes manager informed the inspector that of the thirty eight care staff currently employed at the home, thirteen have achieved a relevant qualification, and that a further six are working towards such a qualification. It is required that at least 50 of the care staff employed at the home obtain a NVQ Level 2 in Care or equivalent qualification. All staff undertake a structured induction programme on commencing work at the home, this includes working supernumery for three days shadowing more experienced members of staff in their duties. Recent staff training has included adult protection and dementia. The inspector was pleased to note that since the previous inspection the home is now up to date with relevant health and safety training, including manual handling, fire safety and first aid. Regular staff meetings are held, and these also discuss health and safety issues. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 and 38. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home has generally appropriate management systems in place, for example around health and safety and quality assurance. EVIDENCE: The manager of the home has many years experience of working in a care setting, including in a managerial capacity. They have successfully completed both the Registered Managers Award and an NVQ Level 4 in Care. Staff and Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 23 service users spoken to informed the inspector that they found the manager to be approachable and accessible. Care plan reviews, staff meetings and staff supervisions all contribute to the quality assurance within the home. The inspector was pleased to note that there have been considerable improvements around quality assurance generally within the home, and the home now seeks the views of service users and relatives as part of the overall quality assurance process. Questionnaires are now issued to service users and their relatives to gain their feedback on the running of the home, and there was evidence that monthly unannounced Regulation 26 visits have taken place. The home has also introduced a Team Audit Process, which involves the homes manager and other members of staff auditing all areas of care and other facilities provided by the home. Their findings are then reviewed by senior managers within the organisation, and an action plan is drawn up. It was noted that Regulation26 reports, service user/relatives questionnaires and the Team Audit Process all highlighted areas of concern with the homes physical environment, and that these concerns are in line with the findings at this inspection. The inspector was pleased to note that since the previous inspection all staff now receive regular formal one to one supervision, including the homes manager. Minutes are taken of supervision meetings, and staff have access to their supervision records. Supervision covers performance, service user issues and training needs. The home has policies in place in line with National Minimum Standards. Those checked by the inspector included grievance and disciplinary and admissions procedure, and were found to be satisfactory. Record keeping within the home was generally of a good standard, records are stored securely, staff and service users can access their records as appropriate. Fire extinguishers were situated around the home, these were last serviced in October 2006. Fire alarms are checked weekly, and were last serviced on the 29/3/07. The home holds regular fire drills. Hot water and fridge/freezer temperatures are checked. The home had in date safety certificates for PAT testing and electrical installation, but a landlord’s gas safety check has not been carried out in the past twelve months, and this must be addressed. The home has in date employer’s liability insurance cover in place. Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 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 3 18 3 2 2 2 3 3 2 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 Requirement The registered person must provide a programme of decoration and maintenance which ensures that the premises are kept in a good state of repair both internally and externally, and that all parts of the home are kept clean and reasonably decorated and furnished. (Timescale 30/11/06 not met) The registered person must ensure that all bedrooms are decorated to an adequate standard, and that furniture in bedrooms is well maintained. (Timescale 30/11/06 not met) The registered person must ensure that all bedrooms are free from offensive odours. (Timescale 30/11/06 not met) The registered person must ensure that the home is well maintained, and address the following maintenance issues: All bathrooms and toilets must have impermeable floor coverings. Timescale for action 31/10/07 2. OP24 23 31/10/07 3. OP24 23 31/10/07 4. OP20 23 31/10/07 Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 26 5. OP28 18 6. OP19 23 7. OP7 15 8. OP9 13 9. OP9 13 10. OP20 13 11. OP29 19 12. OP38 23 13. OP11 15 Rotting window frames around the home must be repaired or replaced. (Timescale 30/11/06 not met) The registered person must ensure that at least 50 of the care staff employed at the home have an NVQ Level 2 in care or equivalent qualification. (Timescale 30/11/06 not met) The registered person must ensure that the damaged and stained floor covering in the kitchen is repaired or replaced. (Timescale 30/11/06 not met) The registered person must ensure that all service users have comprehensive individual care plans in place, covering all areas of need, including needs around equalities and diversity issues. The registered person must ensure that all medications are appropriately administered and recorded. The registered person must ensure that systems are in place so that any medication errors can be identified in a timely manner. The registered person must ensure that all internal communal areas of the home are designated as smoke free areas. The registered person must ensure that CRB disclosure forms are retained in the home, until they have been satisfactorily inspected by persons so authorised to do so. The registered person must ensure that the home has a landlord’s gas safety check carried out at least once every twelve months. The registered person must ensure that the home seeks and DS0000007235.V347678.R01.S.doc 31/12/07 31/10/07 31/10/07 31/08/07 31/08/07 31/08/07 31/08/07 30/09/07 30/09/07 Page 27 Peartree House Version 5.2 records the wishes of services users on arrangements to be made in the event of their death. 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 Peartree House DS0000007235.V347678.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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