Inspection on 23/08/06 for Peartree House

This inspection was carried out on 23rd August 2006.

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

Peartree House 31/07/08

Peartree House 02/08/07

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 Key Unannounced Inspection 23rd August 2006 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 Peartree House DS0000007235.V300208.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.V300208.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 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), Old age, not falling within any other of places category (0) Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds to be used flexibly between categories. Date of last inspection 7th December 2005 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. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 23/8/06 and was unannounced. The inspector had the opportunity of speaking with service users, their relatives and staff from the home. The inspection also included an examination of documents and records, and a tour of the premises. The inspector found instances of good practice, and overall service users expressed satisfaction with the care and support provided. There are however a number of issues that must be addressed, as highlighted within the report. What the service does well: What has improved since the last inspection? 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. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 6 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.V300208.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. It is the view of the inspector that service users are provided with sufficient information about the home to make an informed choice about moving in. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English. Since the last inspection both documents have been dated, and there was evidence that they are now subject to regular review. The Statement includes details of the organisational structure and the aims and objectives of the home. The Guide includes details of the fees payable and a copy of the homes complaints procedure. Service users are provided with a statement of terms and conditions, which include details of fees payable, what they cover and periods of notice required. These are signed by the service user or their representative where appropriate. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 8 There was evidence that pre admission assessments are carried out for prospective service users by the homes manager. These covered needs associated with health, mobility, medication and diet. However, for some recent admissions assessments did not cover service users social and leisure needs. It is required that comprehensive pre admission assessments are carried out for all service users, covering all areas of need. The home has an admissions procedure, and there was evidence that service users are admitted to the home in line with this policy. Service users and their family are able to visit the home before making a decision as to move in or not, and a placement review meeting is held after an initial trial period. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is generally meeting the personal and health care needs of service users. However, more attention needs to be paid to the recording and administration of medications. EVIDENCE: Care plans were in place for all service users, and these were of a satisfactory standard. Plans are drawn up with the involvement of the service user, their family and the homes manager. Plans include needs associated with health, mobility, culture and social and leisure needs. There was evidence that plans are reviewed monthly, and daily logs are maintained for all service users. Risk assessments are in place for all service users, these are subject to regular review, and cover risks associated with wandering, nutrition and falling. Assessments identify any particular risks, and also include strategies to manage and reduce these risks. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 10 Through observation and discussion there was evidence that service users are treated with respect and dignity. Staff were observed to knock and wait before entering bedrooms, and service users were dressed appropriately. At meal times, staff support was seen to be provided in a flexible and sensitive manner, and staff were seen to interact with service users in a friendly and professional manner generally. All service users are registered with a GP, and the inspector was informed that service users are able to retain the GP they had prior to admission where practical. The inspector spoke with a visiting GP on the day of inspection. They informed the inspector that they were always called out as appropriate, and that they were satisfied that the home followed up on any advice and recommendations given. Records are maintained of medical appointments, including details of any follow up action required. Records evidenced that service users have access to health care professionals as appropriate, including dentists, chiropodists and opticians. The home has a comprehensive medication policy in place, and all staff undertake training before they administer medications. Medications are stored in locked cabinets, inside a locked and designated medication room. Medication Administration Record (MAR) charts are maintained, and since the last inspection hand written entries on MAR charts are now signed for. However, there were some issues with MAR charts that must be addressed. Several unexplained gaps were found in MAR charts, on occasions Tipex had been used to correct MAR charts, on occasions the letter F had been used on MAR charts. The key code on the charts stated the F stands for “other please define”, yet there was no definition or explanation given as to what the F indicated. All of this must be addressed. The home has sought and recorded the views of service users on arrangements to be made in the event of their death. Service users are able to remain in the home with a terminal illness, so long as the home can meet their medical needs. The inspector viewed a letter from the family of a recently deceased service user, praising the home for the care provided, stating that “There was comfort and security knowing she was well looked after and treated with respect and kindness.” Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The inspector was satisfied that service users are supported to live valued lives. There is a varied activities programme, and food was of a satisfactory standard. EVIDENCE: The home employs two designated activities coordinators, and there is a designated activities room. This includes a small shop, selling greetings cards, newspapers, sweets etc that service users help to run. Any monies raised through this shop go towards further activities. There is a weekly activities programme, and there was a poster on display advertising this, and activities included bingo and quizzes. On the day of inspection the inspector was present for part of the activities programme, this consisted of a quiz/crossword, and a discussion on international terrorism. The session was well attended, and service users were seen to be involved and interested in the session. The inspector was informed by service users that they very much valued and enjoyed the activities programme provided. Service users are supported to access the community, for example visiting local shops and cafes, and are able to attend a local church. A visiting minister visits the home to spend time with service users on a one to one basis. The Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 12 home also hires professional entertainers who put on shows at the home, such as old time musicals and sing alongs. The home has a visitors policy. The inspector spoke with some visitors on the day of inspection. They informed the inspector that they are able to visit at any time, and can see their relative in private if they so wish. They also said that staff are always courteous to them. The home keeps records of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users spoken to informed the inspector that they are happy with both the quality and quantity of food provided. Service users were observed to be offered drinks and snacks throughout the day. Records are maintained of fridge and freezer temperatures, and food was stored appropriately. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home has appropriate procedures in place around complaints, but that more needs to be done around adult protection issues, for example training for all staff at the home. EVIDENCE: The home maintains a complaints log, this indicated that complaints have been appropriately recorded and investigated. The home also has a complaints procedure, which includes timescales for responding to any complaints received, and contact details of the CSCI. An abbreviated version of this was on display within the home. The home has a copy of the Local Authorities adult protection procedure. The inspector was informed by staff that since the last inspection the home has revised its own adult protection procedure, however, this could not be located during the course of the inspection, and it is required that the home has an adult protection policy, which is in line with current legislation, and is readily available to all staff in the home. The inspector was informed that as yet, not all staff have received training in adult protection issues, this must be addressed, and is a repeat requirement. 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.V300208.R01.S.doc Version 5.2 Page 14 Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that a considerable amount of work still needs to be done to the homes physical environment to bring it 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. The home also provides several smoke free communal areas for service users. All areas of the home are now 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, and the inspector was pleased to note that much work has been done in this area. At the previous inspection it was just an empty space, which service users did not Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 16 access. It now 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 in the “house” area of the home was broken on the day of inspection, and this must be repaired, while one of the upstairs shower rooms did not have an emergency override device fitted to the lock, and this must be addressed. Bedrooms inspected were decorated to service users personal tastes, and service users were able to bring their personal belongings into the home. Rooms had adequate furniture including wardrobes and chest of draws. 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. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, and all heating appliances in bedrooms are appropriately boxed in. However, around the home there were instances of hot water pipes without any protective covering. Work was in progress to address this during the course of the inspection, and it is required that all hot water pipes around the home have protective coverings as appropriate. Bedrooms have adequate natural light and ventilation, and lighting was domestic in character. There was no evidence of any assessment of the premises by a suitably qualified person having taken place and no evidence of aids and adaptations been provided, despite this been identified in previous inspection reports. It is a requirement that such an assessment is undertaken and that the registered person provides any necessary aids, adaptations and equipment to meet the needs of service users. Continued failure to comply with this requirement may lead to the CSCI taking enforcement action against the home. 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. The inspector was pleased to note that the ramp leading in to the laundry room is now far less steep then it was previously. 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 Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 17 the home is well maintained and appropriately decorated. Likewise, work has been done to improve the environment in the kitchen since the last inspection, however, more still needs to be done, in particular, parts of the flooring were found to be dirty, stained and cracked, and this must be addressed. 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. Peartree House DS0000007235.V300208.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 at least once during a 12 month period. 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 inspector was satisfied that the home is staffed in sufficient numbers to meet service users needs. However, service users would further benefit from staff who are suitably qualified, and have undertaken health and safety training as appropriate. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. There was a staffing rota on display within the home, this accurately reflected the actual staffing situation on the day of inspection. The inspector was pleased to note that staffing levels have increased in the homes dementia unit by 94.5 hours a week since the last inspection. The inspector was satisfied that staffing levels are now adequate to meet service users needs. All staff undertake a structured induction programme on commencing work at the home, this includes health and safety issues and the homes physical environment. Records are maintained of staff training, these indicated that staff have recently received training in dementia, medication and care planning. However, as at the last inspection, it was found that staff have not all received all statutory health and safety training, for example in fire safety and first aid. This must be addressed and is a repeat requirement. The inspector was informed that although some staff have achieved a relevant care qualification, as yet the number with such a qualification is below 50 of the Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 19 staff team. It is required that at least 50 of care staff working at the home have achieved an NVQ Level 2 in Care, or an equivalent qualification. The home has policies in place on equal opportunities and recruitment and selection. Staff employment records are held securely in a locked cabinet, that only the manager has access to. As the manager was not present during this inspection, requirements made at previous inspections around staffing records are repeated in this report, and will be tested as part of the next inspection of the home. Peartree House DS0000007235.V300208.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was generally satisfied that this is a well run home, although more attention must be paid to quality assurance matters. 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 service users spoken to informed the inspector that they found the manager to be approachable and accessible. Staff meetings and care plan reviews all contribute to the quality assurance within the home, and copies of previous inspection reports were available to view. The manager carries out a monthly audit of the home, which includes the Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 21 physical environment and records. Record keeping was generally of a good standard. Confidential records are stored securely, and staff and service users can access their records as appropriate. However, as at the last inspection, there was no system in place for seeking the views of service users on the running of the home to help inform future planning, and this must be addressed. Further, over the past twelve months, there was evidence that only nine Regulation 26 visits have taken place. It is required that these happen monthly, and that a copy of the reports of these visits is forwarded to the CSCI, and a copy retained in the home. At the last inspection it was found that not all staff at the home received regular formal supervision. Supervision records are stored securely in a locked cabinet, and only the homes manager has access to this cabinet. Therefore the inspector was unable to check this standard on this occasion. The requirement made at the previous inspection is repeated in this report, and will be tested as part of the next inspection of the home. The home has various health and safety policies in place, such as on fire safety and COSHH. Fire extinguishers were situated around the home, and last serviced in March 2006. Fire exits were clearly signed and free from obstruction. Fire alarms are checked weekly, and last serviced on the 21/11/05. The home had in date certificates for PAT testing, electrical installation and gas safety. The home had in date employer’s liability insurance cover. Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 22 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 2 2 3 2 2 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 3 3 Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 23 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 OP22 Regulation 12 Requirement The registered person must arrange for an assessment of the home by a qualified occupational therapist and ensure that appropriate adaptations and equipment are provided. (Timescale 31/03/06 not met) 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 31/03/06 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 31/03/06 not met) The registered person must ensure that all bedrooms are free from offensive odours. (Timescale 31/03/06 not met) The registered person must ensure that the home has a DS0000007235.V300208.R01.S.doc Timescale for action 30/11/06 2. OP19 23 30/11/06 3. OP24 23 30/11/06 4. OP24 23 30/11/06 5. OP29 19 30/09/06 Peartree House Version 5.2 Page 24 6. OP9 13 7. OP18 13 8. OP29 19 9. OP20 23 written record of staff’s employment history. (Timescale 31/03/06 not met) The registered person must ensure that all medications administered are appropriately accounted for. (Timescale 31/03/06 not met) The registered person must ensure that all staff employed at the home receive appropriate training in adult protection issues. (Timescale 31/03/06 not met) The registered person must ensure that all necessary pre employment checks are carried out on staff, including proof of ID, before they commence working in the home. (Timescale 31/03/06 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. Rotting window frames around the home must be repaired or replaced. Missing and broken handles from doors and windows must be repaired or replaced. (Timescale 31/03/06 not met) The registered person must ensure that all staff receive all appropriate health and safety training. (Timescale 31/03/06 not met) The registered person must introduce systems to gain feedback from service users and their relatives on the care provided at the home to help DS0000007235.V300208.R01.S.doc 30/09/06 30/11/06 30/09/06 30/11/06 10. OP30 18 30/11/06 11. OP33 24 30/11/06 Peartree House Version 5.2 Page 25 12. OP36 18 13. OP18 13 14. OP3 14 15. OP9 13 16. OP21 23 17. OP25 13 and 23 18. OP28 18 19. OP33 26 inform future planning. (Timescale 31/03/06 not met) The registered person must ensure that all staff, including the manager, have regular formal supervision, at least six times a year. (Timescale 31/03/06 not met) The registered person must ensure that the homes adult protection policy is amended to be in line with local authority procedures and current legislation, and that this policy is readily available in the home to all staff. (Timescale 31/03/06 not met) The registered person must ensure that comprehensive pre admission assessments are carried out for all prospective service users prior to them moving in to the home, covering all potential areas of need. The registered person must ensure that correction fluid (Tipex) is not used for any alterations or corrections on Medication Administration Record charts. The registered person must ensure that all toilets are in good working order, and that all toilets and bathrooms are fitted with a lock, that includes an emergency overide device. The registered person must ensure that all hot water pipes throughout the home have appropriate protective coverings fitted. 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 equivilant qualification. The registered person must ensure that monthly unanounced DS0000007235.V300208.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 30/11/06 30/09/06 30/11/06 30/09/06 Page 26 Peartree House Version 5.2 20. OP19 23 Regulation 26 visits take place, and that a copy of the report of these visits is forwarded to the CSCI, and a copy retained in the home. The registered person must ensure that the damaged and stained floor covering in the kitchen is repaired or replaced. 30/11/06 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.V300208.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Peartree House DS0000007235.V300208.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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