Inspection on 07/12/05 for Peartree House

This inspection was carried out on 7th December 2005.

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 02/08/07

Peartree House 23/08/06

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 7th December 2005 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.V259253.R01.S.doc Version 5.0 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.V259253.R01.S.doc Version 5.0 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) Ltd (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.V259253.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds to be used flexibly between categories. Date of last inspection 9th August 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.V259253.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 7/12/05 and was unannounced. The inspector had the opportunity of speaking with service users, staff and the homes manager was present throughout the inspection. The inspector found some areas of good practice in the home, and feedback from service users was generally positive. However, overall the inspector was disappointed to note that there have been no substantial improvements to the home since the last inspection, and there are a number of issues that must be addressed. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, the inspector was disappointed to note that the overall number of requirements has gone up since the previous inspection, and there are a number of issues that must be addressed. The physical environment still needs work, both in regard to cleanliness and decorating. The homes adult protection procedures need to be brought in line with current legislation, and all staff must receive training in this issue. The registered Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 6 person must ensure that medications are accurately administered and recorded, and risk assessments must be comprehensive. 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.V259253.R01.S.doc Version 5.0 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.V259253.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 The inspector was generally satisfied that service users are provided with sufficient information about the home to enable them to make an informed choice. This information is provided through written documentation and visits to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement of Purpose contains all information required by Schedule 1 of the Care Homes regulations 2001. The Guide has been updated since the last inspection, and now includes details of the qualifications and experience of the staff team and of the physical environment, and is now in line with National Minimum Standards. However, neither document has been dated, and there is no indication of when they are next due to be reviewed, this must be addressed. 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.V259253.R01.S.doc Version 5.0 Page 9 Pre admissions assessments are carried out on all service users prior to them moving in to the home. Assessments are carried out by the homes manager, and are clear and comprehensive. Assessments include information on mobility, medical, health and social and leisure needs. There was evidence from the Statement of Purpose and the Service Users Guide that service users and their representatives would be invited to visit the home prior to admission. The inspector spoke to service users who confirmed that they were indeed able to do this. The home does not provide intermediate care. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 It is the inspector’s belief that the home is generally able to meet the personal and health care needs of service users. Service users are supported sensitively to manage their own personal care, and have access to health care professionals as appropriate. However, the home must ensure that medications are appropriately administered and recorded. EVIDENCE: All service users have a care plan in place. The inspector checked several at random, and found them to be of a satisfactory standard. Care plans were clear and comprehensive, and covered needs associated with personal care, health, mobility, medication and social and leisure needs. Care plans are reviewed on a monthly basis, and daily logs are also maintained. However, as at the previous inspection the home could not evidence that all service users have an annual review with their placing authority, and this must be addressed. Risk assessments are in place for all service users, however, these are not all comprehensive. For example, on the day of inspection a service user had a fall which resulted in them been admitted to hospital, yet their was no risk assessment in place around them falling. It is required that Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 11 comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. All service users are registered with a GP. The manager informed the inspector that service users can retain the GP they had prior to admission where practical. Service users have all been offered the opportunity of having a flu vaccination recently. Records are maintained of medical appointments, these evidenced that service users have access to health professionals as appropriate, including the district nurse, chiropodist, opticians and skin care specialists. At the last inspection it was found that service users had not had regular access to dental care. Although many service users have as yet still not had access to dental care, the manager was able to demonstrate that arrangements have been made to ensure that in the near future service users will be offered dental care as appropriate. The home makes use of the Continence Advisory Service, who supply advice and continence products. The home has a comprehensive medication policy, and all staff receive training before they are able to administer any medications. Medications are stored within locked cabinets in a designated and locked medicines room, and within a fridge in the medicines room. Records are maintained of the fridge temperatures. Records are kept of all medications entering the home and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained. However, as at the last inspection these contained several unexplained gaps, and hand written entries were often left unsigned for. Both of these issues must be addressed. Service users are supported to manage their own personal care as much as possible, as outlined in their care plans. Staff were observed to interact with service users in a sensitive and respectful manner, and to knock and wait before entering bedrooms. The manager informed the inspector that service users are able to see visiting health professionals in private. The home has a policy in place on death and dying, and has made efforts to seek the views of service users or their family were appropriate on arrangements to be made in the event of their death. The manager informed the inspector that service users are able to stay in the home with a terminal illness, as long as the home can meet their medical needs. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 12 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 and 15 It is the view of the inspector that service users are supported with appropriate social activities, and that they have control over their daily lives. EVIDENCE: Service users were observed to have some control over their daily lives, for instance over meals and choice of dress. Service users are also able to access the community, for instance on shopping trips. The home employs two designated activities coordinators. There is an activities room, which includes a shop selling cards, papers and sweets etc, which service users help run. There was a poster on display advertising the homes activities programme, which included quizzes and sing-a-longs. The home has a visitors policy. Service users spoken to informed the inspector that they are able to receive visitors at a time of their choosing, and can see visitors in private if they so wish. However, it was observed that in the dementia unit there were insufficient chairs to enable all service users to be seated if any of the service users had guests present, and during the inspection two service users were observed to be sitting on a coffee table due to the lack of seating available. It is required that communal chairs are provided in sufficient numbers. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 13 Records are maintained of menus, these evidenced that service users are offered a varied, balanced and nutritious diet. On the day of inspection service users were offered a choice of meat or fish dish, both appeared to be appetizing and nutritious. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 14 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 It is the view of the inspector that lack of staff training and adult protection policies that are not in line with current legislation leaves service users at potential risk, and these issues must be addressed as a matter of priority. EVIDENCE: The home maintains a complaints log, this evidenced that complaints have been appropriately recorded and investigated. There is also a complaints procedure in place. An abbreviated version of this was on display within the home. However, the abbreviated version is very basic, and does not include any contact details for any one from the organisation, but merely states to inform the manager. Further, it does not give contact details of the local CSCI offices. It is recommended that a more comprehensive version of the complaints procedure is displayed within the home, including contact details of relevant persons. The home has a copy of the Local Authorities adult protection procedures, and also its own policy on adult protection. However, this policy is not in line with current legislation, for example it states that the homes manager or area manager will be responsible for carrying out any investigations into allegations of abuse, where as the decision as to who caries out any investigation should be made by the Local Authority. The manager informed the inspector that most of the staff at the home have received training in adult protection issues, but not all. Both of these issues must be addressed, and are repeat requirements. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 15 The inspector was satisfied that the legal rights of service users are protected. For example all service users are on the electoral register, and service users spoken to informed the inspector that they are able to vote in elections. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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 It is the inspector’s view that a considerable amount of work needs to be carried out to the homes environment. Although service users are provided with an adequate communal and private space, many areas of the home are in need of decorating, and the home must be kept clan and tidy. 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, however, at the rear of the building there is a large tarmac area, which at present has nothing in it. The manager informed the inspector that there are plans to develop this area for service users use, and this is recommended. The Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 17 home has a spacious garden, however, discarded furniture left in the garden must be removed. This is a repeat requirement. 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. At the last inspection two of the toilets were broken, these have subsequently been repaired. 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 were 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. 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 Commission 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. However, cleaning products were also found stored in an unlocked cupboard, in an area that service users routinely access, and this cupboard was left unsupervised during the course of the inspection. It is required that all dangerous substances are stored securely. 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. 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. Further, the kitchen was in need of a substantial amount of work, for example the walls and ceiling need painting, and broken tiles must be replaced. Several areas of the home were also found to be cleaned to an unsatisfactory standard, for instance there Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 18 were discarded tissues found under service users beds. The home must be kept clean and tidy. There were also several maintenance issues around the home that must be addressed. • Bathrooms and toilets must contain a window or a working extractor fan. • 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. • Hot water pipes in the corridor must be sufficiently protected against the risk of scalding and burning service users and others. • The window outside Room 40 requires restricting, as at present it presents a health and safety risk. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 19 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 The inspector has concerns that staff are not always provided in sufficient numbers to meet service users needs, particularly within the dementia unit. Further, the home must ensure that staff receive appropriate health and safety training. EVIDENCE: The home provides 24-hour care and support, including an emergency on-call procedure. The home had a staffing rota on display, this accurately reflected the actual staffing situation on the day of inspection. As well as care staff, the home employs administrative staff, cleaning, laundry, and cooking and activities staff. Since the previous inspection the home now has a designated sixteen bed dementia unit. This has three staff between the hours of 7.45am and 9.45pm. During the course of the inspection it was observed that staff time in this unit was taken up almost exclusively with personal care duties and supporting service users with meals, and that their was very little opportunity to provide any meaningful interaction with the service users. The manager informed the inspector that they believe current staffing levels in this unit to be insufficient, and it is required that the home carries out a review of staffing levels to determine how it can meet all the assessed needs of service users at all times. The home has policies in place on equal opportunities and recruitment and selection. The inspector checked several staff employment files at random. These included evidence of satisfactory CRB checks having taken place and Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 20 employment references. However, files did not contain all information required by Schedule 2 of the Care Homes Regulations 2001, for example not all files contained proof of ID such as a passport or birth certificate, and several files did not contain a full employment history for staff, including an explanation of any gaps in employment. This must be addressed. The home has a structured induction programme, this includes service user issues and policies and procedures. Records are kept of staff training, these evidenced that staff have recently received training in dementia care, first aid and infection control. However, not all statutory health and safety training was up to date, for instance several staff have had no recent training in fire safety or moving and handling. It is required that staff receive all appropriate statutory health and safety training. Of the forty seven care staff currently employed at the home the manager informed the inspector that ten either have or are working towards a relevant care qualification, and that it is the intention of the organisation that all care staff will be given the opportunity of completing such a qualification. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 21 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 It is the view of the inspector that the manager is suitably qualified and experienced to carry out their roles and responsibilities. However, more attention must be paid to several areas, for instance health and safety. EVIDENCE: The homes manager has thirteen years experience of working with elders, including eleven years in a managerial capacity. They are currently working towards the Registered Managers Award and NVQ Level 4 in Care, and informed the inspector that they hoped to have completed these qualifications by the end January 2006. The manager presented as having good working relations with staff, service users and families. Staff were observed to interact with the manager in a relaxed manner, and the management approach has helped to create an open, positive and inclusive atmosphere. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 22 Staff meetings, supervisions and care plan reviews all contribute to the quality assurance within the home. There was evidence of monthly unannounced Regulation 26 visits, and copies of previous inspection reports were available to view. The manager carries out a monthly audit of the home, covering the environment and health and safety issues. However, there is no system in place to gain the views of service users and relatives on the home, and this must be addressed to help inform future planning. Record keeping was generally of a good standard, staff and service users can access their records as appropriate. Care staff in the home receive regular formal supervision from the manager. Records are maintained, and these evidenced that supervision covers performance, training and service user issues. However, there was no evidence that the homes manager receives any formal supervision, and it is required that all staff, including the manager, receive regular formal supervision at least six times a year. The home has various health and safety polices in place, for example on fire safety and infection control. The home has in date certificates for PAT, gas safety and electrical installation. Fridge/freezer temperatures are checked, and since the last inspection hot water temperatures are now also checked and recorded. The home’s fire fighting equipment was last serviced in June 2005, during this service three extinguishers and a fire blanket were condemned and have subsequently been removed from the home. It is required that these are replaced. Fire alarms are tested weekly, and the home holds regular fire drills. At the last inspection a requirement was set that the home meet all the requirements set by the Local Fire Authority as a result of their visit to the home in July 2005. At the time of this inspection this has not been complied with, therefore this requirement is repeated in this report. The home was inspected by the Local Authorities Environmental Health Officer on the 29/11/05, and it is required that the home complies with all requirements set by the Environmental Health Officer. Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 1 3 2 2 3 2 2 2 STAFFING Standard No Score 27 2 28 3 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 2 Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 24 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 30/11/05 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 30/11/05 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. (Timescale 30/11/05 not met) The registered person must ensure that all bedrooms are decorated to an adequate standard, and that furniture in bedrooms is well maintained. DS0000007235.V259253.R01.S.doc Timescale for action 31/03/06 2 OP19 23 31/03/06 3 OP18 13 31/03/06 4 OP24 23 31/03/06 Peartree House Version 5.0 Page 25 5 OP24 23 6 OP29 19 7 OP7 15 8 OP9 13 9 OP9 13 10 OP18 13 11 OP20 23 12 OP26 13 and 23 13 OP29 19 (Timescale 30/11/05 not met) The registered person must ensure that all bedrooms are free from offensive odours. (Timescale 30/1/05 not met) The registered person must ensure that the home has a written record of staff’s employment history. (Timescale 30/11/05 not met) The registered person must ensure that all service users have an annual review of their care in conjunction with their placing authority. (Timescale 30/11/05 not met) The registered person must ensure that all hand written entries on MAR charts are signed. (Timescale 30/11/05 not met) The registered person must ensure that all medications administered are appropriatly accounted for. (Timescale 30/11/05 not met) The registered person must ensure that all staff employed at the home receive appropriate training in adult protection issues. (Timescale 30/11/05 not met) The registered person must ensure that the discarded furniture left in the homes garden is removed. (Timescale 30/11/05 not met) The registered person must ensure that all COSHH products are stored securely. (Timescale 30/11/05 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 30/11/05 not met) DS0000007235.V259253.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Peartree House Version 5.0 Page 26 14 OP38 13 and 23 15 OP1 6 16 OP7 13 17 OP13 23 18 OP19 23 19 OP20 23 The registered person must ensue that the home complies with any requirements set by the Local Fire Authority within the timescales provided. (Timescale 30/11/05 not met) The registered person must ensure that the Statement of Purpose and Service User Guide are both dated and suibject to regular review. The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others. The registered person must ensure that adequate numbers of chairs are provided in communal areas to enable service users and their guests to sit down. The Registered person to repair, make good and re-decorate the catering premises to include: retiling where broken tiles are evident; re-painting of walls, ceiling and woodwork; replastering and floor finishing strip to be replaced. The registered person must ensure that the home is well maintained, and address the following maintenance issues: • • • • Bathrooms and toilets must contain a window or a working extractor fan. 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 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 27 • • or replaced. Hot water pipes in the corridor must be sufficiently protected against the risk of scalding and burning service users and others. The window outside Room 40 requires restricting, as at present it presents a health and safety risk. 31/03/06 20 OP27 18 21 OP30 18 22 OP33 24 23 OP36 18 24 25 OP38 OP38 13 and 23 13 The registered person must undertake a review of staffing levels to determine how the home can meet the assessed needs of service users at all times. The registered person must ensure that all staff receive all appropriate health and safety training. The registered person must introduce systems to gain feedback from service users and their relatives on the care provided at the home to help inform future planning. The registered person must ensure that all staff, including the manager, have regular formal supervision, at least six times a year. The registered person must ensure that all condemned fire extinguishers are replaced. The registered person must ensure that the home implements all requirements made by the Local Authorities Environmental Health Officer as a result of their visit to the home on the 29/11/05, within the timescales set. 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP20 Good Practice Recommendations It is recommended that consideration is given to the development of the rear tarmac courtyard to provide accessible outdoor space for service users, including service users with physical, sensory or cognitive impairments. It is recommended that the home’s complaints procedure is displayed within the home, and that this includes contact details of the CSCI and relevant persons within the organisation to complain to. 2 OP16 Peartree House DS0000007235.V259253.R01.S.doc Version 5.0 Page 29 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.V259253.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!