Inspection on 14/11/05 for Peel Gardens Nursing Home

This inspection was carried out on 14th November 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

Peel Gardens Nursing Home 15/04/08

Peel Gardens Nursing Home 23/04/07

Peel Gardens Nursing Home 24/05/05

Peel Gardens Nursing Home 14/10/04

Peel Gardens Nursing Home 20/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Peel Gardens Nursing Home Off Vivary Way Colne Lancashire BB8 9PR Lead Inspector Mrs Marie Matthews Unannounced Inspection 14th November 2005 09:45 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 Peel Gardens Nursing Home DS0000022494.V265929.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. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peel Gardens Nursing Home Address Off Vivary Way Colne Lancashire BB8 9PR 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) 01282 871243 01282 871344 European Care (UK) Limited Mrs Patricia Joan Cairns Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability over 65 years of age of places (48), Terminally ill (4) Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Within the overall registration of 48 places, no more than 4 TI or 24 OP should be accommodated Under Annex 2, a maximum of 48 service users who fall into the category of PD(E) A max of 24 service users who fall into the category of OP A max of 4 service users who fall into the category of TI Staffing for service users requiring nursing care will be in accordance with the previous communication dated 29 November 2000 The registered provider must, at all times, employ a suitably qualified manager who is registered with the Commission for Social Care Inspection 24th May 2005 Date of last inspection Brief Description of the Service: Peel Gardens is a purpose built two-storey facility that provides accommodation for up to forty-eight people who require nursing care or personal care. Within the maximum number of forty-eight the home is also registered to provide terminal care for four people. The home is situated in a quiet residential area and there is adequate parking. Attractive lawned areas surround the home and there is a patio area that is accessible from the main lounge. There are 44 single bedrooms and 2 double bedrooms; all bedrooms offer en suite toilets and hand basins. The double rooms were in use as single accommodation at the time of inspection. There is a passenger lift to access the first floor. There are a variety of communal areas in the home including two adjoining lounges and a separate dining room on the ground floor. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted at Peel Gardens on 14th November 2005. The inspection involved looking at records, talking to management, two staff, five residents and two visitors, a tour of the premises and generally looking at what was happening in the home. This inspection looked at things that should have been done since the last visit, in May 2005, and a number of areas that affect resident’s lives. At the time of the visit the registered manager was on leave and the inspection was conducted with Mrs Gregory the deputy manager. There were forty-two people living at the home on the day of the inspection visit. Comments from visitors and residents included ‘staff are helpful and friendly’, ‘my mum is happy here’, ‘I’m more than happy with the care I get’ and ‘it’s a dam good place’. The home was assessed against the National Minimum Standards for Older People. This report should be read with the inspection report of 24th May 2005 for the reader to get a complete overview of the home. What the service does well: The home always obtained detailed information about prospective residents before they were admitted to the home to make sure the staff had the skills to meet their needs. The pattern of mealtimes had changed; the main meal was now served at teatime and a lighter meal available at lunchtime. Residents had suggested this and other changes to the menu at a recent meeting. Residents commented that the ‘food is always very tasty’ and ‘the cook makes sure we get what we want’. The home had a good complaints system in place. People felt their concerns would be listened to and responded to and they knew who to talk to if they were unhappy with their care. Resident’s said they were pleased with their rooms, one resident said ‘ I have everything I need and I can get help if I need to’. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 6 Residents were protected by the way the home recruited new staff. Safe procedures were followed and appropriate checks were in place. The home provided staff in appropriate numbers to meet the needs of the residents. Residents and visitors said there were enough staff on duty. Staff had received appropriate training to meet the needs of the people in the home. The home had good systems in place to monitor whether the home was meeting people’s needs. There was evidence of regular meetings with staff, residents and visitors and of action taken in response to any issues raised. What has improved since the last inspection? What they could do better: The care plans contained a lot of detail but the home needed to make sure residents needs and how their needs would be met were clearly identified in the plan. The care plan needed to be developed from the assessment information. The systems for the management of medicines needed to be improved to reduce any risks to residents. The medication policies and procedures and record keeping needed to be reviewed. The dining room floor was still waiting for further work to be done. Once completed this would improve the dining experience. It was noted that a number of areas in the home still required redecoration, replacement or refurbishment. Appropriate request forms had been sent to head office for authorisation. Head office needed to make sure these requests were given prompt consideration. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 7 The registered manager generally ensured that people’s health, safety and welfare was promoted and protected; however some of the service records were overdue and these were discussed with the deputy manager. 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. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. The home consistently obtained detailed information about prospective residents to ensure the home was able to fully meet their needs. EVIDENCE: The care plans of two recently admitted residents were looked at and both had a care needs assessment completed before admission. This allowed the home to assess whether needs could be met. The assessments were detailed. The home confirmed, in writing, that they were able to meet resident’s needs before admission. Peel Gardens Nursing Home DS0000022494.V265929.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 and 9. The care plans did not fully detail the action to be taken by staff to ensure the resident’s needs would be met. The systems for the management of medicines need to be improved to reduce the risk to residents. EVIDENCE: Three care plans were looked at. As at the last inspection the care planning system was being changed and the format varied. Two of the care plans did not include all information about care needs that had been obtained at the recent assessment. The care plans did not fully detail care, to be given by care staff, to ensure that the resident’s needs were met. Two of the care plans had been reviewed regularly. There was evidence to support residents, or their relatives, had been involved in the development of the care plan. Various risk assessments were in place, including pressure, nutrition, moving and handling and falls. However staff needed to detail interventions once a risk had been identified. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 11 Access to healthcare services was documented. Medication policies and procedures needed to be reviewed to include all aspects of medication management. A random check of medication records showed that the date of receipt of medications had not been maintained and there were no records to evidence medication removed from use. The registered person needed to introduce a system for safe disposal of medicines as a matter of urgency. Individual PRN protocols were not seen and transcribing had not been witnessed. Storage was clean and secure. A random check of controlled drugs was done; records were accurate. Care staff were completing blood glucose testing; there must be written evidence to show that care staff had received training, were competent to carry out the task and had received authorisation from the district nurse. The home needed to develop a system that prompts medication reviews. Peel Gardens Nursing Home DS0000022494.V265929.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): 15. The home continued to offer a varied selection of meals that met the tastes and choices of the residents. EVIDENCE: Residents said the pattern of mealtimes had changed. The main meal was now served at teatime and a lighter meal available at lunchtime. Residents had suggested this and other changes to the menu at a recent meeting. A choice of meal was available and residents commented that the ‘food is always very tasty’ and ‘the cook makes sure we get what we want’. The dining room floor was still waiting for further work to be completed; approval for this had been requested from head office. A replacement freezer was needed following a visit by the environmental health department. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 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 and 18. The home had a good complaints system and people were confident they would be taken seriously. The abuse procedure was clear and ensured prompt action to safeguard residents. EVIDENCE: From looking at records and talking to people it was clear that residents and visitors knew who to talk to if they were unhappy with their care. Clear records had been maintained. The abuse procedure contained contact information for local agencies. Staff were aware of whom to contact in the event of a suspicion or allegation of abuse. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 14 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, 22, 24, 25 and 26. The standard of the environment was gradually improving. There was evidence of further planned improvements to ensure residents live in a safe, comfortable and pleasing environment. EVIDENCE: The home employed a handyman who completed weekly and monthly audits of all areas of the home. There was evidence that minor repairs and redecoration had been completed. Progress had been made to improve some of the environmental issues noted at previous inspections. These included redecoration, replacement of a number of failed glazing units, a new washing machine and provision of new chairs and tables for the communal areas. Areas still requiring attention had been notified to head office and included the dining room floor and further failed glazing units. It was noted that the seating and carpeting in the entrance, hairdressing salon chairs, furnishings in the first floor seating area and one lounge on the ground floor were still areas that Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 15 required attention; however there was some evidence that some of these areas were being addressed. Storage of equipment appeared to be a problem. Equipment had been stored in a bathroom and in the stairwell reducing safe access to fire exits. This was discussed with the deputy manager for immediate action. All rooms had accessible call systems in place. Residents had personalised their rooms. A number of carpets had been replaced. Resident’s said they were pleased with their rooms, one resident said ‘ I have everything I need and I can get help if I need to’. Residents were given keys to their rooms if they had requested them but this was not included in the risk assessments. Adjustable beds had not yet been provided for those residents who would benefit from them. Quotes had been obtained but not yet authorised. The grounds were safe, attractive and accessible. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 16 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 and 29. Residents were protected by the safe recruitment practices. The home provided staff in appropriate numbers to meet the needs of the residents. EVIDENCE: Staffing rotas were clear. Staffing numbers were in line with agreed staffing levels. Residents and visitors said there were enough staff on duty. More than half of care staff had achieved an appropriate qualification to enable them to meet the needs of the people in the home. Three staff recruitment files were checked and a safe procedure had been followed. It was again recommended that staff photographs be used for identification purposes. Comments from visitors and residents included ‘staff are helpful and friendly’, ‘my mum is happy here’, ‘I’m more than happy with the care I get’ and ‘it’s a dam good place’. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 17 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, 33, 35, 36 and 38. The systems for service users consultation were good with a variety of evidence that people’s views are sought and acted upon. The registered manager generally ensured that people’s health, safety and welfare was promoted and protected. EVIDENCE: Mrs Pat Cairns, a registered nurse with many years experience, is the registered manager for this home. She has completed the Registered Managers Award this year. Effective quality assurance and monitoring systems were in place. A residents survey had been completed in July 2005 and the results were available. Regular meetings with staff, residents and visitors had taken place. Detailed audits had been completed and action plans developed following monthly Regulation 26 visits. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 18 Accurate records had been maintained for any financial transactions dealing with resident’s money. Staff and records confirmed that staff were regularly formally supervised. Service records were checked. It was noted that water chlorination testing and nurse call system servicing was overdue and regular water temperature testing of bathroom areas had not been done since June 2005. This was discussed with the deputy manager. Risk assessments were in place. Accidents had been recorded appropriately. Some cleaning fluids were stored in a bathroom and an unlocked room. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 19 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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X 2 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 3 3 2 Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement The residents plans must be generated from the assessment and detail the action to be taken by care staff to ensure all needs of the resident are met. Timescale 19/12/04 not met. The registered person must ensure that once a risk has been identified, appropriate interventions are recorded in the care plan. Timescale 19/12/04 not met. The registered person must ensure there is a policy and staff adhere to procedures for all aspects of medicines. The registered person should ensure that documented evidence of agreements with district nurses are kept where nursing procedures are undertaken for non-nursing residents. The registered person must ensure that the home is safe and well maintained. The registered person must ensure that equipment is stored safely and does not restrict DS0000022494.V265929.R01.S.doc Timescale for action 19/12/05 2. OP8 14 19/12/05 3. OP9 13 19/12/05 4. OP9 13 02/01/06 5. 6. OP19 OP22 23 23 02/01/06 19/12/05 Peel Gardens Nursing Home Version 5.0 Page 21 7. OP24 13 8. OP24 16 9. 10. 11. OP26 OP38 OP38 23 13 13 access to fire exits. The registered person must ensure residents are provided with keys to their bedroom doors unless their risk assessment suggests otherwise. Timescale of 19/12/04 not met. The registered person must ensure adjustable beds are provided for residents whose risk assessment determines a need. All areas and furnishings of the home must be kept clean. All substances hazardous to health must be stored safely. The registered person must ensure the service folder is up to date with particular reference to water chlorination, water temperature testing and servicing of the nurse call system. 02/01/06 02/01/06 19/12/05 19/12/05 19/12/05 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. 2. 3. 4. 5. 6. 7. Refer to Standard OP8 OP9 OP9 OP9 OP15 OP19 OP25 Good Practice Recommendations The registered person should ensure that the type of health care/medical equipment in use should be documented in the residents care plan. The criteria for PRN administration should be clearly defined. Transcribing of medications should be witnessed A system prompting reviews of medications should be developed. Work to the dining room floor should be arranged to ensure residents dine in well-maintained surroundings. The kitchen freezer should be replaced following recommendations made by the environmental health department. The programme to replace failed double-glazed windows DS0000022494.V265929.R01.S.doc Version 5.0 Page 22 Peel Gardens Nursing Home 8. OP29 should be continued. Staff files should include a photograph as a means of identification. Peel Gardens Nursing Home DS0000022494.V265929.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. 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