CARE HOMES FOR OLDER PEOPLE
Peel Gardens Nursing Home Off Vivary Way Colne Lancashire BB8 9PR Lead Inspector
Mrs Marie Matthews Key Unannounced Inspection 15th April 2008 09:40 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.V358973.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. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 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 peelgardens@tiscali.co.uk www.europeancare.net European Care (UK) Limited Mrs Patricia Joan Cairns Care Home 45 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service is registered to provide personal care to a maximum of 45 service users, 29 of whom may be in the category of DE (Dementia). 23rd April 2007 Date of last inspection Brief Description of the Service: Peel Gardens has recently made changes to the registration and is now registered to provide personal care for a maximum of forty-five people; twenty-nine of who may be suffering from a dementia. On the day of the key inspection visit work was underway to move the secure specialised unit, to accommodate people with dementia, from the first to the ground floor. 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 is also a sensory garden area with seating, raised flowerbeds and wheelchair access. All rooms were single occupancy and offered en suite toilets and hand basins. 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 and a dining room and two lounges areas on the first floor. Information about the services offered by the home is provided in the form of a service user guide and is available, with a summary of the most recent inspection report, to existing and prospective residents and their relatives. On the day of the inspection the fees ranged from £319.00 to £647.00. Items not included in the fee include newspapers, toiletries, hairdressing and private chiropody. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
The key unannounced inspection, including a visit to the home, took place on 15th April 2008. The inspection process included looking at records, a tour of the home, discussions with the registered manager, two staff and five residents who lived in the home. Information was also included from survey forms filled in by one member of staff, six visitors and four residents. The inspection also looked at things that should have been done since the last visit and a number of areas that affect people’s lives. There were forty-three residents living in the home on the day of the inspection. What the service does well:
Detailed information was collected about prospective residents before they were admitted to the home to determine whether they could be looked after properly. Records indicated that a range of training was provided to give staff the skills and experience needed to meet resident’s needs. A number of staff had achieved a recognised qualification in care and others were working towards achieving this; this showed that the company recognised the importance of training staff to a high standard. Residents said there were enough staff to give them the help and support they needed. There was a person responsible for arranging activities and entertainments and making sure that resident’s social needs were met. Residents commented that suitable activities were provided and records supported this. Staff and residents confirmed that choices were given in many aspects and visitors commented that residents were ‘supported to live the life they chose’. The complaints procedure was clear and accessible to people; people knew how to complain, whom to complain to and were satisfied that their complaint
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 6 would be dealt with appropriately. One visitor said ‘ I can’t imagine anyone wanting to complain’. Resident’s rooms were clean and bright and most had been personalised with treasured possessions. All bedrooms had en suite facilities and lockable storage was available for private items. Residents spoken to were happy with their rooms. People were happy with the care and support they received at Peel Gardens. Comments included ‘staff are caring and dedicated’, ‘the support mum is given is wonderful’, ‘staff do an excellent job and always with a smile’ and ‘the staff are so caring and friendly it feels like a big happy family’. People had been consulted and encouraged to air their views and opinions about whether their needs and expectations were being met. Systems were in place to monitor whether staff had followed policies and procedures and whether people were happy with the service they received. Records supported that the home was safe and well managed and that people’s health, safety and welfare were protected. What has improved since the last inspection? What they could do better:
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 7 All residents should be given a contract or statement of terms and conditions when they move into the home; this would inform them of their rights and obligations whilst residing at Peel Gardens. Staff should be provided with training to assist them with managing challenging behaviour including verbal and physical aggression; this would help to keep people safe from harm. The registered manager said the company was trying to source some training. Medication policies and procedures needed further additions to ensure staff had access to clear and safe guidance in all aspects of practice. The safeguarding procedures that would help staff recognise abuse and respond appropriately to suspected abuse were very detailed but still did not reflect local guidance or include contact information to guide staff. Some areas of the home were still in need of improvement; it was recommended that a regular room-to-room audit be completed to identify all areas requiring attention. To make sure that staff were recruited safely, in accordance with the recruitment procedure, the application forms provided by European Care should be completed for all new applicants. Policies and procedures had been reviewed but were not yet available to staff; staff needed up to date, accessible information to support them with safe practice. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were provided with information to help them to make an informed choice about where to live. People’s needs were assessed prior to moving into the home and they were assured their needs would be met. EVIDENCE: The information about services available at Peel Gardens been updated; people who were surveyed said they were given enough information. Four of the residents surveyed said they had received a contract or statement of terms and conditions; this would inform people of their rights and obligations whilst residing at Peel Gardens. However three files were looked at in detail and none had contracts on file. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 10 Three residents care files were looked at in detail. Detailed information had been collected about prospective residents before they were admitted to the home to determine whether they could be looked after properly; the registered manager had then confirmed, in writing, that their needs would be met. The assessment information was used to develop a plan of care. Records indicated that a range of training was provided to provide staff with the skills and experience needed to meet people’s needs. A number of staff had recently completed specialised training provided by the Alzheimer’s Society to help them to care for residents with dementia. Following a review of care files it was recommended that staff were provided with training to assist them with managing verbal and physical abuse and de-escalation techniques; the registered manager said the clinical head of dementia for the company was trying to source some training (see standard 18). Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs were met although the medication policies and procedures did not always support staff with safe practice in all aspects of medicine management. EVIDENCE: Three care plans were looked at in detail. Individual care plans had been reviewed since the last inspection; the plans were clearer, developed from information obtained prior to admission and included details about how residents care needs would be met. Records showed that residents and their relatives had been involved in decisions about their care. Relatives said they were kept up to date and consulted about changes to care. Visitors commented that people’s needs were met and support was given when necessary. One visitor said ‘I am kept fully informed as to progress and problems’ another said ‘if there are any problems I am told’.
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 12 Personal health care needs were clearly monitored and records supported that residents had access to a range of health care services. Staff were trained in health care matters and recognised the importance of treating individuals with dignity and respect. Any risks to residents had been assessed and action to reduce or remove any risks had been taken. There were a range of specialised aids and adaptations to maintain resident’s comfort and safety and to help them to maintain their independence wherever possible. Weekly audits monitored whether resident’s needs were being met and whether staff were following procedures. Not all the medication policies and procedures were available at the time of the visit. The registered manager said they had been reviewed but had not yet been printed or made available to staff (see standard 33). A number of missing policies and procedures were sent to the commission following the visit; however the procedures needed minor additions to ensure staff had access to clear and safe guidance in all aspects of practice. There were no procedures to support staff with ‘PRN’ or ‘as needed’ medicines, witnessing handwritten directions, recording external medicines, providing medicines for leave and covert administration. Records were clear and accurate and showed that medicines were managed safely. Monthly audits were in place to monitor whether staff were adhering to safe practices. Residents and visitors to the home were treated with dignity and respect. Staff responded in a friendly but polite manner to people and privacy and dignity issues were included as part of the induction training. One resident confirmed that she had been visited by her GP in the privacy of her room. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and recreational activities met people’s diverse needs and expectations. The diet was healthy and nutritious and suited to individual preferences. EVIDENCE: The home employed a person who was responsible for arranging activities and entertainments and making sure that people’s social needs were met. Records in three care plans showed the activities that had been provided both in groups and on a one to one; an activity plan was displayed in the entrance hall. Four residents commented that suitable activities were provided. One resident said she preferred not to join in and this was respected another said she enjoyed tidying her room and staff helped her with this. One relative had commented that there was a need for more activities on the dementia unit although records supported that activities had been provided. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 14 Staff and residents confirmed that choices were given in many areas including meals, activities, clothing and routines. Visitors commented that residents were ‘supported to live the life they chose’. Advocacy information was provided for those residents who needed someone to help them with decisions. Bedrooms were personalised and residents could have access to any information that was held about them. Residents said they were able to have visitors at any reasonable time and people were helped to keep in touch. The registered manager said ministers from different denominations visited regularly to meet residents spiritual needs and expectations. Records showed that residents were given a choice of varied and nutritious meals, usually a meat or vegetarian option. Some of the recent records that would evidence choice were missing and this was discussed with the registered manager. One resident said ‘the food is very satisfactory’, four others commented that they liked the food. The meal served on the day of the visit looked nutritious and appetising; two residents said they had enjoyed it. The chef was advised of any new admissions or special diets required and hot drinks were available throughout the day and night. Staff were available to provide assistance to some residents that needed extra support. The ground floor dining room was spacious, clean and bright and the tables were attractively set; the registered manager said this room had been re decorated and blinds had been ordered for the windows. The chairs in the dining room on the first floor were mismatched and some had food debris or spillages on the covers. Only two of the tables were set the other was not covered and it was stained and scratched. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had access to a robust and effective complaints procedure and were protected from abuse by staff awareness and policies and procedures EVIDENCE: The complaints procedure was clear and accessible to people; people knew how to complain, whom to complain to and were satisfied that their complaint would be dealt with appropriately. One visitor said ‘ I can’t imagine anyone wanting to complain’. There had been one complaint in the last twelve months; records showed that the procedure had been followed properly. The safeguarding procedures, provided by European Care were very detailed but still did not reflect local guidance or include contact information to guide staff in the event of any suspicion of abuse; at the last inspection visit the inspector had been assured that local contact information would be attached to the procedures to provide clear guidance for staff. From discussions with staff and review of records it was clear most staff had received recent safeguarding training. A safeguarding training pack that had been issued to all staff; safe and appropriate guidance to ensure the right action was taken to protect people was included. There had been one safeguarding referral in the past twelve months; this had been referred to the appropriate agencies.
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 16 Staff had access to a whistle blowing and responding to verbal and physical abuse procedures. Following a review of care records it was recommended that staff should be provided with training to assist them with managing verbal and physical aggression; the registered manager said the clinical head of dementia for the company was trying to source some training. There were financial procedures to support staff with managing resident’s finances. One visitor said ‘mum is safe’. Any reasons for restraint had been recorded and discussed with residents or their representative. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was safe, clean, comfortable and generally well maintained; plans were in place to improve some areas of the home but could be more detailed. EVIDENCE: On the day of the key inspection visit work was underway to move the secure specialised unit to accommodate people with dementia from the first to the ground floor. During a tour of the home it was clear that some areas had been improved since the last key inspection visit including replacement of a number of failed double glazed units, repairs to and painting of the outside of the home and redecoration of the dining room, corridors and some bedrooms; the registered
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 18 manager said there were plans to re decorate the main lounge and refurbish the entrance hall. However there were areas that still needed attention to improve the environment for those people who lived in the home and there was no formal plan to support ongoing improvements and developments. The AQAA referred to some of the improvements to be made over the next twelve months but did not record all the plans as discussed with the registered manager. The registered manager said the ground floor corridor carpet referred to in the last key inspection report was due to be replaced this month but had been delayed until work to re-locate the dementia unit to the ground floor had been completed. The hairdressing salon remained shabby and the seating was badly damaged, skirting boards, walls and doors in various rooms were also damaged, there were still a number of failed glazed units (the AQAA states they are being replaced as an ongoing programme) and a number of carpets were stained. The chairs in the dining room on the first floor were mismatched and some had food debris or spillages on the covers (see standard 15); one of the tables was stained and scratched. The registered manager said the handyman was responsible for the day-to-day maintenance of the home including all the redecoration and repairs; records showed that the handyman checked some areas each month. It was recommended that a regular room-to-room audit be completed to identify all areas requiring attention; including those noted during the inspection visit and discussed with the registered manager. Fire safety services and environmental health had visited the service within the last eighteen months; the registered manager said there were no areas of concern. Outside areas were safe, tidy and accessible; there was a new sensory garden on the front lawn area that included raised flowerbeds, seating and wheelchair access. Residents said they enjoyed the views from their bedrooms. There were a variety of communal and seating areas for residents and their visitors. Furnishings were comfortable and appropriate for the residents who used them. Resident’s rooms were clean and bright and most had been personalised with treasured possessions. Lockable storage was available for private items such as medication, money and valuables. All bedrooms had en suite facilities and there were toilets easily accessible from lounge and dining areas. Residents spoken to were happy with their rooms. Bathrooms were fitted with suitable aids and adaptations; the manager said all bathrooms were due to be redecorated. Sluices were located separate from other facilities. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 19 People were provided with a range of specialised aids and adaptations to maintain their comfort and safety and to help them to maintain their independence wherever possible. Call systems, to be used to call for assistance, were provided in most rooms and the reasons for non-provision were clearly recorded. Four residents said the home was usually clean and odour free. The laundry was fitted with appropriate equipment and a replacement washing machine was on order to ensure resident’s laundry needs were met. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team were experienced, well supported, competent and provided in sufficient numbers to meet resident’s needs. Some aspects of the recruitment process need improvement to ensure the procedure followed was safe and robust. EVIDENCE: Residents said there were enough staff to give them the help and support they needed and staffing rotas were clear. Records showed that staff had received appropriate induction and ongoing training to help them to understand the needs of residents in their care. A number of staff had achieved a recognised qualification in care and others were working towards achieving this. One staff member said ‘staff are very caring about the residents and put their hearts and soul into the job’ and ‘there is always ongoing training which is helpful and varied’; another said ‘there is a good team’. The recruitment procedure was clear. Three staff recruitment files were looked at to help decide whether a safe procedure had been followed. The files were organised and contained the required information to ensure that staff were
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 21 suitable to care for vulnerable people. However there were concerns regarding the suitability of the application forms; the application form on all three staff files did not include full employment histories, referee detail or a declaration of any cautions or convictions and the registered manager was strongly advised to ensure the company forms were completed for all new staff to ensure a safe recruitment procedure was followed. The registered manager was also advised to record reasons why employer references, as detailed on the application form, had not been provided. People were happy with the care and support they received at Peel Gardens. Visitors made positive comments about the staff including ‘staff are caring and dedicated’, ‘the support mum is given is wonderful’, ‘staff do an excellent job and always with a smile’ and ‘the staff are so caring and friendly it feels like a big happy family’. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was safe and managed by a qualified and competent registered manager; quality assurance systems monitored whether the home met people’s needs and expectations. EVIDENCE: The registered manager is Mrs Patricia Cairns. Mrs Cairns is a registered nurse with a range of experience in management and care. She has obtained a qualification in management to support her in her role and has updated her skills with further training. Regular management meetings allow her to meet with other registered managers within the group for support.
Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 23 People had been consulted and encouraged to air their views and opinions about whether their needs and expectations were being met. Systems were in place to monitor whether staff had followed policies and procedures and meeting people’s needs. Policies and procedures had been reviewed but the registered manager said they had not yet been printed or made available to staff; existing procedures provided staff with safe guidance in many aspects of their practice. The home had achieved a recognised quality assurance award; this allowed external assessors were able to monitor whether the service met the required standards. The AQAA had been completed in full and showed the service was aware of what improvements were needed over the next twelve months. Finance records were checked for two residents; records were clear and accurate and showed that resident’s finances were safe guarded by the systems. Staff received regular one to one support to help them to identify whether they were meeting people’s needs and whether they required any further support or training. Maintenance records were sampled. The records supported that the home was safe and that people’s health, safety and welfare were protected. Records confirmed that staff received regular update of safety training to ensure they and others were safe from harm. Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 4 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X 3 2 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 13 Requirement Up to date policies and procedures must be accessible to all staff to support them with safe practice guidance. Timescale for action 02/06/08 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. Refer to Standard OP2 OP9 Good Practice Recommendations All residents must be provided with a written statement of terms and conditions/contract that informs them of their rights and obligations whilst residing at the home. Medication procedures should provide staff with safe guidance in all aspects of practice including: ‘PRN’ or ‘as needed’ medicines, witnessing handwritten directions, recording external medicines, providing medicines for leave and covert administration. Records of food served should be maintained. Food debris and spillages should be removed from the dining area following every meal. The safeguarding procedures should reflect local guidance
DS0000022494.V358973.R01.S.doc Version 5.2 Page 26 3. OP15 4. OP18 Peel Gardens Nursing Home and include contact information to guide staff in the event of any suspicion of abuse. Staff should be provided with training to assist them with managing verbal and physical aggression. There should be a plan to support ongoing and planned improvements to the home. A regular room-to-room audit should be undertaken to identify all areas requiring attention. 6. 7. OP25 OP29 Failed double-glazed windows should be replaced as part of the twelve-month plan. The European Care application form should be used as part of the recruitment procedure for all staff to ensure detailed information about applicants is obtained. 5. OP19 Peel Gardens Nursing Home DS0000022494.V358973.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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