Inspection on 17/07/06 for Pelham House Residential Home

This inspection was carried out on 17th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pelham House Residential Home 31/07/08

Pelham House Residential Home 20/09/07

Pelham House Residential Home 01/09/05

Pelham House Residential Home 19/04/05

Pelham House Residential Home 01/11/04

Pelham House Residential Home 10/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pelham House Residential Home 5/6 Pelham Gardens Folkestone Kent CT20 2LF Lead Inspector Michele Etherton Unannounced Inspection 17th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pelham House Residential Home DS0000023502.V305285.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. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham House Residential Home Address 5/6 Pelham Gardens Folkestone Kent CT20 2LF 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) 01303 252145 Mrs Margaret Jane Thomas Mr George Alexander Thomas Mr George Alexander Thomas Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (21) Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration for the category MD is restricted to one (1) resident whose date of birth is 17.02.1942 1st September 2005 Date of last inspection Brief Description of the Service: Pelham House is a large detached house, located in a quiet residential area of Folkestone. The home is sited at the end of a cul-de-sac. The home environment is well decorated, comfortable and homely. The home has a number of small lounge facilities enabling users the opportunity for quiet and private time either alone or with other users or relatives. There is a large accessible garden to the rear of the home. The home also has a conservatory with houseplants, where service users can access the garden facilities. The home does not have a lift or stair lift to the first floor, all service users accommodated on the first floor, therefore, must be mobile. The majority of service users within the home are self-funding. The home offers a service to older people and has retained a stable staff group who have a broad range of health and social care experience. The home promotes independence, and encourages service users to maintain their links with the community and outside interests. The range of fees for this service are between £320-£500 per week. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit as part of an inspection process. The site visit commenced at 9:35 am and ended at 5:35 pm. All key inspection standards were reviewed as part of this inspection, including an assessment of progress made by the home towards meeting outstanding requirements. The site visit comprised of a tour of the premises including some service user bedrooms and all communal spaces. Discussion with ten service users, one relative and four staff in addition to the Registered Manager and provider. A review of some documentation was also undertaken including: staff rotas and training matrix, staff files and supervision records, four service user files, Medication administration and accident records. Since the last inspection an adult protection alert has been raised against the home and investigated, the Commission has been advised that the outcome has indicated no case to answer in respect of home practices or individual staff, and consequently the adult protection referral has now been closed. What the service does well: What has improved since the last inspection? One of the providers has become the Registered Manager. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 6 The exterior of the property has been repainted. A new cooker has been installed in the Kitchen. Two service user bedrooms have been redecorated and re-carpeted. Carpet has been ordered to replace that currently in the downstairs hallway, conservatory and a small lounge area. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Service users are consulted with in respect of moving to the home and have access to information to aid their decision-making. Admissions are not made to the home until a needs assessment has been undertaken by an experienced member of the management team, decisions in respect of admissions could be better supported by a more in depth completion of assessment information. Service users and their relatives are provided with opportunities to visit the home prior to admission to aid decision-making. The home offers respite on occasion but lacks the appropriate resources to provide intermediate care EVIDENCE: Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 9 Feedback from survey information from service users indicated that all had been actively involved in the selection of the home and had had access to information about the home to help with their decision making, discussion with service users during the site visit indicated mixed views, a good proportion indicated they had visited prior to admission with their relatives, and had been visited for assessment purposes by the Home manager or provider. None of those interviewed expressed concerns in respect of the admission process or their choice of home. Assessment information was noted on four user files viewed, the home would benefit from ensuring these are completed fully with more in depth information to aid decision making in respect of meeting needs and development of support plans. The home is able to provide respite from time to time when a vacancy arises, but lacks the resources to provide an intermediate care service, and does not aspire to do so. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Care plans are in place but require additional information in respect of needs and how objectives will be met, risk assessments require review and additional detail to minimise the risk to residents and staff. Service users and or their relatives are not routinely consulted about care plan or asked whether they agree with it. Service users health is monitored and appropriate action taken. The home seeks professional advice on health care issues, acts upon it and generally is able to provide the aids and equipment recommended. Further improvements are needed in the recording of medication. Service users are encouraged to maintain independence in personal care routines and where support is offered this is undertaken in a manner that ensures privacy and protects their dignity EVIDENCE: Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 11 The content of four user files viewed at the site visit were mostly compliant with schedule 3 of the care homes regulations, current user photographs are gradually being added to individual files. Care plans still lack some important information in respect of service user behaviours, interests, mental health etc; there is also an absence of some important risk assessments. The home has failed to address an outstanding requirement in this respect. Staff confirmed care plans are developed from initial consultation with users at admission, but users are not routinely consulted about their care plans after this. Relatives reported that the home communicates well with them regarding their relative’s care and health needs, service users spoken with expressed overall satisfaction with their care and routines within the home. The home is required to evidence more clearly that service users and/or relatives have been consulted regularly about care plans and are in agreement with them. There was evidence delays in information being updated, the provider/manager must ensure staff have adequate time to undertake this important task. User files viewed provided evidence of access to routine and more specialised healthcare support. Service users confirmed hospital and routine healthcare appointments, and appointment letters were noted on files. Staff confirmed service users are weighed monthly and this is recorded in the weight book. Handwritten entries on MAR sheets are still not being signed and dated and the home is still to meet an outstanding requirement in respect of this. Staff confirmed access to relevant training. There was evidence within user files viewed of some self-medication but risk assessments were not in place for this. A review of MAR sheets highlighted the use of sticky labels, the home are required to discontinue this practice because of the risk of medication error. Staff demonstrated an understanding of service users medication needs but would benefit from the development of individualised user Medication profiles and PRN guidelines to ensure consistency and appropriate administration of PRN medications is maintained and this is a recommendation. Survey feedback was received from two G. P’s as part of the inspection process who reported overall satisfaction with the service and the management of medication and healthcare needs within the home Service user feedback through surveys and face to face interviews indicated that they feel very happy with the support they receive from staff who they find “helpful”, “approachable” “always willing to lend a hand”, they feel their personal care routines are satisfactory and in keeping with their wishes and that their privacy and dignity is respected by staff. Service users confirmed they are encouraged to maintain their own personal hygiene where able to. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 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): 12,13,14,15 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Service users make day-to-day decisions and choices in respect of their routines and activities but would benefit from some individualised activities to provide motivation and stimulation. Visitors are able to visit the home at any time and see their relative in private. The home supports residents with financial or advocacy information to promote resident’s autonomy and choice. The home provides a well-balanced nutritional diet and the overall provision of meals is of a good standard. Residents confirmed choice and variety of meals and special diets are catered for. EVIDENCE: Feedback from users highlighted no strong views about the lack of activities. Four of those interviewed stated clearly that they did not wish to participate in organised activities with one commenting that “I don’t want to have to do Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 13 what I don’t want to do”, some service users also felt an activity programme would impact on their sense of freedom and take away some element of choice. More than half of those spoken with expressed an interest in some activity outside of the home although routinely fail to raise this as an area for development within quarterly provider satisfaction surveys. Users spoke positively of the newly introduced monthly outing to the Salvation Army, comments included “that was lovely, I really enjoyed that”, “I’d like to do that more often”, the home is still to evidence individual consultation with users in respect of activities and this remains an outstanding requirement. Relatives indicated overall satisfaction with the home but expressed a desire to see some activities to provide motivation and stimulation to their relatives. Comments received included. 1st class home” “ kind, caring, nothing too much trouble, I could not be more satisfied Home from home, the client is treated with dignity and respect” “ its clean with a happy atmosphere”. Relatives were observed moving freely around the home and clearly there is a relaxed and flexible visiting arrangement. The home diary recorded service user outings with relatives and friends. Service user survey feedback and that obtained from discussions indicated a strong sense of personal control over their affairs and the provider indicated that they try not to become involved in the financial affairs of service users, preferring to direct them to someone more appropriate, most users spoken with indicated that their families or solicitors manage their affairs. The home has systems in place for the safe keeping of users valuables, if needed. The vast majority of those spoken with commented positively on the range and variety of meals offered. Feedback, from surveys highlighted no issues in respect of meals, service users are not consulted about menu development and the home should consider how to involve them more. Discussions with staff indicated that pureed meals are provided to two users but these are not always presented as separate portions, unless a service user has specifically requested their meal to be pureed together, the home should be promoting presentation of pureed meals in line with current practice Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 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): 16,18 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. The home has a simple complaints procedure; service users expressed confidence in respect of making complaints. Service users feel safe and protected by the procedures and systems within the home EVIDENCE: The home has a complaints procedure, and this is displayed. Service user feedback indicated an awareness of the complaints procedure and who to complain to if needed. Discussion with users indicated the majority were more likely to complain via a third party than directly to staff or the manager, but were clear this was not as a result of undue fears about making complaints. Some relatives had indicated a lack of awareness of the complaints procedure and the home should consider how it could promote better awareness of the procedure and instil confidence in users to complain on their own behalf. The home reports in pre-inspection information that no complaints have been received by the home in the past 12 months. An adult Protection alert has been raised against the home; this has been investigated and recommended for closure, no actions be required by the home as a result of the investigation. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 15 The home should consider the development of behaviour management guidelines in respect of service users exhibiting behaviours that impact on their safety or the safety of others; all parties concerned should agree these guidelines. Service users, relatives and others associated with the service state that they are very satisfied with the service provision. Service users feel safe and well supported. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 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): 19,24, 26 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. The home is maintained to a good standard of interior and external redecoration. Service users are enabled to furnish their rooms with personal possessions to reflect their own taste. A good standard of cleanliness is maintained throughout the home. EVIDENCE: Service users reported in survey information that the home is well maintained and always clean. The home was clean at the time of the site visit with no noticeable odours. The home is maintained to a good standard of decoration with a good mix of modern and antique furniture, the exterior has recently Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 17 been repainted. Bedrooms’ are routinely redecorated and re-carpeted as they’ become vacant, two have been updated recently. A new cooker has been installed in the kitchen. Carpet in the downstairs hallways, conservatory and some small seating areas is showing signs of wear and replacement carpeting is on order. Bedrooms viewed were personalised to the tastes of the service users with some having a range of their own possessions and furnishings installed. Service users spoken with were happy with their particular room and found the ambience of the home very homely. The home employs two cleaners, Feedback from service users and relatives was very positive in respect of the cleanliness of the home. Service users were happy with laundry arrangements within the home. Not all staff spoken with had completed infection control training although a programme of training has been underway including this course. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Staff demonstrated a good understanding of service users care needs, and have developed a positive working relationship with them. A programme of NVQ2 training is in place. Improvements are required to the staff recruitment and vetting practices within the home to address shortfalls. Mandatory training for staff is now being provided and the home must ensure all staff achieve this in a timely manner. EVIDENCE: The stated dependency levels of the user group compared to the current staffing levels are not in keeping with staffing levels proposed by the care homes staffing tool and it is a recommendation that this is reviewed. Despite this, feedback from service users, relatives and health and social care professionals highlighted no issues in respect of staffing. There appears little flexibility within current staffing levels to enable staff to facilitate activities or spend time with service users; the home should consider these important service user quality of life areas in any review of staffing. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 19 Information supplied by the home for pre-inspection information indicates that 53 of staff have achieved NVQ2 level of training. Three staff files were reviewed two of these being for new staff. Two had some required information missing although staff had commenced work at the home, there has been some slippage in the adherence to operating a robust recruitment procedure and this could place service users at risk, a requirement has been issued in respect of this. The manager was reminded that where an unclear CRB is received for a staff member, the home must evidence clearly how it has come to its decision to employ, and what additional checks it may have undertaken to inform that decision. A programme of staff training is underway and staff confirmed that they have access to training. The home will need to ensure that all staff have achieved mandatory core skills training, and it is important that the manager/provider consider ways in which to motivate and provide incentives to staff to train. The home provides basic induction and this will need to be reviewed against the new mandatory social skills council induction standards. The home manager and provider will need to familiarise themselves with these and associated knowledge sets, and amend staff induction accordingly. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 38 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. A registered manager is now in place and staff’ are clear about the management structure, roles and responsibilities. The manager would benefit from undertaking NVQ4 and RMA to support service development in keeping with current thinking Good Systems are in place for user consultation but improvements are needed to evidence how user feedback influences service development, the home needs to develop further systems for self audit and quality assurance. The home has implemented an effective financial system to support residents with their finances. Staff supervision is in place but the content and frequency of supervisions needs improvement. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 21 Mandatory training is now being provided, and all safety checks have been carried out to provide a safe environment for residents to live in. EVIDENCE: One of the joint providers has now registered as the Home manager. He has experience of social care and management and has attained management qualifications, he has expressed a willingness to continue with his training and personal development to attain the RMA and NVQ4, this would greatly benefit service development and give the manager a broader understanding of current thinking in respect of social care. The provider undertakes quarterly surveys of service users and makes an analysis of these, improvements are needed to ensure feedback is given to service users at least annually as to what the outcomes of the surveys have been and how users comments influence service development, a copy of any annual Quality assurance report should be forwarded to CSCI. The home will need to strengthen current quality assurance measures and provide evidence that self-audit systems are in place, and this is a recommendation. The manager /provider advised that where possible they try to avoid any involvement in service user finances, by ensuring that either the user, their relatives or other significant people take control of this. They do not retain personal allowance monies for any service user, although they do keep records of users personal possessions and will store valuables on request, issuing receipts for this. Staff confirmed that they receive regular supervision sessions, a review of supervision records, highlighted that frequency of supervision has slipped and content inadequate and not in keeping with the standard, the home are recommended to review this. The accident book indicates a relatively low level of accidents within the past 5 months, but the home must be more proactive at amending risk assessments etc where falls are increasing and evidence monitoring where there is a higher incidence for individual clients. The home has indicated within pre-inspection information provided that all Policies and procedures have been reviewed in February 2006 and that Maintenance and associated Health and safety servicing and checks have been undertaken within appropriate timescales. Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13,15 Requirement To provide further detial of how to meet the objectives for residents in the care plan. To develop Risk Assessments with further detail to minimise the risk to residents and staff(not met within previous timescale of 31/12/05) Home to evidence clearly consultation with users and/or relatives in respect of care plans, care plans to be signed. To review the Medication Policy and procedures in line Royal Pharmaceutical Society Guidelines, and forward a copy of the policy to the commission. To countersign written information on medical administration sheets(not met within previous timescale of 31/10/05 Use of sticky labels to be discontinued. Pharmacists advice to be sought in respect of this To record residents social care needs and implement a planned activity programme(not met within previous timescale of 31/10/06) DS0000023502.V305285.R01.S.doc Timescale for action 31/10/06 2. OP9 13 31/07/06 3. OP12 16 31/10/06 Pelham House Residential Home Version 5.2 Page 24 4. OP29 18 The provider/manager must ensure that a robust recruitment procedure is adhered to for the protection of service users 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The home should consider the development of medication profiles and PRN guidelines for individual service users to ensure medication is administered appropriately and consistently. The home to review care staffing levels against current user dependencies using the Care staffing tool Home to review existing quality assurance measures to develop a system for self audit and evidence clearly how service user and staff feedback influence development of the service Home to review content and frequency of formal care staff supervision sessions 2 3 OP27 OP33 4 OP36 Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Pelham House Residential Home DS0000023502.V305285.R01.S.doc Version 5.2 Page 26 - 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!