Inspection on 12/09/05 for Pelham Lodge Care Home

This inspection was carried out on 12th September 2005.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pelham Lodge Care Home 21/06/07

Pelham Lodge Care Home 25/05/06

Pelham Lodge Care Home 09/12/04

Pelham Lodge Care Home 28/04/04

Pelham Lodge Care Home 25/11/03

Pelham Lodge Care Home 12/12/02

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

CARE HOME ADULTS 18-65 Pelham Lodge Care Home Clifton Lane Ruddington Nottingham NG11 6AB Lead Inspector Jayne Hilton Unannounced 12 September 2005 at 10:00 am th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pelham Lodge Care Home Address Clifton Lane Ruddington Nottingham NG11 6AB 0115 921 3272 0115 984 5191 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Limited Paul David Battershall Care Home 9 (Nine) Category(ies) of Learning Disability (LD) - 9 (Nine) registration, with number of places Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/05/05 Brief Description of the Service: Pelham Lodge is a care home which provides care and accommodation for 9 adults with a learning disability.It has been operating as a registered home since 1999 and is now owned by Voyage Ltd. The home was extended from 6 places to 9 in January 2004.The home is situated on the outskirts of the village of Ruddington and is within walking distance of the village centre, which offers pubs, shops and other facilities.The home is a converted private house and has 7 single bedrooms in the main house, three of which have en-suite facilities. There are a further 2 self-contained bedsits attached to the house but accessed from their own front doors. These each have a lounge with kitchen and laundry facilities and a bedroom with full en-suite facilities.Five of the bedrooms are on the first floor, access to which is by staircase only.There is a large garden to the rear, which is very attractive and secure. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on 12th September 2005, by Jayne Hilton. The focus of the inspection was to assess the compliance of the requirements and good practice recommendations set at the previous inspection and to assess the remaining standards not inspected at the last visit. Most of the people who live at Pelham Lodge were at home and were observed going about their daily routines. The methodology included examination of accident records fire safety records, sampling development plans for specific information, the examination of staff rotas, examination of medicine management, speaking with three people who live at the home, two staff and the manager. Some environmental standards were assessed as part of the previous requirements. The outcomes for service users are very positive. What the service does well: The People at Pelham Lodge are enabled to take control of their lives within the limitation of the structures required by their development plans and contracts. Staff support people in a respectful way and allow responsible risk taking. The people at Pelham Lodge are well integrated in the community within the structures of their support. They enjoy a full range of activities and leisure interests and have various day- time occupations. The people at Pelham Lodge are offered a healthy diet and enjoy their meals and mealtimes, choice options are provided. Where limitations are imposed on the people at the home these are justified within a development/care plan. The people who live at the home are confident and aware about making complaints and being heard. People are protected from abuse and self –harm. Medication is generally well managed. The people at Pelham Lodge benefit from the support of an effective staff team with sufficient numbers and complimentary skills with clarity of staff roles and responsibilities. The people who live at Pelham Lodge have their views respected within an excellent system of self -monitoring and development. Policies and procedures are in place and overall good record keeping was noted. The people who reside at Pelham Lodge and the staff who work at the home are protected by good systems for health and safety and a competent and accountable management of the service. There was evidence of an excellent range of audits carried out in the home, which includes, weekly medication audits, weekly food hygiene, a vehicle checklist, the annual development plan, monthly health and safety audits a Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 6 monthly general audit and training plans. Service users surveys were also seen and copies of the feedback are given to the people who live in the home and a copy is kept in the individual development files. There was also evidence of professional views being sought. The people at Pelham Lodge have a comfortable, clean and generally well equipped, environment in which to live. What has improved since the last inspection? The financial records regarding people’s personal finances were now satisfactory. The auditing processes for residents finances meet with Standard 7.7 and standard 26.6, Regulation 13 and Regulation 17, schedule 3[9]. Evidence had been provided with the action plan that all resident’s monies were appropriately accounted for and that tighter auditing practices were taking place to find any errors in calculations that may occur. There was clear evidence that alternative meal options are offered. Because of the peoples complex needs the fridge and pantry is locked. This limitation is justified within each individuals development plan. The downstairs shower room and toilet has recently been decorated and there are plans to refurbish the kitchen. The laundry floor has recently been painted. Radiator covers were seen in most areas examined. There was now, window restrictors on most of the ground floor windows, the process will be completed shortly. Laundry facilities meet the standards regarding washing machine with sluice and the provision of a dryer. The dining chairs have recently been replaced. The manager reported that routine maintenance was ongoing due to, the needs of the client group and the handyperson reported that he now works 3 days a week. Water outlet temperatures are now tested at least monthly and the fire authority risk assessment is now in place. Staff, were noted to wear aprons when preparing and serving food on the day of the inspection and COSHH [Control Of Substances Hazardous to Health] regulations were adhered to. The manager requested that the inspector clarify that the requirement set under standard 23 at the previous inspection was by no means a reflection on the homes standards but was set to ensure that the a service user was protected by personal circumstances and by which terms of confidentiality made this difficult to expand on within the report. Action has been taken to resolve the issues. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 7 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 Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the above standards were assessed at this inspection. All were assessed at the previous inspection and were found to be met. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 The People at Pelham Lodge are enabled to take control of their lives within the limitation of the structures required by their development plans and contracts. Staff support people in a respectful way and allow responsible risk taking. The financial records regarding people’s personal finances were now satisfactory. EVIDENCE: Picture symbols are used as an additional communication method and these were seen around the home and within development plans and complaints etc. There were examples of people in the home making decisions within the constraints of their special needs and contracts. The people spoken with confirmed that key workers work very closely with them and that they choose activities. The people spoken with informed the inspector that they were fully involved in the day to day running of the home and were very vocal about the leisure and recreational activities which are provided and spoke about house meetings which minutes were seen. There was evidence of a service user survey in place and feedback to the people who had contributed. Two development plans were examined in relation to assessing requirements and recommendations set at the previous inspection. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 11 Risk management strategies were observed within development plans. The auditing processes for residents finances meet with Standard 7.7 and standard 26.6, Regulation 13 and Regulation 17, schedule 3[9]. Evidence had been provided with the action plan that all resident’s monies were appropriately accounted for and that tighter auditing practices were taking place to find any errors in calculations that may occur. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 17 The people at Pelham Lodge are well integrated in the community within the structures of their support. They enjoy a full range of activities and leisure interests and have various day- time occupations. The people at Pelham Lodge are offered a healthy diet and enjoy their meals and mealtimes, choice options are provided. Where limitations are imposed on the people at the home these are justified within a development/care plan EVIDENCE: The development plans examined supported what the people told the inspector, that they have lots of opportunities for practical life skills. Specialist interventions are well documented. The people who live at Pelham Lodge informed the inspector of their daily lifestyles, which included attending college, work placements [horticulture and Stonebridge Farm, birds of prey training. In house activities are provided; the home boasts a pool table and opportunities for games and music. The garden is large and provides garden interests and for kicking a football around. There is also a sensory area, a ball Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 13 pool and a memory garden. One person stated he enjoys the garden and growing plants. A smoking/garden room has been erected to provide shelter for those that wish to smoke. The home has a couple of vehicles, which enable transport to the varying venues. Transport is provided by Voyage at no personal cost to the people living at the home. The people who live at Pelham Lodge confirmed that they are given their mail unopened and knock before entering their rooms etc. Staff members were observed interacting well with service users throughout the inspection. The people who live at Pelham Lodge confirmed they take responsibility for keeping the house clean and tidy with staff support. The people in the house were observed to move freely within the building. Menus are devised to suit people’s preferences and there was clear evidence that alternative meal options are offered. People explained that they have cooked breakfasts at weekends. Because of the peoples complex needs the fridge and pantry is locked. This limitation is justified within each individuals development plan. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Medication is generally well managed, however staff must ensure that they sign the medication record after every administration. A system for ensuring safe storage temperatures needs to be set up also. The people who live at Pelham Lodge have their emotional and health needs met, however it is recommended that staff, are trained in chiropody if they are to undertake these procedures. EVIDENCE: The management of medicines was well organised and the home has copies of The Royal Pharmaceutical Societies Guidance Booklet and its own policies available for staff. The system used is the Boots Blister Pack system and training has been, provided by the pharmacist. There was evidence of the training programme. The policy for drug errors was appropriate and there are no reported drug errors, since the previous inspection. A sample list of staff signatures is provided, however there was no evidence of storage temperatures for the medication and this must be undertaken and documented daily, with any action taken to remedy the situation should the appropriate temperature of 25 degrees be exceeded. There were some noted gaps on the Mar [Medication administration records], which is not satisfactory and must be addressed. The home carries out weekly audits on the medication systems, which is good practice. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 15 The manager reported that well person checks were now documented and weight records now contain comments for action. Chiropody training has not yet been accessed for staff. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The people who live at the home are confident and aware about making complaints and being heard. People are protected from abuse and self –harm. EVIDENCE: A sample of people spoken to, informed the inspector that they were aware of how to make a complaint, information was seen in the entrance in a symbol format and there were no complaints recorded since the last inspection. The complaints policy was examined and states a response will be made to complaints within one working day. Staff spoken with confirmed they had undertaken training in adult protection. Policies and procedures are in place for the Protection of vulnerable Adults, Whistle blowing and use of restraint. The manager requested that the inspector clarify that the requirement set under standard 23 at the previous inspection was by no means a reflection on the homes standards but was set to ensure that the a service user was protected by personal circumstances and by which terms of confidentiality made this difficult to expand on within the report. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,29. 30 The people at Pelham Lodge have a comfortable, clean and generally well equipped, environment in which to live. The provision of en-suite facilities for the bedrooms in the main house would improve the quality of life for individuals. EVIDENCE: The house is well lived in, and inevitably is subject to wear and tear due to the complex needs of the people who live there. That said the environment was ‘homely’ and clean. The downstairs shower room and toilet has recently been decorated and there are plans to refurbish the kitchen. The laundry floor has recently been painted. Radiator covers were seen in most areas examined. There was now, window restrictors on most of the ground floor windows, the process will be completed shortly. Laundry facilities meet the standards regarding washing machine with sluice and the provision of a dryer. The dining chairs have recently been replaced. The manager reported that routine maintenance was ongoing due to the needs of the client group and the handyperson reported that he now works 3 days a week. There is an issue regarding the use of a commode for one person and no sluicing provision. The situation may be remedied shortly as a room may Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 18 become vacant with en suite facilities. Should this arrangement not take place a sluice provision should be provided. As the main part of the home is pre-existing the environmental standards and sizes of rooms meet the standards, however there are issues around dignity regarding some individuals continence needs and the provision of en-suite facilities would improve their quality of life. The registered provider is strongly urged to make consideration regarding the provision of these facilities. As already covered earlier in the report, the garden facilities are very good. The people who currently live at Pelham Lodge do not require any specialist aids and adaptations. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 The people at Pelham Lodge benefit from the support of an effective staff team with sufficient numbers and complimentary skills with clarity of staff roles and responsibilities. EVIDENCE: The staffing rota was examined and found to be satisfactory, although currently some staff were on annual leave or paternity leave. The usual cover is four or five staff on in morning shift and four in an afternoon, however some occasional shifts have dropped to three. The manager reported that this was rare and that the level would never fall below three. Some service users are funded on a one to one basis within this calculation. The manager is on site during the day weekdays in addition to this. Bank staff are utilised and staff are paid for overtime, however not all feel they can work extra hours. The manager was interviewing prospective new staff on the day of the inspection and reported that a recent advert had produced a good response. Staff meetings take place and minutes of these were examined, policies and procedures were on the agenda for August 2005. Job descriptions are provided and staff confirmed they had a copy of the General Social Care Council’s Code of conduct booklet. On speaking with one staff member it was confirmed that staff are aware of their own knowledge and skill limitations and Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 20 know when it is appropriate to involve someone else with more specific expertise. There are no volunteers currently. The four staff on duty on the day of the inspection were observed to be confident and comfortable in their approach to the people who live at the home. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41, 42, 43 The people who live at Pelham Lodge have their views respected within an excellent system of self -monitoring and development. Policies and procedures are in place and overall good record keeping was noted. There are some areas for which improvement could be made, including fire safety tests, water outlet testing and accident records and the security of the records and storage in the staff office. The people who live at Pelham Lodge are protected by good systems for health and safety and a competent and accountable management of the service. EVIDENCE: There was evidence of an excellent range of audits carried out in the home, which includes, weekly medication audits, weekly food hygiene, a vehicle checklist, the annual development plan, monthly health and safety audits a monthly general audit and training plans. Service users surveys were also seen and copies of the feedback are given to the people who live in the home Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 22 and a copy is kept in the individual development files. There was also evidence of professional views being sought. The policy manual was available for staff and there was evidence that these are reviewed periodically and as needed. Accident records were examined and appear satisfactory, although it is recommended that these are kept secure under the Data Protection Act 1998 guidance. The fire safety records were examined and there was evidence that these are not being carried out weekly, several gaps were noted in the records since the last inspection. Development plans are kept secure in the staff office, however the files are visible and the names can be seen through the staff office window on approach, as are cabinets etc. It is recommended that the security of the development plans and the home in general be reviewed and additional action taken to minimise any risk to security of the building and contents. Systems are in place for the prevention of legionella and water outlet temperatures are now tested at least monthly, where they are found to exceed 43 degrees, action needs to be taken and documented and a retest documented. Staff were noted to wear aprons when preparing and serving food on the day of the inspection and COSHH [Control Of Substances Hazardous to Health] regulations were adhered to. The fire authority risk assessment format is now in place and the manager reported that a general review of risk assessments was to be carried out to improve the analysis of risks in the home and to the individuals. Regulation 26 visits are carried out as required, reports are sent to CSCI monthly. The Inspector requests that these now only be kept available in the home for inspection and not sent to CSCI unless requested. An annual development plan and satisfactory insurance cover was seen. Pelham Lodge Care Home C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pelham Lodge Care Home Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 4 3 2 3 3 C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 24 NO Are there any outstanding requirements from the last inspection? 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 YA20 Regulation YA12, 13, 16, Medicines Act YA12, 13, 16, Medicines Act 16,17, 23 Requirement Ensure that medication is always signed as administered after visibly observing it being taken. Ensure medication is stored at a safe temperature and that this is documented daily. Ensure fire alarm tests are carried out every 7 days. Timescale for action 12/10/05 2. YA20 12/10/05 3. YA41 12/10/05 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. Refer to Standard YA 19 YA30 YA 41 YA41 YA42 Good Practice Recommendations Provide training for staff in basic chiropody. If the planned room change does not occur, consideration of the provision of sluicing facilities should be made. Where water temperatures exceed 43 degrees, any action taken to remedy this, including retest should be recorded. Accident records should be stored under the guidance for Data Protection 1998. Review the security of the staff office and its contents which are visible from the window, particularly cabinets. and development plans. C03 C53 S8733 Pelham Lodge V246057 120905 Stage 2.doc Version 1.40 Page 25 Pelham Lodge Care Home Commission for Social Care Inspection Edgeley House Tottle Road Riverside Business Park Nottingham, NG2 1RT 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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