Inspection on 21/06/07 for Pelham Lodge Care Home

This inspection was carried out on 21st June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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 25/05/06

Pelham Lodge Care Home 12/09/05

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 Key Unannounced Inspection 21st June 2007 11:20 Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 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 Lodge Care Home DS0000008733.V339645.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 Adults 18-65. 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 Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham Lodge Care Home Address Clifton Lane Ruddington Nottingham NG11 6AB 0115 921 3272 0115 9845191 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) Voyage Limited Position vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Pelham Lodge is registered to provide accommodation and personal care to a maximum of 9 people whose primary care needs fall within the following category: Learning Disability (LD) 9 Date of last inspection 25th May 2006 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 bed-sits 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. Fees range between £1,008.68-£2,135 a week extra charges are for chiropody and hairdressing. This information was provided by the inspector on 5/06/07 Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over four and a half daytime hours. The main method of inspection used was called ‘case tracking.’ This involved selecting one resident and looking at the quality of the care they receive by talking to them, examining their care file and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. Other residents were spoken with throughout the inspection process and selected information assessed regarding their individual needs. There was one relative spoken with at the inspection. Five members of staff and the operations manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. This inspection was conducted unannounced. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and a Pre-inspection questionnaire completed by the registered provider. Five completed resident’s satisfaction questionnaires and two relatives questionnaires were also received prior to this inspection. A random Inspection was undertaken of the home on 28th February 2007. A copy of the inspection outcome letter can be obtained on request from The Commission for Social Care Inspection. What the service does well: Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 6 Service users needs are assessed prior to moving to the home and are provided with the information they need. 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 daytime occupations. The people who live at Pelham Lodge receive personal support in the way they prefer. Their physical and emotional health needs are generally met. The people who live at the home are confident and aware about making complaints and being heard. There are procedures in place to protect them from harm. Staff reported that most of the team are working to improve the service and to be more consistent and skilled in their approach, for the benefit of the people who live in the home. The health welfare and safety of service users and staff is promoted, they have a comfortable, clean and well equipped, environment in which to live. The people who live at Pelham Lodge are supported by staff who are appropriately recruited and trained. What has improved since the last inspection? What they could do better: Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 7 Development plans and risk assessments are not kept up to date, are not appropriately reviewed and do not reflect how the individuals needs are being met. Refresher training in documenting and evaluating behaviours is recommended and formal supervision needs to be a priority to ensure consistency of practices within the team. A requirement is set for medication administration to be managed in a safe way. A security review is required to ensure safety for everyone is maintained. 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. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to moving to the home and are provided with the information they need. EVIDENCE: The Registration certificate was fully displayed on the day of the inspection. The certificate was reviewed, the name of a previous manager was still on the certificate, so a new certificate is to be requested by the Inspector. New service users needs are fully assessed prior to them moving to the home. Staff and service users are consulted as part of the procedures. Assessments were seen in the care plan examined and was deemed appropriate to meet the standard. The inspection report was not displayed. The registered provider should ensure that information is provided to inform everyone how they, can access a copy of the inspection report. People who live at the home are provided with a service user guide and contract Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at Pelham Lodge are involved in their development plans, which are currently being revised alongside risk management strategies. However development plans and risk assessments are not kept up to date, are not appropriately reviewed and do not reflect how the individuals needs are being met. The provider was able to demonstrate that this had been identified and that further support and training was to be provided for staff. EVIDENCE: One Care plan was examined in detail and the support offered to the individual followed through. Although it was clear that new systems had been implemented to improve the management of care and the record keeping in relation to staff support and interventions, these had not been kept up to date or evaluated in a satisfactory way. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 11 The record keeping in relation to the management of behaviour indicated that staff, are not clear about the expectations or fully understanding of what they should be recording and why the information should be recorded in a certain format. Further training in this area is already planned as the registered provider had identified this. Staff also need to have opportunities to reflect on incidents and look at what could have been done better in respect of following management plans and sharing ideas of what works well. Positive achievements of the people who live at Pelham Lodge were not recorded as staff were recording negative experiences only. There was some evidence that positive achievements and goals had been achieved and that staff felt more confident and skilled in dealing with complex challenging behaviour, but the care plan did not reflect this. The Care development plans and risk assessments examined had not been reviewed for over six months. Several recording sheets were inconsistently completed including daily activities and support for room cleaning and meals taken. A monitor alarm was in use and its use was documented and although the reason for its use is clearly in the interest of the persons safety, there was no evidence of full agreement to its use by the person or their representative and this should be obtained. The people who live at Pelham Lodge were not able to confirm at this visit they were aware of their development plans but evidence was seen of their signatures in the care plan. There was other evidence that the people were involved in their care/ development plans such as personal histories/pen pictures and consent for medication. Staff reported that most of the team are working to improve the service and to be more consistent and skilled in their approach, for the benefit of the people who live in the home. Comments made in by relatives in the returned questionnaires included the following: Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 12 “The care staff work very hard and definitely care for the residents but do seem to lack support from management in the necessary skills required to look after different specialist needs” “ I believe the service meets the different needs of people ethnicity etc”. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 daytime occupations. EVIDENCE: A new structure of activities has been devised for one person, with new risk assessments but these are not currently being documented and monitored. Other service users continue to have full daily lifestyles, which included attending college, work placements, horticulture and Stonebridge Farm, birds of prey training. In house activities are provided; opportunities are provided for games and music. The garden is large and provides garden interests and for kicking a football around. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 14 There is also a sensory area, a ball pool and a memory garden. A smoking/garden room has been erected to provide shelter for those that wish to smoke. The people who live at Pelham Lodge confirmed they had recently been on holiday, several had been to Cornwall and one person on Safari in Africa. Staff members were observed interacting well with service users throughout the inspection and respecting privacy and dignity. Relatives and friend are made welcome. The people who live at Pelham Lodge take responsibility for keeping the house clean and tidy with staff support. They also have responsibility for maintaining their own private space, however where the people who live in the home are unable to manage this even with staff support; it is the responsibility of staff to ensure that people live in safe, comfortable clean and hygienic environment. Record sheets for this purpose were not completed since April 2007. Comments from people who live in the home included the following: I like to choose what meals I want what I wear” “My home smells nice” “ Staff are kind and I like living here” “I like all the staff, I like the food here, I like it when we go on day trips”. Menus are devised to suit people’s preferences and there was clear evidence that alternative meal options are offered. Food stocks were kept to a minimum to aid stock rotation. Cultural needs are catered for on the menu. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at Pelham Lodge receive personal support in the way they prefer. Their physical and emotional health needs are generally met. Medication is generally well managed, however some areas could be improved to ensure errors are minimised. The people who live at Pelham Lodge have their emotional and health needs met, however it is recommended that record keeping be improved. EVIDENCE: In the care/development plans examined, clear guidance was seen for staff in personal preferences of the people who lived in the home. Equality and diversity is promoted and maintained. Evidence of individual cultural and healthcare needs was demonstrated such as skin and hair care and food provision on the menus. The new NHS ‘health check’ records discussed at the previous inspection were viewed. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 16 Where weight loss had occurred this had not been followed up. Weights were not being monitored regularly and this is recommended. One persons annual well person ‘s check was overdue by seventeen months. During the inspection it became known that a person who lived in the home had a health issue that evening/night staff had been aware of but had not been reviewed or actioned by day staff, neither had any entry been made in the daily records for the individual. However in balance, it is recognised that the individual had expressed a wish for his relative to visit and that staff were mindful of supporting the individual’s wishes. A senior staff member actioned this once brought to her attention and a prompt medical appointment and treatment achieved. There is a need to review the policies and procedures in relation to responding to healthcare needs of individuals and to ensure health checks are kept up to date. The registered provider employs a psychiatrist who is on hand to provide support to staff and residents of the home. He reported that there was ongoing input alongside the Operations manager in the absence of a registered manager to coach staff to improve practice. Speech and language therapists have also been contacted for support and input. The management of medicines was generally well organised. The Community pharmacist undertook an audit on 20th March 2007. Several recommendations were made. The issues were reviewed at this inspection and were found to be complied with apart from, external and internal medicines were still being stored together and action should be taken promptly to ensure they are stored separately. The home carries out weekly audits on the medication systems, which is good practice. The records showed a concerning discrepancy for medication on 17th June 2006 and the registered provider is requested to inform the Commission and of the outcome of the enquiry as to its occurrence. The Medication Administration Records were noted to have an omitted signature for everyone on the same day for one dosage time. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 17 Therefore a requirement is set for medication administration to be managed in a safe way. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the home are confident and aware about making complaints and being heard. There are procedures in place to protect them from harm however a review of security would fully ensure this. EVIDENCE: A complaints policy is in place and states a response will be made to complaints within one working day. The complaints procedure is available in a picture format. The complaints records were viewed. Five complaints made by individuals living at the home were recorded. They were in respect of another person living in the home. Staff spoken with said they would report any expressed concerns by service users or any poor practice. Relatives said they were not aware of how to make a complaint. It is recommended that relatives be informed about how to complain/express concerns to the home. All staff undertake training in adult protection. The training programme confirmed this. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 19 The home has referred any safeguarding adults issues appropriately since the last inspection. All staff have been trained in dealing with complex challenging behaviours. Due to events during the inspection the financial records of individuals were not examined. During the inspection it became apparent that an individual had not left his accommodation secure when going out. It is recommended that security is reviewed to ensure personal possessions are safeguarded and that people are not left vulnerable to intruders. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Pelham Lodge have a comfortable, clean and well equipped, environment in which to live. Bedrooms suit individual needs and preferences. EVIDENCE: The home has recently been partly refurbished with new kitchen and kitchenette, office, dining room and lounge all have been fitted with new carpets/flooring. The ground floor bathroom is looking tired and greatly in need of refurbishment also. 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. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 21 There is a large garden, which provides open outside space and is safe place for people with various sensory items around. The Laundry facilities were viewed and all were satisfactory. Hygienic practices were observed and policies are in place for infection control, food safety etc. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 22 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at Pelham Lodge are supported by staff who are appropriately recruited and trained. Refresher training in documenting and evaluating behaviours is recommended and formal supervision needs to be a priority to ensure consistency of practices within the team. EVIDENCE: The staffing rota was examined and found to be satisfactory. Some service users are funded on a one to one basis within this calculation. Regular bank staff are utilised to enable consistency for the people who live at the home. Staff confirmed that they had received training in PDA [Pathological Demand Avoidance] and had undertaken medication training. Training records showed that staff have completed training in the following, Health and safety, Manual handling, fire safety, first aid, basic food hygiene, infection control, abuse awareness and strategies for crisis intervention and prevention The provider did not provide information about National Vocational Qualifications. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 23 A sample of four staff personal files was examined and found to be satisfactory in respect of robust recruitment practices. Supervision was taking place but was not regularly undertaken as currently there is no registered manager in post and the task reliant on the deputy manager currently. The Deputy manager reported that she had to prioritise responsibilities in the absence of a manager and would be also undertaking some management training in the near future. Relatives commented that they felt the staff needed more support from the organisation. The inspector observed much interaction between staff and people who lived in the home; staff appeared confident and calm in their approach, promoted a relaxed atmosphere and dealt with the challenges presented in a professional way. There is wide diversity in the staff team and its composition reflects the culture and gender of people using the service. Staff should be provided with training in Equality and Diversity and refresher training in recording ABC charts [Antecedent, Behaviour and Consequences] and reflective practice of their own behaviour when evaluating possible triggers for challenging behaviour. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 24 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live and work at Pelham Lodge have not been supported by a registered manager for some time, which has affected the consistency of service provided. The health welfare and safety of service users and staff is promoted, however a security review is recommended to ensure safety for everyone is maintained. EVIDENCE: There have been a number of changes of management in the home, which has affected the stability of the staff team. The operations manager reported that a new acting manager had been successfully recruited and would be starting employment the day after the inspection. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 25 Service users surveys had lapsed due to the absence of a manager in the home, as had service user’s meetings. Regulation 26 visits are carried out as required, reports are sent to CSCI monthly. The policy manual was available for staff and there was evidence that these are reviewed periodically and as needed. Systems are in place for the prevention of legionella and water outlet temperatures are now tested at least monthly. There were no health and safety issues noted in the home and information provided to the Commission for Social Care Inspection indicated that health and safety checks were up to date. However it is recommended that a security review be undertaken of the premises. Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 27 YES 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 YA6 Regulation 14,15 Requirement Ensure Development plans and risk assessments are up to date to fully inform staff on how service users needs are to be met. Previous timescale set 28/04/07 not met Ensure all limitations on freedom such as monitor alarms are fully recorded within the development plan and agreed by the service user and /or representative. Partly Met. This will ensure that service users are protected and their rights upheld 3 YA20 13 [2] Ensure the systems for medication are further improved. External and Internal medication must be stored separately. Ensure medication is signed for after its administration. This will minimise the risk of error and ensure service users Pelham Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 28 Timescale for action 21/08/07 2. YA7 17 21/08/07 21/08/07 are kept safe. 4. YA23 13 Undertake a security review of the premises and make arrangements to protect service users personal belongings and are not left vulnerable to intruders Ensure staff receive the formal supervision that they need to carry out their job. 21/08/07 5 YA36 18 21/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA9 YA19 YA22 YA24 YA24 YA24 Good Practice Recommendations Ensure all record sheets implemented for specific issues eg personal care charts and daily logs, are completed fully. Ensure service users receive health checks at least annually and weight records kept monthly. Inform relatives how they can make complaints Refurbish the ground floor bathroom Ensure window restrainers are fitted to the windows in the bungalows for security. The mesh centres of some radiator covers were looking grubby and some were stained and require cleaning/repainting. If the planned room change does not occur, consideration of the provision of sluicing facilities should be made. [Repeated recommendation] Ensure information on which staff have achieved NVQ [National Vocational Qualifications] is made available on request. Provide training for staff in equality and diversity and refresher training in recording of and evaluating behaviour. Reinstate service user surveys and meetings. DS0000008733.V339645.R01.S.doc Version 5.2 Page 29 7. YA30 8 9 10 YA32 YA35 YA39 Pelham Lodge Care Home Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 © 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 Lodge Care Home DS0000008733.V339645.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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