Inspection on 25/05/06 for Pelham Lodge Care Home

This inspection was carried out on 25th May 2006.

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 21/06/07

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 25th May 2006 10:00 Pelham Lodge Care Home DS0000008733.V294930.R02.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.V294930.R02.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.V294930.R02.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 Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Pelham Lodge Care Home DS0000008733.V294930.R02.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 12th September 2005 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 £1,009-£2,085 a week extra charges are for chiropody and hairdressing. This information was provided by the inspector on 25/05/06 Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was carried out on 25th May 2006, by Jayne Hilton for duration of six hours. Most of the seven residing people who live at Pelham Lodge were at home initially and were observed going about their daily routines on the inspectors arrival, however individual interviews with service users were not possible due to most service users going out to their various activities and those remaining were either not willing to be interviewed or circumstances meant this was not possible. 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 people who live at the home at various intervals, two staff and the acting manager. A part tour of the environment was carried out also. The outcomes for service users are overall positive. What the service does well: The people who live at Pelham Lodge are provided with the information they need. The assessment documentation provided opportunities for people to develop and work towards goals within the limitations of their specialist needs. Contracts are provided. 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 daytime occupations. The people at Pelham Lodge are supported in their relationships and sexuality and receive respect and appropriate responses from the staff. Equality and Diversity is generally well promoted. The people at Pelham Lodge are offered a healthy diet and enjoy their meals and mealtimes. The people who live at Pelham Lodge receive personal support in the way they prefer. Their physical and emotional health needs are met. There was detailed information within development plans for the individual’s wishes at the end of life. The people at Pelham Lodge are supported by, competent and qualified staff. They are protected by robust recruitment practices and effective supervision. The people at Pelham Lodge have a comfortable, clean and generally well equipped, environment in which to live. Bedrooms suit individual needs and preferences. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000008733.V294930.R02.S.doc Version 5.2 Page 7 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.V294930.R02.S.doc Version 5.2 Page 8 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 the following standard(s): 1,2, 3,4,5 Service users have the information they need to make an informed choice about where they live and know that their needs are assessed and met. Prospective service users have an opportunity to visit and to test drive the home and are to be issued with terms and conditions of the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: The Registration certificate was not fully displayed on the day of the inspection. 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 two care plans examined and were deemed appropriate to meet the standard. Most service users are referred by a social worker; their assessments are kept within the individuals file. Trial visits can be facilitated. A new service users guide and statement of purpose has been produced with symbols and will contain the details of the terms and conditions to the home. The acting manager reported that new documents are to be issued to service users in the near future. The Registered Provider needs to ensure that Regulation 14 is complied with in relation to informing service users in writing that the home can meet their individual needs. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 9 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 the following standard(s): 6, 7, 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 satisfactory and regularly audited. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: Three development plans were examined and discussed in detail with the staff on duty on the day of the inspection. 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 development plans such as personal histories/pen pictures and consent for medication and declarations about voting. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 10 The review process appeared satisfactory and monthly summaries were in place, which evaluated the development plans. 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. Key workers work very closely with service users and that they choose activities, trips to concerts etc. Evidence was seen regarding Care programme approach and Assessment of a young person still in education. Records were examined of service users finances and these were satisfactory. From observation of staff practice and the inspector was able to determine that service users 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 are available. There was evidence of a service user survey in place and feedback to the people who had contributed. Responsible risk taking is promoted within the constraints of 1:1 support contracts and individual needs. Risk management strategies were observed within development plans. Development plans were stored securely. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 11 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 the following standard(s): 12, 13, 15, 16, 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 daytime occupations. The people at Pelham Lodge are supported in their relationships and sexuality and receive respect and appropriate responses from the staff. The people at Pelham Lodge are offered a healthy diet and enjoy their meals and mealtimes. Where limitations are imposed on the people at the home these are generally justified within a development/care plan Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” 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 generally well documented. Where limitations are imposed on the people at the home these are generally justified within a development/care Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 12 plan, however more evidence should be detailed regarding the decision to administer PRN medication for behaviour. The people who live at Pelham Lodge 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. 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 home has a couple of vehicles, which enable transport to the varying venues. Transport is provided by Voyage currently, at no personal cost to the people living at the home. Taxis are also used if needed. Holidays were discussed; two service users are going to France. Staff have carried out risk assessments a change to transport was made in relation to the outcome of the risk assessment. One person went to Amsterdam and a weekend at Skegness was recently organised. Staff members were observed interacting well with service users throughout the inspection and respecting privacy and dignity. The people who live at Pelham Lodge take responsibility for keeping the house clean and tidy with staff support. Ironing is not a favourite task. 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. Food stocks were kept to a minimum to aid stock rotation, but there was comments made by staff members on the staff meeting agenda that stocks did run out occasionally. Improved organisation of food shopping is therefore recommended. Cultural needs are catered for on the menu. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 13 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 the following standard(s): 18,19,20 The people who live at Pelham Lodge receive personal support in the way they prefer. Their physical and emotional health needs are generally met. A review of strategies and training is required to ensure service users needs in relation to challenging behaviour are fully met met. There was detailed information within development plans for the individual’s wishes at the end of life. Medication is generally well managed, however staff must ensure that they sign the medication record after every administration. 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: In the three 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 seen and demonstrated such as skin and hair care and food provision on the menus. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 14 Agreed house rules have been implemented in the home in relation to night hours. The people who live in the home are expected to take responsibility to go to their rooms at 10pm in respect of reduced night staffing and their activities the following day. Various professionals support the people who live in the home, their details were documented. Staff spoken with discussed that there were concerns within the staff team that they were not always able to manage the challenging behaviour of some service users and sanctioning was a topic of conversation also. The inspector discussed the issues with the acting manager who reported he is aware of some issues and informed the inspector of the possible introduction of new strategies and further training for staff. The staff discussed well person’s checks and the new NHS ‘health check’ records used. Records are also held within the development plans for chiropody, dentist and other health checks. The inspector observed that blood tests taken were not followed up and more detail; is required and the reason why a visit to the GP or medical tests are undertaken. Body charts are used for injuries sustained. Where people have complex challenging behaviours a ‘behavioural analysis folder’ is kept to run parallel with the development plan. All physical interventions are documented in this. A professional visiting chiropodist now provides chiropody needs. Weight charts were seen to be in place, and an additional action column identifies weight gain/loss, this needs to indicate if a development plan is needed There was detailed information within development plans for the individual’s wishes at the end of life. The management of medicines was generally 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. The acting manager reported that the medication systems had been thoroughly reviewed recently and improved. The community pharmacist had worked closely with the manager. 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, and evidence of storage temperatures for the medication, the record sheet should contain any action taken to remedy the situation should the appropriate temperature of 25 degrees be exceeded. The home carries out weekly audits on the medication systems, which is good practice. A member of staff was observed to sign the medication record prior to visibly observing the service user taking the medication, which is not appropriate and was indeed a requirement, set at the previous inspection. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 15 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 the following 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: A complaints policy is in place and states a response will be made to complaints within one working day. ‘I am worried’ cards are provided and these can be posted in a post box within the home, which the acting manager checks daily All staff undertake training in adult protection. The training programme confirmed this. There have been a number of safeguarding adults issues which had been appropriately reported and investigated by the home/and or Social services Teams. No regulatory action has been necessary from these reported incidents. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 16 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 the following standard(s): 24,30 The people at Pelham Lodge have a comfortable, clean and generally well equipped, environment in which to live. Bedrooms suit individual needs and preferences. There are areas in need of refurbishment this, with the provision of en-suite facilities for the bedrooms in the main house would improve the quality of life for individuals. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” 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 reception area had been stripped of paper and loose plaster and damp areas were evident. This is to be part of refurbishment work, which the acting manager reported is to be commenced shortly. The carpet in the activities room was ruffling and frayed at the door edging creating possible trip hazards. The frayed area was made safe during the inspection. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 17 New flooring is planned as part of the refurbishment. Radiator covers were seen in most areas examined. The mesh centres of these were looking grubby and some were stained and require cleaning/re-painting. Laundry facilities meet the standards regarding washing machine with sluice and the provision of a dryer. 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 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. Two bedrooms were examined. Both were well personalised and people were observed accessing their rooms with door keys. Lockable facilities were observed. As already covered earlier in the report, the garden facilities are very good. There was some copper piping in the laundry, which because of how it had been placed around the entrance exit step was becoming damaged where people tended to step onto it. This needs to be remedied urgently to prevent further damage and risk to service users and staff. Gloves and aprons and paper towels were seen in ample supply around the home Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The people at Pelham Lodge are supported by competent and qualified staff. They are protected by robust recruitment practices and effective supervision. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: The staffing rota was examined and found to be satisfactory. The usual cover is four or five staff on in morning shift and four in an afternoon, two staff covers waking nights. Some service users are funded on a one to one basis within this calculation. The acting manager is on site during the day weekdays in addition to this, although he has been on several training courses recently. Bank staff are utilised. A recent staffing review has resulted in some staff hours have been reduced under new contractual arrangements Staff meetings take place, however a recent one had to e cancelled. The acting manger also informed the inspector of Team Leader away days. 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 know when it is appropriate to involve someone else with more specific expertise. There are no volunteers currently. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 19 From information on the annual training programme and by speaking with staff the inspector was able to ascertain that seven out of 19 care staff have completed National Vocational Qualifications at level 2 or above and one more is currently in process [level 3]. One member of staff is currently undertaking NVQ4 All staff have completed induction training. Induction booklets are provided which are based on skills for work standards. The majority have completed training in the following, Health and safety, Manual handling, fire safety, first aid, basic food hygiene, infection control, abuse awareness and SCIPr Uk [Strategies for crisis intervention and prevention]. Senior staff authorised to dispense medication have undertaken medicine management training. A sample of four staff personal files was examined and found to be satisfactory. A staff member interviewed informed the inspector that she had just completed NVQ, it was also confirmed that supervision and appraisals take place, evidence of these and team meeting minutes was seen. 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. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The people at Pelham Lodge benefit from a well managed home where generally good record keeping is noted. 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 live at Pelham Lodge are protected on the whole by good systems for health and safety and a competent and accountable management of the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: There has been a change of management in the home and the new acting manager has submitted an application to be registered. Staff commented that the new acting manager had made some changes and that they felt more consulted with and could participate in decision making about the running of the home. The acting manager reported that he was making changes slowly and was working closely with staff to enthuse responsibility and accountability. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 21 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 and a copy is kept in the individual development files. 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, and these are kept secure under the Data Protection Act 1998 guidance. The fire safety records were examined and these are being carried out weekly. Development plans are kept secure in the staff office. Blinds assist privacy and security. Systems are in place for the prevention of legionella and water outlet temperatures are now tested at least monthly. Staff were noted to wear aprons when preparing and serving food. On the day of the inspection COSHH [Control Of Substances Hazardous to Health] regulations were not adhered to fully, in respect of paint being stored in the laundry room. 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 DS0000008733.V294930.R02.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 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 3 2 2 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 4 X X 2 X Pelham Lodge Care Home DS0000008733.V294930.R02.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 2 Standard *RQN YA2 Regulation 17, Registration Regulations. 14 Requirement Timescale for action 25/07/08 25/08/06 3. YA20 4 YA24 5 6 YA35 YA42 The Registration Certificate must be fully displayed The registered Person must provide confirmation in writing to the service users that the home can meet their needs. 12,13,16,MedAct Ensure that medication is always signed as administered after visibly observing it being taken. Previous timescales set 12/10/05 not met Outstanding 23 Ensure remedial action is taken regarding the damaged copper piping in the laundry room 18 Provide further level training for staff in physical interventions 12, 23 Ensure paint is stored under COSHH [Control of Substances Hazardous to Health Guidance] 25/06/06 25/07/06 25/09/06 25/06/08 Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 24 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 2. Refer to Standard YA18 YA18 YA30 Good Practice Recommendations Ensure blood test results are followed up and records are more detailed about the reason for the test Ensure where PRN is given to manage behaviour the decision process is fully documented. If the planned room change does not occur, consideration of the provision of sluicing facilities should be made. Pelham Lodge Care Home DS0000008733.V294930.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road 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. Extracts may not be used or reproduced without the express permission of CSCI Pelham Lodge Care Home DS0000008733.V294930.R02.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. 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