CARE HOMES FOR OLDER PEOPLE
Pendarves 25 Pendarves Road Camborne Cornwall TR14 7QF Lead Inspector
Paul Freeman Unannounced Inspection 7th December 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Pendarves Address 25 Pendarves Road Camborne Cornwall TR14 7QF 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) 01209 714576 01209 714576 Mr Davood Mohajeran Mrs Kima Mohajeran Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. To temporarily accommodate one named person outside the registered categories of the home from 14/3/05 to 18/3/05 Total number of service users not to exceed a maximum of 10 Date of last inspection 14th November 2006 Brief Description of the Service: Pendarves is a three storey Victorian house situated on the outskirts of Camborne. There is therefore a large range of social amenities in close proximity to the home. The home provides twenty-four hour care for up to 10 older people and presents as warm and friendly. The care home is owned and run by Mr and Mrs Mohajeran who are committed to providing care that encourages independence and meets individual residents needs and promotes their independence, dignity and choice. Mr and Mrs Mohajeran are also committed to providing a healthy and safe environment. The home is well maintained and a chair lift is provided for access to the upper floors. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned key inspection took place on 7 December 2006 and 8 December 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 1 December 2005 and to inspect other core standards. Therefore some of the key standards considered included care planning, health, staffing arrangements and safe working practices. The registered manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. As part of the key inspection information was also collected to contribute to the Commissions current thematic inspections of care homes regarding; standard 1-Information, standard-2 contracts, standard-3 needs assessments and standard-16 complaints. The findings are also included in this report. Residents are very satisfied with the services and facilities provided and state they have confidence in the manner the home is managed and the care and support they receive from staff. The current fee levels at the care home are between £295.00 and £340.00. The level of fees is determined by the residents needs. What the service does well:
The provider assesses each prospective resident. The assessment takes account of the person’s needs and views about the care and support they require. In addition their relatives and any professional involved with the individual are consulted. This makes sure the providers can accommodate the person’s needs, preferences and choice. Prospective residents are also provided with written information about the service and facilities to help them make an informed decision about residing at the care home. Each resident is also provided with a contract that details the fees and the terms and conditions of residency. In addition residents are advised in writing of any contractual changes. All the residents have a care plan that details their needs and the most appropriate ways of providing the care and support they require. The information in the plans provides staff with clear directions about the care and support required. The plans are regularly reviewed with residents and their
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 6 relatives or representatives to make sure they are up to date and that a satisfactory service is provided to each person residing at the home. Residents were very complimentary about the care and support they receive and said that staff always treated them in a positive, respectful and dignified manner. Residents stated they felt in control of their lives and found the staff and Providers to be trustworthy, reliable and approachable. Good arrangements are in place to meet residents’ health needs and medical services are promptly accessed when required. Residents are able to administer their own medication when this is safe. Where staff assist residents suitable arrangements are in place to safeguard the residents and satisfactory records are maintained. Residents were positive about the treatment they receive. The residents said they were always treated with dignity and respect and felt in control of the events that took place. It is also evident that positive and trusting relationships have been established between the residents and staff. The visiting arrangements are flexible and residents commented that staff always positively welcomed visitors. Satisfactory arrangements are in place to deal with any concerns or complaints a resident, relative or representative may have. Residents stated there were no barriers to raising any issues of concern were confidant that all matters would be dealt with in a positive manner. A homely and well-maintained environment is provided. Residents said they were very satisfied with the facilities. A programme of redecoration and furniture replacement is in place and residents commented that any repairs are completed efficiently. Appropriate communal areas are located on the ground floor and comprise of two sitting rooms and a dining room. Residents’ bedrooms have single occupancy and are suitably furnished and decorated. The rooms have all been personalised by the occupants and are furnished to the required standard. Residents are provided with suitable disability equipment to maximise their independence when this is required and a stair lift is in place to promote access to the upper floors. Bathrooms and toilets are distributed throughout the care home and are within a reasonable distance from the communal areas and residents bedrooms. The home is pleasant, clean and a good standard of hygiene is maintained. Sufficient number of staff is on duty to meet the needs of residents. Residents commented they were very pleased with the manner in which the staff Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 7 provided care and support. The residents said staff were flexible and treated them in a respectful and dignified manner. The staff is appropriately trained and an ongoing programme of training is in operation. This makes sure that staff has the skills and abilities to provide a positive and reliable service to residents. Good arrangements are also in place to recruit, select and vet new staff. Newly appointed staff also completes a period of induction. This makes sure they are aware of their roles and responsibilities and is able to provide the care and support required. The home is well run and managed by the Providers in a manner that promotes the best interests of the residents. Both Providers play an active role in the day-to-day delivery of care. The staff are appropriately supported and stated that advice, guidance and support is always available whenever it is required. Residents are regularly consulted about the services and facilities provided to make sure that every reasonable step in taken to meet their needs, preferences and choices. Good arrangements are in place to promote safe working practises and to minimise risks and safeguard residents’. What has improved since the last inspection? What they could do better:
In certain instances night time arrangements were not included in care plans. This means that staff are not given the information and guidance they require to safeguard the residents. Care plans should also be reviewed four weeks after a resident’s admission. This will make sure the care and support they require is in place. Where a General Practitioner changes a prescribed medicine more detailed records should be made to make sure the staff have up to date information and residents are safeguarded.
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 8 The bathroom on the third floor also accommodates the laundry but the Providers have plans to relocate the laundry in the New Year. This will mean the bathroom can be reinstated and the facilities improved. The lighting arrangements in residents bedrooms require review to make sure that each residents has sufficient lighting that meets the recognised standard (lux 150). It is recommended the fire policy and procedure is reviewed to make sure that staff are provided with clear information and guidance about their roles and responsibilities. This will further develop and strengthen the arrangements in place. 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. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered are 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each prospective resident is assessed prior to admission to make sure the providers are able to meet their needs, preferences and choices. Prospective residents are also provided with appropriate information about the service and facilities during assessment. All residents are provided with a contract that is signed by the parties concerned and is annually reviewed and updated. The contact provides residents with information about the fees and terms and conditions of residency. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 11 EVIDENCE: The providers reported that each prospective resident and their relatives or representatives are provided with a service users guide. This document adequately details the facilities and services provided. However no records are made when the documents are issued. The providers are advised to make suitable records about the events that take place before a resident is admitted. This provides a clear account of the steps that have been taken and could usefully resolve any issues that are disputed later. The records will also evidence that prospective residents and their relatives or representatives have been appropriately introduced to the setting. Residents’ that have recently moved to the care home confirmed they were provided with information before they moved to the home. The residents also confirmed their relative or representatives had been consulted. Each resident is provided with a contract that details the fees and the terms and conditions or residency. Residents said they were very satisfied with the arrangements in place. The providers assess each prospective residents needs. This makes sure the facilities and services are appropriate to meet the needs, preferences and choices of the person concerned. Residents said they had met with the providers and were fully involved in the assessment process. In addition the providers will take account of the views of the relatives or representatives and of any professional that are actively involved with the person concerned. This makes sure the providers have a comprehensive picture of the care and support required. A dedicated intermediate care or rehabilitation service is not provided at the care home. The providers and staff do make every reasonable effort to promote residents independence. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is good. Each resident has care plan that details their needs, preferences and choices and provides staff with good guidance and direction. Good arrangements are in place to meet residents’ health needs and medicines are administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have an individual plan of care that summarises their needs, preferences and choices. The care plans also provide staff with satisfactory information, guidance and direction to provide the care and support required. In certain instances night time arrangements are not included in the care plans. The requirement set at the last inspection is therefore re-notified.
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 13 The documentary evidence indicates that plans are regularly reviewed with residents to make sure they are up to date and that residents are satisfied with the service and facilities provided. In certain instances there was no evidence to indicate a formal review had taken place after the first four weeks of residency. It is recommended the providers ensure that reviews occur at this time. This will make sure the care plan for new residents are appropriate and provide staff with adequate guidance and direction. Residents stated they were very satisfied with the care and support provided. It is evident that positive and trusting relationships have been established between the residents and staff. Good arrangements are in place to meet residents’ health needs and health services are promptly accessed when required. Residents were also confidant about the care and support they receive when they were unwell. Medication is safely managed and administered. Residents are able to administer their own medicines when it is safe to do so. Where staff assist residents the staff have been suitably trained and good records are maintained. Where a medicine has been discontinued or altered by a General Practitioner a suitable record should be made on the records to indicate the date and contents of the directions and who gave the directions. This will make sure that staff have access to up to date information and that residents are safeguarded. Medicines are held in secure facilities and suitable arrangements are in place to dispose of unwanted medication. There is a good relationship with a local pharmacist who also reviews the administering arrangements on an annual basis. Residents were also positive about the treatment they receive. The residents said they were always treated with dignity and respect and felt in control of events. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents experience a positive and flexible lifestyle and feel in control of their lives and the care and support provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were satisfied with the lifestyle they experience at the care home. The residents stated the arrangements were flexible and they were able to direct the care and support provided. Therefore residents were confidant they were able to make decisions for themselves and their personal choices and preferences are consequently accommodated. The residents were also satisfied that sufficient activities occurred in the home and the local community to satisfy their needs and interests. Activities regularly occur at the home on a planned and spontaneous basis. This reflects
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 15 the residents’ preference and choice and provides suitable stimulation and occupation. However the care plans and assessments of need would benefit from more information about residents interests, hobbies and leisure pursuits to make sure that every resident’s preferences and choices are taken into account. The visiting arrangements are flexible and residents commented that visitors are always welcomed at the home. Visitors are requested to avoid mealtimes to avoid any potential disruption to the other residents at the home. Residents were also very satisfied with the food provided. A varied and nutritional menu is in place that reflects the residents’ needs, preferences and choices. The menu promotes healthy living and reflects cultural needs. The staff undertaking the catering have been suitably trained and the kitchen is maintained to a satisfactory standard. Suitable health and safety measures are also in place to make sure residents and staff are safeguarded. The residents described the food as “good” and said they were “well cared for.” Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 16 and 18. Quality in this outcome area is good. Good arrangements are in place to positively deal with any complaints or concerns and to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Providers or the Commission has received no formal complaints since the last inspection in December 2005. The providers have established a suitable policy and procedure for complaints and the arrangements are included in the documentation prospective residents receive prior to admission. The policy and procedure is also on public display for residents or visitors. Residents stated there were no barriers to raising any complaints or concerns. Residents were confidant that any issues would be dealt with efficiently and in a satisfactory manner. A suitable policy is in also in place to protect residents’ from abuse and any issues or concern s are reported to the statutory authorities for investigation.
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 17 Although no allegation or disclosure have occurred the providers have improved and developed the procedures to make sure they compre3hensively reflect the Department of Health guidelines ‘No Secrets’. Appropriate training is also in place for the staff to make sure they have up to date information and knowledge. This provides residents with a further safeguard. A satisfactory whistle blowing policy and procedure is also in place. This provides staff with an opportunity to raise any concerns or issues with a third party and offers residents further protection. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 19 and 26. Quality in this outcome area is good. The environment and facilities are well maintained and provide a homely and comfortable setting for residents. The laundry facilities would benefit from relocation and this will enhance the bathroom arrangements on the upper floor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The environment comprises of a three-storey building that has bedrooms on all three levels. The facilities provided are of a good standard and are well maintained. Therefore a homely atmosphere exists and residents said they were very satisfied about all aspects of the environment.
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 19 Communal areas are located on the ground floor and comprise of a sitting room, an adjoining dining room and a conservatory at the rear. The rooms are appropriately decorated and suit the needs of the residents. Bathrooms and toilets are located throughout the care home and in reasonable proximity to communal areas and residents bedrooms. Residents’ bedrooms are well presented and the occupants have clearly personalised their rooms. All the rooms have single occupancy and include a sink. Some of the room are also provide with a toilet. The furniture and fittings in the rooms are domestic in nature wherever possible and appropriate heating is provided throughout the home. Generally the lighting is also satisfactory but in certain rooms requires review to make sure the appropriate standard of lighting (lux 150) is met. A good standard of hygiene and cleanliness is maintained and where required residents are provided with disability equipment to maximise their independence. A chair lift is also provided to access the upper floors. The laundry is located on the upper floor in a room that also includes a bath. It is the Providers intention to relocate the laundry to the ground floor and provide a suitable bathroom in the present location. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is good. Sufficient numbers of appropriately trained staff are on duty each day and night. Good arrangements are in place to recruit, select and vet new staff and newly appointed staff undergoes a period of induction. This makes sure that staff have the competencies to provide a good standard of care This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both registered providers play an active role in the delivery of care to the residents. In addition there are sufficient numbers of staff on duty during the waking hours and each night to make sure that residents are safeguarded and their needs are met. Additional staff is also provided at peak times or when required e.g. first thing in the morning to make sure residents needs and choices are accommodated. No waking night staff is currently employed but staff sleep at the home to assist with emergencies. This is currently satisfactory given none of the residents routinely require assistance each night. The residents are also very
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 21 satisfied with this arrangement and said they found the overnight arrangements to be reliable. The registered providers confirmed that waking night staff would be provided if required or if any residents regularly required assistance each night. Residents commented the staff were, “very good” and they were very satisfied with the manner in which the staff provided care and support and met their needs. Residents said they felt in control of the care they received and found the staff to be flexible in their approach and available when required. The staff is suitably trained and the providers have established an annual programme of training for all staff. This makes sure the staff has update knowledge and the appropriate skills to maintain a good standard of care and support. In addition a number of staff are trained to NVQ 2 standard. Good arrangements are in place to recruit select and vet new staff to make sure that staff have the required skills and abilities and that residents are safeguarded. Each newly appointed staff member also completes an induction programme that ensures they are aware of their roles and responsibilities. The providers were advised to make sure the induction programme meets the guidelines recently established by Skills for Care. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is good. The home is well managed for the best interests of residents. Appropriate arrangements are in place to promote safe working practises and to safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well run and well managed by the Providers who both play an active part in the day-to-day delivery of care. Residents commented they found the home was run in a way that promoted their best interests. The staff
Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 23 said they found the Providers to be supportive and available whenever they required assistance or guidance. Residents are regularly consulted about the services and facilities provided. Consultation takes place at residents meeting, individual discussions and through an annual questionnaire. There are positive outcomes from all aspects of consultation and no significant areas of deficit or need were identified. At the time of the inspection the providers are not assisting any residents in the management of their personal allowances. Assistance will be provided if not other third party support is available. A suitable policy and procedure that safeguards residents is also in place. Satisfactory arrangements are in place to maintain a safe environment and to safeguard residents from unreasonable risks. The equipment and services at the care home are also regularly monitored and serviced. The Fire Brigade completed an inspection recently and were satisfied with the arrangements in place. However it was noted that two of the nominated fire doors near to the kitchen were wedged open. The providers were advised that more suitable arrangements needed to be in place to safeguard all concerned. Staff regularly undergoes fire training and the fire equipment is monitored on a regular basis. A policy and procedures to guide, direct and inform the staff about the fire arrangements is in place. It is advised the policy is regularly reviewed to make sure it is robust and comprehensively addresses the issues and actions required. It would also be beneficial for the policy to detail the roles and responsibilities of the fire warden. This will further develop and strengthen the arrangements in place. Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Night time arrangements must be included in each residents care plan. (Previous timescale of 28 February 2006 not met). Timescale for action 28/02/07 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. Refer to Standard OP9 OP21 Good Practice Recommendations Where appropriately qualified medical practitioners alter a prescribed medicine a suitable record should be made of the instruction, date and name of the practitioner. The laundry facilities should be relocated to the ground floor and a suitable bathroom should be established in the current location of the laundry. The policy and procedures regarding fire should be reviewed and improved so that staff is given clear direction about their roles and responsibilities. 3. OP38 Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 26 Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Pendarves DS0000008928.V322901.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
