Inspection on 27/06/07 for Pendean House

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pendean House 19/01/06

Pendean House 12/09/05

Pendean House 13/10/04

Pendean House 04/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pendean House West Lavington Midhurst Chichester West Sussex GU29 OES Lead Inspector Mrs J Aston Unannounced Inspection 27th June 2007 09:30 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 Pendean House DS0000024193.V338754.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. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendean House Address West Lavington Midhurst Chichester West Sussex GU29 OES 01730 812896 01730 817294 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) www.bupa.com BUPA Care Homes (BNH) Limited Mrs Jaqueline Travers Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Pendean House is registered as a care home with nursing to provide accommodation for up to 44 residents in the category, Old age not falling into any other category. The property is a large detached and extended house situated in the rural setting with extensive well-maintained garden and grounds. Accommodation is provided in 23 single rooms and 10 double rooms. Communal space comprises of a garden room, lounge and dining room. Pendean House is owned by BUPA Care Homes Limited, the Responsible Individual on behalf of the organisation is Mr Stuart Pendlebury. The Registered Manager in charge of the day-to-day running of the home is Mrs Jacqueline Travers. The fees range from £900 - £1200 per week. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. The Inspector however for this report has referred to those living in the home as “residents”. This inspection is the first inspection in 2006-2007. It is called a key inspection as only the key standards determined by the Commission have been assessed during this inspection. This inspection will determine the frequency of inspections hereafter. Planning for this inspection took place prior to the visit to the home. An Annual Quality Assurance Assessment form was received prior to the inspection and information from that will be referred to in this report. The Manager of the service was also asked to distribute a number of surveys to people living in the home, relatives, advocates and Health Care Professionals. In total eleven surveys were received from people living in the home, thirteen from relatives/advocates and two from Health Care Professionals. Information and comments obtained from the surveys will also be referred to in this report. An unannounced visit to the home took place on the 27th June 2007. Eight hours were spent in the home. A tour of the premises was undertaken, six people living in the home and seven members of staff were spoken with during the visit. A sample of records relating to residents, members of staff and health and safety in the home was examined. All of the National Minimum Standards have been met at previous inspections. Out of the twenty-two key standards assessed at this inspection eight are met to an excellent standard. What the service does well: The information received whilst undertaking this inspection provides evidence that Pendean House continues to provide an excellent standard of care and is a caring and well-managed service. There were numerous comments received from residents and relatives through surveys received prior to the inspection complimenting the service. Residents said, “I am well supported and looked after.” “All staff are very experienced and look after me well.” Relatives said, “I think this is an extremely well run care home. The staff are knowledgeable kind and caring.” “Nursing staff are gentle and seem to have the right type of nursing experience.” “Friends and relatives are made to feel welcome and part of the community at Pendean. One is always kept up to date and one feels that the welfare of the Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 6 people who live there is their number one priority. Everyone treats us visitors with friendliness.” Health Professionals said, “Extremely sensitive and respectful staff who strike exactly the right balance between formality and informality according to the individuals needs.” “They provide an environment that is as inclusive or private as the individual needs. From top to bottom the care team has a warmth, drive and sense of humour that is extremely welcoming.” Pendean House provides a wide variety of activities that are well managed and residents are kept informed of what is on everyday. All residents receive individual attention with some kind of activity or conversation even if they are ill and confined to their bedrooms. The accommodation provided is of a very high standard with beautiful grounds and gardens. The staffing levels in the home allow members of staff to do their job well and provide company and assist with activities. What has improved since the last inspection? What they could do better: There were no requirements or recommendations made at this inspection. Pendean House continues to provide an excellent service. A relative said, “Pendean is so well run, I find it hard to suggest any improvement.” A residents said, “It can’t improve standards are high.” Please contact the provider for advice of actions taken in response to this Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 7 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. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 8 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 Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 9 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): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of a prospective resident are assessed appropriately before admission to the home. EVIDENCE: During the visit to the home the Statement of Purpose and Service User Guide were examined. Both documents contained comprehensive information about the service. It was noted when visiting residents in their rooms that each resident has a copy of the Service User Guide. From the information gathered through surveys received prior to the inspection residents/relatives felt that they received enough information about the home before moving in. A sample of records relating to residents was examined during the visit to the home. It was seen that a Professional had undertaken a Continuing Health Care assessment where appropriate before admission to the home. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 10 A pre-admission assessment had also been completed by a trained nurse from the home prior to or on admission. Information about the resident’s needs had been recorded on a care plan. This process demonstrates that all parities can be sure that a resident’s individual and sometimes complex needs can be met by the service before admission. Intermediate care in not provided in this setting. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs and wishes are recorded appropriately. The health care needs of each service user are known to staff and are met well. Staff team operate safe storage, handling and recording of service users medication. Service users feel they are treated with respect. EVIDENCE: The needs of each resident and the support they require are recorded on a care plan. During the visit to the home five care plans were examined. It was noted that although the needs of each resident was recorded the documentation did not support the amount of work the Inspector is aware that the staff team undertake to ensure the needs of each person are met. It did not demonstrate how the resident or relatives are involved in the compilation and reviewing of the care plan. The Manager explained that a new care planning recording system is being introduced that will be applied to all BUPA homes. All staff will receive training in using this system starting with the Manager next week. The new system will address the points raised. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 12 It was clear from talking with residents and staff that the health needs of each resident are met well. A Doctor who is retained by the home visits the residents every week and is kept up to date about changing health needs or any visits required by nursing staff who fax information through to the surgery every Monday. A nurse said that they have a very good relationship with the GP who is excellent at considering action to be taken to improve a resident’s health in an anti-discriminatory manner. The Inspector noted that where residents were unwell and in bed they had drinks available to them at all times; jugs of squash or water in their rooms. Where necessary members of staff record the fluid and food intake of residents who are unwell and record the weight of all residents. The necessary equipment is in place to prevent pressure areas developing and to ensure safe moving and handling of residents. During the visit to the home the storage and handling of medication was examined. The Inspector found that all medication was stored appropriately and securely. The records relating to the medication administered were in good order. The Manager explained that a new system is being used in the home to ensure that the privacy of each resident is respected. Where a resident is being supported with personal care a notice is put on the bedroom door that states, “Only care staff to enter” and taken off when personal care is complete. Observations of members of staff talking with residents noted their manner was respectful and friendly. Residents told the Inspector that the staff are excellent and are respectful and polite. There were many comments about staff received through surveys used as part of the inspection process, residents said, “Staff are always willing what more could you want.” “All staff are very experienced and look after me well.” Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have comprehensive information about the home to ensure that it will meet their social, cultural, religious needs and their interests. There are many opportunities for residents to be involved in a wide range of activities that are well organised. Residents are assisted to maintain relationships with family and friends or representatives. EVIDENCE: Pendean House employ a full time activities co-ordinator. This enables a regular and varied programme of activities to be organised and provided. The activity co-ordinator confirmed that she visits each resident every morning to remind them of the activities for that day and to take their post round and to read letters to them if they so wish. Each resident is provided with a programme of activities and relatives are informed of dates for their diaries. The garden room is used as the activity and hairdressing room. Activities range from reading a book, (using a microphone so everyone can hear) cooking, call my bluff, memory bingo, crosswords, movement to music, and outings to Arundel wildfowl trust, Guildford, mystery trip, to Felpham for fish and chips. They have had a tea dance and have watched tennis with a strawberry cream tea. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 14 A marquee is put out on the lawn for birthday parties etc. Outside groups like the Lions use the marquee and with any event the residents are always invited. Residents are invited to come down to the garden room for coffee and sherry in the mornings. They have communion every Wednesday. There is a car available to use and a minibus is hired for trips. The Inspector was informed that for any trip the staffing ratios are always one member of staff to one resident a nurse always accompanies them on any outing. Risk assessments are undertaken for all activities and outings. The activity coordinator also informed the Inspector that time is planned in to allow her to read or sit and talk with residents who are unwell and unable to come down to the garden room. The activity co-ordinator also organises and chairs residents meetings on a regular basis. On the day of the visit to the home communion had been arranged and took place in the lounge. Residents spoken with confirmed that the activities regularly take place. A relative said, “There are activities in an atmosphere that is positive rather than depressing, but people can take part or not depending on their needs and mood. This is largely due to the excellent quality of the staff.” The information provided from relatives through surveys indicates that the home always or usually helps their relatives keep in touch with them, they are always or usually kept informed about important issues effecting their relative and the service always or usually supports people to live the life they choose. The menus are varied and provide a variety of meals and a choice. The Inspector saw the lunch during the visit to the home and noted that it looked well presented. Residents confirmed they had a choice of meal and were always informed of what the meals were going to be. Many residents said the home provide “Very good food.” It was noted as part of the assessments of the needs of the residents and a nutritional assessment is also undertaken and kept under review. The Inspector was also made aware that some residents choose to have a dinner party occasionally. They request dinner in the evening that is a meal of their choice with a bottle of wine. Some residents also meet in the late afternoon for a drink in the reception area. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures for dealing with complaints. Through training the staff team have awareness about signs of abuse and know how to report any allegations. EVIDENCE: All residents have a copy of the complaints procedure in the Service User Guide in each of their rooms. The Manager and Matron maintain an atmosphere in the home that supports residents to air their concerns. Residents are able to make complaints to any member of staff. A resident said that they were happy to approach the Manager. The Commission has not received any complaints in respect of this service. The Annual Quality Assurance Assessment from received prior to the visit to the home recorded that five complaints had been received in the last twelve months. The complaints record was examined during the visit to the home that demonstrated the complaints had been responded to appropriately and within the stipulated timescale. The West Sussex Multi-disciplinary Adult Protection Procedures are followed by the home. From training records it could be seen that members of staff have received training in recognising signs of abuse and this is updated as required. There have been no allegations of abuse raised about this service. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Pendean House provides a very high standard of accommodation that is comfortable and safe. There is a high level of procedures to prevent the spread of infection. EVIDENCE: Pendean House provides an excellent standard of accommodation. The decoration and furnishings are of a very high standard and the home was immaculately clean everywhere. All residents’ rooms looked individualised and comfortable. All of the people spoken with during the inspection said that they always found the home to be immaculately clean. The grounds are extensive, well maintained and beautiful and easily accessible. The outside of the property looks very well maintained and attractive. Documentation seen during the visit to the home demonstrated that the safety checks and maintenance of utilities and equipment is up to date. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 17 The property inside is very well maintained. The information provided on the Annual Quality Assurance Assessment form prior to the inspection stated that the Manager has introduced a monthly walk around the home with the maintenance person and housekeeper to identify any areas that require attention. The Manager also operates a cyclical system of focusing on an individual resident that includes a spring clean of the residents room, review of activities and a complete review of their needs and care plan. The environment is enhanced by a tasteful reminiscence display that includes small household objects, tobacco tins, cards and other objects of interests. Members of staff from the domestic team were spoken with during the inspection. They confirmed that staff have dedicated roles for laundry, cleaning and working in the kitchen and have sufficient staff to do this well. They are fully aware of infection control procedures, ensure that hazardous substances are stored safely and that they have plenty of cleaning materials and equipment. Residents spoken to say, the laundry system is very efficient. All members of staff are aware of the infection control policy and procedures in the home and have received training in the prevention of infection. They confirmed that there is sufficient protective clothing and all recognise the indication used where barrier nursing and strict infection control procedures are to be used. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a trained staff team who have time to meet their needs and protected through the homes recruitment procedures. EVIDENCE: The staff team consists of a mix of female and male staff, a mix of ages, different nationalities and levels of experience and all have dedicated roles. Inspection material provided prior to the inspection confirmed the staffing levels within the home and on the day of the visit to the home there was a good number of staff appropriate to meet the needs of the residents. All who were spoken with during the visit to the home said that there was always plenty of staff in the home at all times. Residents spoken with said that members of staff are friendly and kind. Comments received from residents and relatives from surveys said, “Nursing staff are gentle and seem to have the right type of nursing experience.” “The staff are kind, thoughtful always cheerful and always most willing to help.” A sample of five records relating to the recruitment of staff was examined. This demonstrated that the necessary recruitment checks had been undertaken prior to them working in the home. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 19 Where overseas staff had been employed there was evidence of the persons identity, passports had been seen with permission to enter the country and to work, and two references. Criminal Record Checks are applied for as well as a check against the Protection of Vulnerable Adults Register. The training record demonstrated that members of staff receive an appropriate induction, training in health and safety topics and in topics relevant to the residents’ needs. Members of staff spoken with confirmed that they had received this training. The range of training provided covers induction through to National Vocational Qualifications (NVQ) level 2 & 3. The Annual Quality Assurance Assessment form recorded that 81 of the staff team are trained to NVQ Level 2 and above. Members of staff spoken with confirmed that they had been supported with this training. Other topics covered that are relevant to residents’ needs and good practice are in Protection of Vulnerable Adults, stroke awareness, and dementia and in end of life care. All catering staff have undertaken a food hygiene course and are included in fire and moving and handling training. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31, 33, 35, and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Pendean House is very well managed and run in the best interests of the residents. The home is well maintained and safe and the safety of residents and members of staff is considered and risks minimised as far as possible. Residents’ finances are managed appropriately. EVIDENCE: Mrs Travers the Registered Manager of the home is appropriately qualified and very experienced and has achieved the Registered Managers Award. The service has obtained the Investors in People Award and continues to retain this. This is obtained by demonstrating that a service or business invests time, money and effort in training staff, developing their skills and listening and promoting their views and ideas. Mrs Travers is now undertaking training in the Gold Standards Award. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 21 There is a clear line of leadership and support and members of staff spoken with said they felt very well supported. There is always a Manager on call along with the two maintenance people. Regular meetings are held within each team that promote team working and continuity. The atmosphere in the home on the day of the visit was friendly, helpful and cheerful. Members of staff, residents and relatives said they felt that the management team were approachable and caring and they had confidence in raising concerns that action would be taken. The home does not take responsibility for managing a resident’s finances however an administrator does assist residents to manage small amounts of money for small expenses. This money is kept in a separate account and all transactions are recorded with receipts kept and the account is audited. The Annual Quality Assurance Assessment form provided prior to the inspection recorded that annual safety inspections are undertaken on equipment and utility supplies and maintenance systems are in place to ensure the safety of residents. Documentation relating to this was seen during the visit to the home. The Manager and staff team support service users to keep safe through highlighting any potential risks to them. A resident confirmed that she has freedom to go out whenever she wants but is sensible and takes the homes mobile phone with her. It was seen that potential risks from the environment or whilst staff are supporting a person with moving or using a piece of equipment had been assessed where appropriate. A quality assurance system is in operation and consists of Customer service questionnaires given to residents, BUPA have an internal audit that is undertaken annually, residents meetings are held regularly and the manager holds meetings with relatives. The Manager confirmed that a policy and procedure has been put together and a report about the last quality assurance exercise was sent to the commission to meet the requirement made at the last inspection. There was evidence from the Annual Quality Assurance Assessment form that the Manager and her team are continually reviewing the service and acting upon residents’ comments and suggestions. For example recent questionnaires returned indicated that the residents would like some raised flowerbeds in the garden and this has been put into action. Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 4 X 3 X X 3 Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Pendean House DS0000024193.V338754.R01.S.doc Version 5.2 Page 25 - 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!