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Inspection on 01/11/07 for Amberleigh Manor Care Home

Also see our care home review for Amberleigh Manor Care Home for more information

This inspection was carried out on 1st November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff at Pendean have gone through significant changes in management since 2006. Evidence was in place to demonstrate that the business manger, administration manager and staff team have worked hard in improving the service for residents. Staff were observed with the residents, and it was noted that there was a good rapport between staff and residents, which provided a comfortable, relaxed and homely atmosphere. Good efforts were made to provide social gatherings for residents and their families and friends and the activities coordinator worked hard to ensure residents were engaged and stimulated in activities that were preferred and enjoyed.

What has improved since the last inspection?

What the care home could do better:

Although it was clear that the business manager and the staff team have worked hard in improving the service for residents, once an experienced manager is appointed, the stability of the management of the home will be enhanced for both staff and residents. An error was found on the medication administration records, and therefore staff administering medication must be more vigilant when signing to say that medication has been administered. The policy regarding the procedure to follow in relation to safeguarding adult issues should be in line with the Local Authority procedure in all Safeguarding matters and the `seriousness` of the safeguarding issue and how it is to be investigated should not be decided by anyone other than the Local Authority Safeguarding coordinator.

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Alfreton Derbyshire DE55 5JF Lead Inspector Angela Kennedy Unannounced Inspection 10:00 1 November 2007 st 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 Nursing Home DS0000002069.V351939.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 Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendean Nursing Home Address Primrose Hill Blackwell Alfreton Derbyshire DE55 5JF 01773 860288 F/P 01773 860288 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) mskelley@myway.com Mr Mohinder Singh Kelley Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (33) of places Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No more than 7 DE/E service users can be accommodated, in the designated areas identified for accommodating this category of service user. Staff must receive suitable training in meeting the needs of service users with dementia. There must be a specialist dementia advice and training on an ongoing basis, provided by a Registered Mental Nurse (RMN). To allow two named persons DE(E) to be accommodated in an area outside the designated area for the duration of their stay. 23rd February 2007 Date of last inspection Brief Description of the Service: Pendean nursing home is a converted and extended country house providing nursing and personal care for up to 40 older persons, including up to seven service users with dementia (all aged 65 years and over).Accommodation is provided on two floors, with 28 single bedrooms and 6 shared rooms. One single and one double room have en suite facilities. (At the time of the inspection one shared bedroom was being used as single accommodationmeasuring less than 16 square metres). There is a passenger lift, handrails to corridors, grab rails provided to toilets and an emergency nurse call system throughout the home. Moving and handling equipment is provided. There is access for service users to a garden and patio area. The homes scale of charges at this inspection were between £345- £510 depending on the category of resident and the room size occupied. Expenses such as toiletries, chiropody, and hairdressing services were additional to the weekly fee. A price list was available within the home for hairdressing services, which at the time of this inspection ranged from £4.50 for a gents cut, £6 for a hair set and £25 for a perm. The current fee for a chiropodist visit was £5. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over seven hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment, however this document had not been returned to the commission prior to the completion of this inspection report. Two residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Several members of staff were spoken with and two staff were spoken with at length to gain their views on the service and support provided to residents and the training and support given to staff. What the service does well: What has improved since the last inspection? Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 6 Major improvements were seen in the care planning documentation for residents. Information recorded was detailed and corresponded with any risks identified and how these risk were to be reduced. Care plans were reviewed regularly to ensure any changing needs were identified. Improvements to the décor and furnishings of the home have improved, which creates a more attractive environment for residents and their visitors. A fire risk assessment is now in place, which demonstrates any risks identified and the fire safety measures that have been put in place to safeguard residents, staff and visitors of the home. 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. The summary of this inspection report can be made available in other formats on request. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 8 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were assessed prior to admission to ensure the service could meet their needs. EVIDENCE: The two residents’ files looked at, had needs assessments in place that had been undertaken prior to admission, evidence was in place that demonstrated further information had also been obtained upon admission. These assessments addressed all areas of health, personal and social care, Care managers assessments were also in place for residents who were funded by the local authority. Care plans had been developed from the information provided within the needs assessments. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 9 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Resident’s health, personal and social care needs were set out within their care plans, which ensures that staff receive the correct information to support residents in meeting their needs. EVIDENCE: Within the two residents files seen, considerable improvements had been made to the care planning documentation and other associated records. The information contained within the care plans and risk assessments provided clear and detailed instruction to the staff team of how the resident’s needs were to be met. Staff spoken with confirmed that the care plans in place were clear and provided sufficient detail for them to follow, to enable residents needs to be met. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 10 Care plans addressed all identified areas of health, personal and social care needs and assessments were in place, which included; nutrition, mobility, falls, moving and handling and pressure area care. Each care plan seen was cross-referenced to a risk assessment. This demonstrated that all areas of support that had been identified, was then assessed, enabling any risks identified to be addressed and the appropriate action put in place to reduce the risk. All of care plans and risk assessments seen had been completed and reviewed on a regular basis. A named nurse and key worker system was in place to ensure care plans and risk assessment were reviewed regularly. One member of the care team spoken with discussed her role as a key worker and confirmed that she was responsible for reviewing care plans in consultation with the named nurse. This member of staff appeared to have a good knowledge and understanding of the needs and support of the resident that she was key worker for. A residents / relatives consent to care form was in place within the care plans seen and this had been signed and dated by the resident or their representative within the two care files seen. Records of residents weight was maintained according to assessed need. This had been undertaken in one residents file on a monthly basis, and on a fortnightly basis for the other resident. This ensured that any sudden reduction or increase in weight was identified and addressed. Records were kept of doctor’s visits, opticians, dentist and hospital appointments. The administrator confirmed that a chiropodist visited residents on a six weekly basis to provide foot care. Daily information sheets were completed by staff regarding the well being of each resident. Residents spoken with were very positive about the care and support provided by the staff team, and comments included “they look after us well, I cant really complaining about the care I get, its very good”. Residents spoken with confirmed that staff treated them respectfully. Throughout the inspection staff were observed with the residents, and it was noted that there was a good rapport with staff and residents chatting and having a joke with each other. The medication administration practices of the service were assessed. Initially the medication administration records for the two service users case tracked were checked. However on doing so one error was noted, where the Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 11 nurse on the morning shift had signed for the resident’s medication for 6pm that evening. This medication was checked and had not been administered to the resident. All of the medication administration records were then looked at and no further errors were noted. Resident’s photographs were in place on medication administration records to identify the residents. The controlled drugs register was examined and this had been completed correctly. The storage of medication was looked at and was found to be satisfactory, this included medication stored in the clinical fridge, where fridge temperatures had been recorded to ensure this medication was stored at the required temperature. A requirement had been left at previous inspections that care staff that were responsible for administering external preparations for residents such as creams and other external medication must receive the appropriate training. At this inspection it was confirmed that a programme to assess care staffs competency in administering external preparations was due to commence. It was confirmed that until this is done, nursing staff would continue to administer external preparations. Following this inspection visit, written evidence has been provided to demonstrate that care staff are undertaking training in this area. It was confirmed that senior care staff were to undertake medication administration training, and once completed it was stated that senior care staff would then accompany nursing staff on medication rounds, to ensure their competency was maintained. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The planned activities and contact with families and friends enabled residents to have choice and control in their lives, and maintained their wellbeing. EVIDENCE: A member of the care team was employed for 16 hours a week to co-ordinate activities for residents. This member of staff was spoken to regarding the activities planned both in house and within the wider community. The activities provided for residents included; table skittles, dominoes, soft netball, target games, ludo, snakes and ladders and card games and craft work. Some of the craftwork undertaken by residents was seen. Since the last inspection two DVD players had been purchased and these were used to provide film entertainment for residents. The activities coordinator stated that ‘musicals’ were a favourite with many of the residents. A bingo DVD had also been purchased which appeared popular with residents. Trips out were organised for residents and during the warmer months these had been to places of interest such as Matlock and boat trips in Nottingham. A Christmas shopping trip was being planned at the time of this inspection. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 13 External entertainers visited the residents three or four times a year and provided a variety of musical activities, such as singing or playing musical instruments. Plans for Christmas activities and entertainment were being organised. This included a Christmas party for residents and their family, including an external entertainer, and several other social gatherings for residents and their family, including Christmas Day lunch and entertainment. Church services were held within the home each month for any residents who wished to participate. It was confirmed that at the present time there were no residents who went out to local church or religious services. From observation and discussion with residents and staff it was apparent that considerable efforts have been made to ensure residents social needs are met. However the activity recording sheets within residents’ files didn’t reflect this and there were gaps of up to a month where no activity had been recorded. On discussion it was confirmed that the activities coordinator was responsible for recording the activities undertaken by individual residents. It was agreed that this was unrealistic and that care staff should complete activity recording sheets at the end of each shift, this will then give a clear refection of the activities offered and undertaken by each resident. Visiting hours at Pendean were open and residents were able to receive their visitors within the communal areas of the home or within their private accommodation, as they preferred. Residents spoken with confirmed that their visitors were made welcome by the staff team. Residents were observed moving freely around the home during the inspection, one resident was seen with the activities coordinator wrapping presents for the raffle prizes, some residents were seen walking around the home and chatting to other residents and staff, some residents were seen talking with staff and some residents preferred to stay in their bedroom. One resident who liked to stay in bed until late morning was able to do so and told the staff when they required support getting up. Information regarding local advocacy services and their contact details was advertised on the notice board within the corridor. This further enhances resident’s personal autonomy and choice. The menus were seen and, as at the last inspection a vegetarian option wasn’t always displayed. Discussions took place regarding this. It was confirmed that vegetarian options were always made available if requested. Following this inspection written evidence has been provided to demonstrate that menus state a vegetarian option is available. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 14 A new chef has been employed at Pendean and residents spoken with were complimentary regarding the quality of meals available. It was stated that all vegetables are now fresh and purchased regularly and that all meals provided are now ‘home cooked’. Pendean Nursing Home DS0000002069.V351939.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to and acted upon. Residents are protected from harm through staff training, polices and procedures. EVIDENCE: The complaints procedure at Pendean was seen; this was displayed within the entrance and other areas of the home and included the 28-day timescale for response to complaints, and the previous contact information for the commission for social care inspection in Derby. Due to the closure of this office, this will now need to be amended to show the CSCI Nottingham office contact details. Pendean had received no complaints since the last key inspection. The commission had received one concern in August 07 and this was regarding the recruitment of two staff that had commenced work at Pendean without appropriate recruitment checks in place. The acting manager at that time confirmed this was the case and provided written confirmation within ten days that she had secured the appropriate recruitment information for these two staff. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 16 Residents spoken with said they had no complaints and said that they would speak to the staff if they did and residents felt confident that if they had any concerns they would be taken seriously by the staff team and dealt with. Information provided on the Training Matrix demonstrated that training in safeguarding adults (Adult Protection) had been undertaken by the staff team and was updated as required. The policy regarding safeguarding adults, titled “Protection of Vulnerable Adults Policy” was looked at and referred to the local authorities safeguarding adults’ policy. It was noted that the policy advised that ‘incidents concerned to be minor’ could be dealt with directly by the person in charge, although this policy advised that ‘if in doubt as to the seriousness of the alleged incident’ it should be reported immediately to the vulnerable adults coordinator at the local authority. (Social Services) It is recommended that as the local authority are the lead agency in investigating any safeguarding adults referrals this part of the policy be amended to advise that the Local Authorities safeguarding coordinator be contacted for all safeguarding referrals and investigations. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 17 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): 19,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Pendean provides a comfortable and attractive home for residents and good standards of hygiene are maintained. EVIDENCE: A requirement had been made at previous inspections regarding the review and replacement of carpets as necessary on stairs and in hallways. A tour of the building was undertaken to assess these areas and establish the works that had been undertaken regarding this requirement. All requirements regarding the review and replacement of carpets have now been met. And in addition to this several other bedrooms had new carpets and had been redecorated. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 18 At the last inspection some of the furniture and fittings seen appeared worn and in need of repair, this included curtains in one room that had partially come down and some of the furniture seen. These matters have now been addressed and new dining furniture and new curtains and bedding had been purchased. At the last inspection it was noted that the staircase within the new build part of the building had a low banister, and although this staircase was inaccessible to residents as it had locked gates at the top and bottom, the banister was accessible to residents on the first floor, which could be potentially hazardous to residents with behavioural problems or confusion. The homes administrator had stated that residents with such conditions were accommodated on the ground floor and therefore did not access this area. However it was recommended that a review of this area regarding the potential for harm to residents should be undertaken, to ensure residents’ safety was maintained. No changes had been made to this area and the homes administrator confirmed that no residents with confusion or dementia were accommodated on the first floor. Air sanitizers were in place throughout the building and no unpleasant odours were noted. At the last inspection visit, assessments had taken place that looked at the suitability of Yale locks for each individual, this included each resident’s preference as to whether they wished to use the locks or have the locks disabled. A requirement was made for an assessment to be undertaken for those residents who required and would be able to use alternative locking systems on their bedroom doors. The locking system (Yale) in place has been assessed and it was confirmed that these locks are to be removed and an alternative locking mechanism used. It was stated that locks will be changed five at a time and the priority will be for the most vulnerable residents to have their locks changed first. The laundry area was seen and provided sufficient equipment to ensure residents clothing could be laundered suitably and meet with disinfection standards. One member of staff was employed at Pendean on a full time basis to undertake laundry duties and one member of the care staff team covered the laundry for two shifts a week. These two staff were rostered on shift to ensure laundry services were available to residents seven days a week. Residents clothing appeared well laundered and residents spoken with said they were happy with the laundry services provided. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The skill mix and numbers of staff on duty enabled resident’s needs to be met. Staff receive the appropriate training to ensure residents safety and welfare is maintained, and the recruitment documentation in place ensures residents protection is further enhanced. EVIDENCE: At the time of this inspection visit there was twenty six people living at Pendean, staffing levels had therefore been reduced to reflect the numbers and needs of the resident group .The staffing rotas were looked at and demonstrated that staff were rostered on shift as follows; three to four care staff and one or two registered nurses were on shift in the mornings, three care staff and one registered nurse were on shift in the afternoon and at night two care staff and one qualified nurse were on duty. Although it was stated that the staffing levels in place exceed that of the recommended levels set by residential forum for care homes in older people, this should be the minimum staffing levels worked to. However there was no evidence to suggest that the staffing levels in place at the time of inspection were not sufficient and residents spoken with indicated that their needs were met by the numbers of staff on duty. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 20 Sixteen staff had achieved a National Vocational Qualification (NVQ) in Care at level 2 or above, three staff were undertaking NVQ training at level 2 and two staff had achieved an NVQ 3 in care, with five undertaking NVQ training at level 3 the time of this inspection. Three staff files were looked at to examine the recruitment documentation in place. Evidence included satisfactory criminal records bureau checks, POVA first checks, two satisfactory references, identification documents, medical health declaration forms, documentary evidence of relevant qualifications and training and details. Also in place were completed employment application forms. A staff-training matrix was in place, which demonstrated training that had taken place recently, this showed that all mandatory training was kept up to date. Sixteen members of staff had commenced a distance-learning course on dementia; the sixteen staff was a mixture of care staff, nurses and administration staff. This course was in its sixth week. Staff that were accessing this course stated that they were finding it very useful and providing them with a good knowledge base about dementia and the care of a person with dementia. Twenty-three staff had attended a fire-training course that had taken place over a four-day period and covered emergency evacuation procedures. Other training provided included pressure ulcer prevention and management, which was attended by seven staff. Eighteen members of staff had undertaken First Aid training, which ensured a qualified first aider was on duty at all time The guidance regarding care homes providing first aid has recently been amended and allows services to undertake a first aid risk assessment specific to their individual service. Information pertaining to the factors that can be taken into account and the criteria for who can be regarded as a qualified first aider were provided at this inspection visit. However if a risk assessment is not in place the Commission will require that someone who has undertaken a suitably approved first aid at work qualification be on duty at all times. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The interim management arrangements in place demonstrated that residents’ welfare was maintained and the health and safety of residents and staff was protected. EVIDENCE: At the time of inspection there was no manager in post at Pendean. Interim management arrangements were in place at Pendean. The business manager of the service provided management support. The business manager was based at Pendean for three days a week and was available by telephone for the remainder of the week if required. Support was also provided by the homes administration manager and the registered nurses on duty. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 22 It was confirmed that an advert has been placed in the local press for a new manager; this advert was seen and was specific in the criteria requested. Evidence was in place to demonstrate that both the business manager and the staff team have worked hard in improving the service for residents. Staff spoken with confirmed that they felt supported in their role and indicated that they had clear guidance in their day-to-day responsibilities. Satisfaction questionnaires were sent out to residents and their representatives on a three monthly basis, and the business manager confirmed that these would be audited and the results would be included in the annual service review report, along with any actions that had been taken as a result of the feedback received. The business manager had organised a residents/ relatives meetings but unfortunately there was a poor response to these, and evidence was seen to demonstrate this. Therefore the business manager had written to all residents’ representatives regarding this. The system for handling residents’ personal monies was examined and there was confirmation that there are suitable accounting procedures in place. The transaction records of the two residents case tracked were examined, and the figures recorded on the transaction records corresponded with the monies held for both of these residents. A requirement from previous inspections was that care staff should receive formal supervision. This was discussed with the business manager and it was confirmed that supervision planning was in process, and supervision forms had been developed. The qualified nurses were to provide supervision to care staff. Some of the safe working practices at Pendean were examined and found to be satisfactory, this included portable electrical appliance tests, waste disposal contract, bacteriology and legionnaires tests and service certificates for moving and handling equipment and gas and electrical wiring certificates. Records were seen that demonstrated that the maintenance person employed at Pendean undertook weekly checks on the fire alarm system, emergency lighting, fire extinguishers and hot water temperatures and a maintenance contract was in place for the fire alarm system, fire fighting equipment, emergency lighting and nurse call system. A fire risk assessment undertaken on 25th September 07 was in place, which demonstrated any risks identified and the fire safety measures that have been put in place to safeguard residents, staff and visitors of the home. Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 23 As stated in standards 27-30 eighteen members of staff had undertaken First Aid training, which demonstrates that the first aid measures in place were satisfactory. Pendean Nursing Home DS0000002069.V351939.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 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 X X X X 2 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 2 X 2 X 3 X X 3 Pendean Nursing Home DS0000002069.V351939.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 OP9 Regulation 13 (2) Requirement Timescale for action 01/05/08 2. OP9 13 (2) 3. OP24 13 (4) 12 (4) Care staff that administer creams and other external medication must have appropriate training. (Original timescale 30 May 2006, 30/08/06 and 30/11/06 and 31.05.07) Medication administration 01/01/08 records must be signed accurately following administration of medication. Alternative locking mechanism 01/05/08 must be in place on resident’s private accommodation when the present locking mechanism is assessed as unsuitable. A full time manager must be appointed and an application to register with the commission must be processed. The results and action taken following quality assurance surveys should be published and made available to residents and their relatives, staff and other interested parties. Care staff must receive formal supervision. Supervision plan to DS0000002069.V351939.R01.S.doc 4. OP31 9 01/02/08 5. OP33 24 01/05/08 6. OP36 18 (2) 01/02/08 Pendean Nursing Home Version 5.2 Page 26 be put in place. Previous timescale 30/10/06 and 31/07/07 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 OP12 OP18 Good Practice Recommendations Activities and social events offered to and undertaken by residents should be recorded by care staff at the end The Safeguarding Adults policy should be amended, to ensure that staff are aware of the best practice procedure to follow in the event of any safeguarding adults concerns, referrals or investigations. The banister on the staircase in the new build should be reviewed regarding any potential dangers to residents and action should be taken on any risks identified. Staffing levels should be continuously reviewed to reflect the dependency levels and personal needs of each resident. 3. OP19 4. OP27 Pendean Nursing Home DS0000002069.V351939.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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