Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 13/09/05 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 13th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report 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 manager has a great deal of experience and has worked at the home for some time. The manager as well as the office support worker are clearly dedicated to their role. There is a strong staff team that work well together. Several staff have also worked at the home for some time. Medication is well managed, with safe systems in place. It was evident from observations that staff knew the residents well. Activities, especially outings were greatly appreciated by some of the residents. The home is above the target of 50% care staff achieving NVQ 2 Care qualification.

What has improved since the last inspection?

Since the last inspection the registered persons have developed written terms and conditions for all residents. Bedroom doors have been fitted with locks, although they were not locks recommended by the fire service. All staff have received one day training in dementia care since the last inspection.

What the care home could do better:

The home is in need of upgrading and renewal, with a particular need for replacement carpets, up grading of bathrooms and hoisting equipment, and bedroom furniture. The maintenance hours have been substantially reduced and this has meant inadequate decorating taking place around the home. There were also several issues concerning maintenance that had not been dealt with, including broken bathroom locks and damaged radiator covers. The registered providers were asked after the last inspection to provide a written programme for the upgrading and renewal of the home detailing timescales for achievement. This has not been undertaken. The providers were also not meeting the requirement to complete a monthly report concerning the home, evidencing that they have inspected the premises and talked with staff and residents in order to ascertain the quality of the environment and care provided. The above issues will be addressed separately with the registered providers. Staff had not undertaken infection control training, even though this has been highlighted at the previous two inspections. Although an activities programme takes place, there was inadequate stimulation for residents unable to take part in the activities planned.

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Derbyshire DE55 5JF Lead Inspector Jill Wells Unannounced 13 September 2005, 10.00am th 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 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 C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pendean Nursing Home Address Primrose Hill Blackwell Derbyshire DE55 5JF 01773 860288 01773 860288 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr & Mrs Kelley Lynn Armstrong Care Home with Nursing 40 Category(ies) of 33 - Old Age registration, with number 7 - Dementia Over 65 of places Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1.Registered person will only admit up to those service users category DE, E. 2.No more than seven DE E service users will be accommodated in the designated areas identified for accommodating this category of service user only. 3. Staff must receive suitable training in the care needs of those service users with dementia. 4. There must be at least one staff member who is suitably trained to meet the needs of those service users with dementia on duty on each shift and allocated to the care of that client group. 5.Specialist dementia advice and training must be provided on an ongoing basis by a Registered Mental Nurse (RMN) employed in the home. Date of last inspection 7th March 2005 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 accommodation-measuring 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. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a 6.5 hour period. During the inspection five residents and three staff were spoken to. Documents were inspected including residents records and information provided for residents and relatives. A full tour of the building was undertaken. Time was also spent with the registered manager and secretary. What the service does well: What has improved since the last inspection? Since the last inspection the registered persons have developed written terms and conditions for all residents. Bedroom doors have been fitted with locks, although they were not locks recommended by the fire service. All staff have received one day training in dementia care since the last inspection. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 6 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. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 Information provided for residents and their relatives/representatives were available but out of date and in some cases inaccurate. A new contract had been devised for all residents, that meets the standards required. Adequate information was not made obtained from the relevant Social Services staff when new residents were admitted. EVIDENCE: The statement of purpose for the home was displayed in the entrance hall. However this needed to be revised as some information was not up to date. There were inaccuracies within the statement of purpose. This included information within the document that there was one assisted bath to eight service users which met by the minimum standards. This was not the case. Room sizes had been included within the statement of purpose. The service user guide included a glossy brochure as well as the information within the statement of purpose. The service user guide also required revision. The manager stated that all residents or their relatives/representatives received a service user guide. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 9 Since the last inspection new contract/terms and conditions had been created to ensure that all residents, including social services funding residents received the homes terms and conditions. This document met the requirements. Four residents care records were checked during the inspection. They had documented needs assessments completed by the home. The residents that were funded by Social Services did not have an assessment or copy of the nursing care assessment as required for the purposes of admission to the home via care management arrangements. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Service user plans were in place but needed some improvement. Residents healthcare needs were being met. Medication storage, administration and recording was in good order. EVIDENCE: Four residents care plans were checked as part of case tracking methodology used. They were generally of a good standard and evidenced reviews, although this was not on a monthly basis. The residents plans could be improved by including aspects of individuals needs that had been met or partly met by the resident and needed to be encouraged in order to promote independence. There was little information within the plans to include stimulation. This was particularly the case with service users diagnosed with dementia. There were recognised tools used for the assessment of risk in relation to nutrition, pressure ulcers, moving and handling and falls prevention. Nurses and care staff spoken with were familiar with the personal care needs of the residents that they cared for. Record showed that residents were registered with the GP and there was evidence of regular access to outside health care professionals for example opticians, chiropodist and dentists. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 11 Medication procedures and practices were inspected and found to be in good order. The manager stated that the pharmacy used by the home undertook three monthly audits and gave advice when required. There was a separate medication room and medication was stored securely. Medication administration records were well kept. Controlled drugs and relevant records were checked and found to be in order. There was an up-to-date British National Formulary to ensure that staff had up-to-date information concerning drugs. The manager was in the process of setting up a contract in order to dispose of drugs no longer required, using the new guidelines. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Some but not all service users needs were met concerning social interests and stimulation. Service users receive a wholesome balanced diet. EVIDENCE: Two care staff had responsibility for activities organised within the home. Activities included nail care, weaving, skittles, cards, dominos, and sit down football and netball. There was also regular hairdresser visits and the availability of a shop to purchase sweets and toiletries. Activities were generally organised in the afternoon. There was a list displayed in the entrance hall of outings that had been organised using a community transport mini bus. These included a trip to the zoo, and a boat trip later in September. The home had also had a summer fayre earlier in the year. Although there were records of activities planned within the home, these had not been recorded or displayed since the 1st August. It was explained that this was because staff had been busy organising the summer fayre. On discussion with the activities co-ordinator it was of concern that there were few activities arranged to meet the needs of residents with dementia. The activities coordinator would benefit from specific training around activities and stimulation for people with dementia. Records were not being kept of who had been involved or offered the opportunity to take part in the organised Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 13 activities. There was not evidence of other forms of stimulation for residents unable or reluctant to take part in planned activities. Three meals a day were provided. The lunchtime meal was a cooked meal. The menu for the day was displayed within the home. There was not a choice stated on the menu, although the manager explained that any service users that did not wish to have the main meal would be offered an alternative. Hot and cold drinks were regularly provided. Staff were available to offer assistance with eating where necessary. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 There was a clear complaints procedure for residents and relatives to use. EVIDENCE: The complaints procedure was displayed in the entrance hall. It was also stated in the service user guide and statement of purpose. It was noted that these documents stated the address of the Commission for Social Care Inspection (CSCI) but there was no telephone number. The number was written on the main notice in the entrance hall at the time of the inspection, but was still required on the other documents. There had been no complaints since the last inspection. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 The environment was not well maintained, was in need of urgent decorating and refurbishment and did not fully meet the needs of all service users. EVIDENCE: A tour of the building was undertaken. The main entrance door was locked and alarmed. Visitors were encouraged to sign in and out. There was a payphone in the entrance hall. The layout of the home was suitable for its stated purpose, it was accessible and generally well maintained. However there were some maintenance issues highlighted at the inspection that had not been passed to the maintenance person. It was of concern that the maintenance person was working for 18 hours per week, where previously there had been 40 hours per week dedicated to maintaining the home. This reduction in hours was particularly reflected in the decoration of the home, which in some parts was badly needed. At the last inspection there had been a requirement for a written programme to be provided for the upgrading and renewal of the home detailing timescales for achievement. This included replacement of bedroom furniture, replacement Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 16 of carpets as necessary, and upgrading of bathrooms including hoisting equipment. The timescale for this was 31 May 2005. A written programme had not been produced. From inspecting the home it was now evident that upgrading and renewal in these areas were urgently required. Of particular concern were the carpets in the lounge areas, stairs and hallway which were dirty and worn. The dining chairs were not suitable for the residents as they were very heavily and difficult to clean. Since the last inspection locks had been placed on bedroom doors. These were not of the type recommended by the fire service. There would be a concern regarding the deadlock facility, and immediate access to residents locked in bedrooms. However the manager stated that all staff have bedroom keys with them at all times. There were several lounge areas within the home. One area was on the first floor but was infrequently used. A call system had been placed in this room since the last inspection. Although there were designated bedrooms for seven residents with dementia that the home are registered to accept, there was not designated communal space for these residents. Residents are encouraged to use any communal area. The radiator cover on the far lounge was damaged. The carpets in this room was in need of replacement, and was uneven due to the carpets been fitted over an existing carpet. There was damage to walls and door areas caused by wheelchairs. The main lounge area had a designated place for residents to smoke. At the time of inspection there was only one resident that smoked. Lighting in communal rooms were sufficiently bright and domestic in character. Furnishings of communal rooms were domestic in character, however some furniture was not of a high quality and was worn and easy to mark as they were made from velour type material. Toilets were clearly marked, and close to communal areas. It was of concern that there were only two assisted bathing facilities for 40 residents. There had previously been a third assisted bath, but this was no longer in use. The bath hoisting equipment provided was the older hand mechanised type. At the last inspection it was highlighted that a bathroom was being used for storage purposes and was inaccessible for use as a bathroom. Bedding and other potentially flammable items were stored in this room. There had been no change in the situation. Bathroom 101 had a broken lock. There was a small hole in the ceiling in bathroom 107 after the roof had leaked. The toilet 108 had a door that would not close correctly. There was no lock on the door of bathroom 111. Cleaning solutions were seen unattended in a bathroom area. This was removed by the manager at the time. This was highlighted at a previous inspection. Although the cleaning containers now had a label stating the chemical within the container, there were not instructions on these containers of action to be taken if misuse or an accident occurs. There were two sluice rooms at the home. Only one of these rooms was kept locked. The second sluice room only had an alarm system in place. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 17 A second stand aid (mobility aid) had been purchased since the last inspection. The manager had attempted to obtain a new loop system suitable for the needs of residents, and this work was still in progress. There were a number of environmental adaptations including a shaft lift, grab rails and raised toilet seats in toilet areas. There were two shared bedrooms which were less than 16 square metres, although one was being used as a single room. Some parts of the home were not well cleaned, including toilet and bathroom areas where dirt and dust was seen in corners, behind doors and around the base of toilets. The manager has recently had difficulty recruiting domestic staff. At the time of the inspection there were 45 domestic hours vacant. Several bedrooms were inspected. Much of the furniture was very old and in need of replacement including wardrobes and chests of drawers. This had been highlighted at the previous inspection, however no action has been taken by the providers. Several of the rooms inspected had a mismatch of carpets, decorating, curtains and bedding. Lockable storage facilities were provided in all bedrooms. At the previous inspection it had been highlighted that adjustable height beds had not been provided for all service users receiving nursing care. The manager stated that there were still two residents requiring adjustable height beds. Several beds were of the divan type. This was causing great difficulty when moving and handling equipment was required. An example was given where a resident had to be moved down to the bottom of their bed using a slide sheet in order for staff to use a stand aid hoist, as the equipment would not go under the divan at the side of the bed. This was not acceptable practice. Rooms were individually and naturally ventilated. Rooms were centrally heated. The extension of the building had a heating system where the heating had to be on in order to obtain hot water. This at times cause difficulties for staff trying to regulate rooms at an appropriate temperature. Water was stored at 60°C and distributed at 50°C to prevent risks from legionella. Preset valves were fitted on bath taps to provide water at no hotter than 43°C. It was stated that these temperatures were regularly checked. The laundry facilities were not inspected on this occasion. Two mechanical sluicing disinfectors were provided in the home. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 30 Staff numbers, training and skill mix generally met the needs of residents at the home. EVIDENCE: Records of staff duty rotas were examined. There were generally two nurses on duty and four or five care staff in the day. There was one qualified nurse and four care staff on duty at night. Agency staff were being used, particularly to cover some night shifts due to vacancies, although the manager had recently recruited to these vacancies and was waiting for new staff to start. There was one registered mental nurse (RMN) employed by the home as a condition of registration. As stated previously there were 45 hours per week domestic hours vacant. The office support worker worked alongside the manager four days per week. Kitchen hours were not inspected on this occasion. There were 22 care staff employed at the home.10 care staff had achieved NVQ 2 Care, and three had almost completed. One care assistant had achieved NVQ 3 Care. The manager stated that all staff had undertaken a minimum one day specialist dementia training which was a condition of registration. As stated previously staff, particularly the activities co-ordinators would benefit from training in how to stimulate and organise activities for residents with dementia. Since the last inspection the manager had attempted to access an induction programme that complied with identified sector skills requirements. This had not been successful, however further information was provided to the manager. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 19 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 and 38 There is an experienced and committed manager at the home, who encourages an atmosphere of openness amongst staff, residents and relatives. EVIDENCE: The registered manager was a qualified nurse, and had many years experience within a hospital setting as well as managing homes. The manager was in the process of undertaking NVQ 4 Management, and expected to have completed this by the end of 2005. Staff and residents that were spoken to thought highly of the manager, stating that she was approachable and firm but fair. Staff appreciated the way that she would get involved with all aspects of the home and support staff as required. It was stated that staff meetings and residents meetings take place, however minutes were not inspected on this occasion.The manager regularly worked on rota with other nurses and care staff. Although this was good practice regarding keeping up-to-date and being aware of the practices within the home, she will need to ensure that the amount of shifts undertaken did not compromise her role as registered manager. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 21 There were clear lines of accountability within the home. The registered providers visited the home on a regular basis, although it was stated that they spend little time talking with residents. At the last inspection an immediate requirement and serious concerns letter was sent regarding the requirement of a monthly report to be completed by the registered providers. This requirement was still not met. The provider will be written to concerning this matter. The requirements not met from the previous inspection are the responsibility of the registered provider. The registration certificate was displayed in the entrance hall, as was the insurance certificate for employers liability. It was of concern that individual records situated in the nurses station were not secure. A recent incident involved a confused resident that damaged records. Mandatory training records were not specifically inspected on this occasion, although staff spoken to stated that they had received all up-to-date mandatory training apart from infection control. As stated previously the manager needs to ensure safe storage and labelling of hazardous substances. Windows had restrictors in place to ensure safety. Safe working practice risk assessments and accident records will be inspected during the next visit. Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 2 1 2 2 1 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 2 x x x 1 2 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 16(2) (c) Requirement Timescale for action 30th November 2005 2. 33 26 3. 24 12(4)(a) Adjustable height beds must be provided for service users receiving nursing care in accordance with assessed needs. Original timescale was to complete a rolling programme by 31 August 2005 Immediate The registered persons must undertake unannounced monthly visits to the home in accordance with the criteria set out within regulation 26 of the care homes regulations, including the provision of a written report, that must be provided to the Commission and the registered manager. This will be raised separately with the registered persons as an immediate requirement and serious concerns letter has already been sent concerning this matter. There must be written risk 30 October assessments concerning the use 2005 of the Yale type locks provided on all bedrooms, that have not been approved by the Fire Officer. The risk assessment must include risks concerning fire, access to residents in an Version 1.40 Page 24 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc 4. 38 13(3) 5. 1 4(1) (c) Schedule 1 6. 19 23(2) (b) (c) emergency, as well as independence and privacy. Infection control training must be provided for all staff. Original timescale January 2004 and June 2005 The registered person must not provide accommodation to any service users unless the needs of the service user has been assessed and the registered person has obtained a copy of this assessment, including copies of the care management assessment and nursing assessment where relevant. The registered person must confirm in writing to the service user, (or representative as applicable), that having regard to the assessment, the care home is suitable for the purpose of meeting the service users needs in respect of their health and welfare. Original timescale 31 May 2005 A written programme must be provided for the upgrading and renewal of the home, detailing timescales for achievement, which includes:review and replacement of bedroom furniture. Review and replacement of carpets as necessary, in particular two lounge areas, stairs and hallway. Review and upgrading all bathrooms including hoisting equipment. Previous timescale for written programme 31 May 2005. The dining furniture requires renewal as it is not suitable for residents living at the home. This issue is to be raised separately in writing to the registered persons. 30 November 2005 30 October 2005 13th October 2005 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 25 7. 21 23(2) (j and (l) 8. 38 13(4) (a) and (c 9. 1 4 and 5 10. 7 15 11. 12 16(2) (m) (n) Bathrooms must be accessible to service users and sufficient numbers provided. Suitable provision must be made for storage in the home. Original timescale 31 May 2005 This issue is to be raised separately in writing to the registered persons. Cleaning solutions must be stored in properly labelled containers in suitably locked cupboards. The labels must include action to be taken if the solution is misused or an accident occurs. The statement of purpose and service user guide must be revised to ensure that it is accurate and up-to-date. The service user plan must include in detail the action which needs to be taken by staff to ensure that all aspects of individuals health, personal and social care needs are met. This must include dietary preferences social interests, stimulation and ways that staff need to promote individuals independence. Care plans must be reviewed on a monthly basis. Activities and stimulation must be reviewed to ensure that they meet the needs of residents with dementia or residents who are otherwise unable to access activities organised. The activities coordinator must be provided with adequate training in order to assist them to meet all residents needs. Activities organised within the home must be advertised. There should be a record of activities and stimulation provided or offered for individual residents. 30 January 2005 30 September 2005 30th October 2005 30 November 2005 30 November 2005 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 26 12. 16 22 13. 19 23(2) 14. 19 23(2) 15. 16. 17. 18. 26 22 26 23 13(4) 23(2) (n) 23(2) 23(2) (n 16(2) (c) 23(2) (p) Documents stating the homes complaints procedure must include the telephone number of the Commission for Social Care Inspection. The registered provider must ensure that all parts of the home are adequately decorated. A programme must be made available to CSCI of decorating work planned. Registered provider must ensure that all parts of the home are adequately maintained. This includes the damaged radiator cover in the far lounge, rubber seal coming off windows, small hole in bathroom 107 ceiling, toilet 108 door that will not close, bedroom 28 radiator cover off/loose, no lock on bathroom 111 and damage in lounge area caused by a wheelchair usage. The sluice room must be locked for safety of residents. A loop system must be provided for the benefit of residents using hearing aids. All parts of the home must be clean at all times. The registered provider must ensure that all beds provided allow use of appropriate mobility aids. The heating and hot water system must allow for suitable control of heating system, ensuring that heating is always at a comfortable level and hot is water available All records, including residents records in nurses station must be secure at all times. 30 October 2005 Programme to be sent by 13 November 2005 30 October 2005 30 September 2005 30 December 2005 30 September 2005 30th December 2005 30 January 2006 19. 25 20. 37 17 30th October 2005 Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 27 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. Refer to Standard Good Practice Recommendations Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road, Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pendean Nursing Home C02 C52 S2069 Pendean Nursing Home V243185 220805 Stage 4.doc Version 1.40 Page 29 - 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!