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Inspection on 15/05/08 for Amberleigh Manor Care Home

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

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 home makes good efforts to provide appropriate social entrainment and activities for the people living there. The appointment of activities co-ordinator has assisted with this.There are good opportunities for family and friends to visit and maintain contact with their relatives. They is a good rapport between the care staff and people living at the home. The home has a well-qualified and competent staff team who have been working at the home for a long time. The home offers good training opportunities for the staff.

What has improved since the last inspection?

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Alfreton Derbyshire DE55 5JF Lead Inspector Nancy Bradley Unannounced Inspection 15th May 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V364563.R02.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 sheilagh_kelly@yahoo.com mskelley@myway.com Mr Mohinder Singh Kelley 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) 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.V364563.R02.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. 1st November 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 site visit are as follows: Residential £365.00 per week. Residential EMI £400.00 per week. EMI Nursing £520 per week. Nursing £500.00 per week. Expenses such as toiletries, chiropody, and hairdressing services were additional to the weekly fee. A price list was site visit ranged from £5. The current fee for a chiropodist visit was not available. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection and took place over a total of eight hours. We spoke with the acting manager, the administrator ,care staff and people living at the home. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since the last key inspection. This included the following: The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. We sent out “Have Your Say” questionnaires and we received four completed questionnaires from people living there who confirmed they were very happy at the home, they liked living there, had no complaints and were well looked after by the staff. At the time of this site visit the home had thirty-two people in residence. We received six completed questionnaires from care staff. All were happy working at the home, and made very positive comments about the acting manager. One staff member stated they help people in vulnerable situations and give them both practical and emotional support. What the service does well: The home makes good efforts to provide appropriate social entrainment and activities for the people living there. The appointment of activities co-ordinator has assisted with this. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 6 There are good opportunities for family and friends to visit and maintain contact with their relatives. They is a good rapport between the care staff and people living at the home. The home has a well-qualified and competent staff team who have been working at the home for a long time. The home offers good training opportunities for the staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pendean Nursing Home DS0000002069.V364563.R02.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.V364563.R02.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): Standards 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that peoples’ needs are fully assessed and met prior to admission. EVIDENCE: The care records of two people living at the home were looked at in detail, one of which was the most recent admission to the home. The majority of the people admitted to the home have their needs assessed through the care management system. The home currently has several people who are self funding and no care management assessment was available for them. Although there was evidence to show the home had undertaken their own assessment. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 9 These assessments addressed all areas of health, personal and social care with care plans being developed from the information provided. The homes care needs assessments had not always been signed or dated by the person undertaking the assessment. There was little evidence to show families of the people living at the home had been fully consulted regarding the placement. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some work has been undertaken in this area continuing inconsistencies in the care planning system and recording may compromise the service people living at the home receive. EVIDENCE: The care records of the two people seen, indicate that improvements had been made to the care planning documentation and other associated records. The information contained within the care plans and risk assessments provided detailed instructions to the staff team of how the peoples’ needs were to be met. Care plans appeared to be very clinical and impersonal, and seemed to be oriented towards a nursing perspective rather than a strictly social care approach. There needs to be a clearer distinction between nursing and the social aspect of residential care. Staff confirmed that the care plans were in place and provided sufficient detail for them to follow, and to enable them to met people’s needs. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 11 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 tissue viability. Each care plan seen was cross-referenced to a risk assessment. This demonstrated that all areas of support that had been identified and assessed. Risk assessments identified any areas of potential risk and show the appropriate actions required to reducing risk. Care plans and risk assessments seen had been completed and were reviewed on a monthly basis. However the level of recording did differ and in some instances “No change” was recorded. From records seen at this site visit people living at the home who were self-funding were not always being formally reviewed annually or six monthly. One person who was self- funding had not had their care formally reviewed since being admitted over three years previously. All monthly reviews are completed by a named nurse this includes both nursing and residential placements. From care records seen people living at the home or their relatives were not always signing care plans. Signatures are required to show their consent to the care they are receiving. Records of people’s weight was maintained according to assessed need. However there were gaps in some people weight records. As records were to monitor people increase or lose of weight this error was brought to the attention of the administrator. Records were kept of doctors’ visits, optician’s, dentist’s podiatry and hospital appointments. The nursing staff completed daily information sheets on all people living in the home. As with the reviews the level of information recorded did differ. Information was not always recorded on the appropriate forms. People spoken with and completed questionnaires were positive about the care and support provided by the staff team, and comments included “they look after us well, I cannot really complain about the care I get, its good”. People spoken with confirmed they had a good rapport with the staff working at the home. The medication administration practices of the service were assessed. Initially the medication administration records for the two people case tracked were checked. However in doing so errors were found in medication records. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 12 The nursing staff were not always signing peoples’ MAR sheets after medication had been administered. All of the medication administration records were then looked at and no further errors were noted. However it was noted and confirmed by the nurse on duty that the same tube of cream and bottle of laxative medication was used for all of the people living at the home. This was brought to the attention of the administrator Peoples’ photographs were in place on medication administration records confirming their identity. 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. At the time of this site visit only the nursing staff administer medication. Staff authorisation signatures for the administration of medication could not be found at the time of this site visit. Completed staff questionnaires indicated that several of the residential care staff would like to undertake medication-administration training. Pendean Nursing Home DS0000002069.V364563.R02.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 and 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 enables people living at the home to have choice and control in their lives, and maintains their wellbeing. EVIDENCE: The home has engaged a member of staff to arrange activities for the people living there. Discussions with the staff member highlighted difficulties with motivating some people to take part. The member of staff works for sixteen hours per week. Activities provided include included; table skittles, dominoes, soft netball, target games, snakes and ladders and card games and craftwork. Some of the craft and artwork undertaken by the people was seen The home has two DVD players and most of the people have a TV in their rooms. The activities coordinator stated that ‘musicals’ were a favourite with many of the people living at the home. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 14 The home organises trips out and photographs of these were displayed around the home. External entertainment is organised throughout the year. Church services are conducted at the home once a month, as none of the people living at the home is able to attend local church or religious services in the community. From observation and discussion with people at the home it is clear the home makes every effort to meet people’s social needs. The activities co coordinator is responsible for recording the daily activities on people’s care records. Visiting hours at Pendean were flexible and people living at the home are able to receive their visitors within the communal areas of the home or within their privacy of their own room which ever they preferred. People spoken with confirmed that their visitors were made welcome by the home. Any restriction on contact is clearly recorded in peoples’ care records. The people spoken with during the site visit were positive about living at the home. The daily routine is flexible and they were able to make decisions about how they spend their time during the day. People were seen moving freely around the home and engaged in whatever activity they choose to do. One person spoken with stated they went to bed and got up when they wanted and that the staff supported them with this. Information regarding local advocacy services and their contact details was advertised on the notice board within the corridor. This further enhances people’s personal autonomy and choice. The menus were not seen during this site visit, although the home did agreed to send details of these to us, at the time of writing this report we have not received them. A new chef has been employed at Pendean and people spoken with were complimentary regarding the quality of meals available. A concern had been raised with us about the quantity of the food available. We checked the food store and they were low on some food stocks. This was addressed with the administrator who stated that they had changed supplier and a delivery was due later in the day. The delivery arrived before we left. Pendean Nursing Home DS0000002069.V364563.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard peoples’ welfare and ensure that their concerns are listened to and acted upon. EVIDENCE: The home has its complaints procedure on display throughout the home giving information to both people living at the home their families and friends. The procedure contains the current contact details of the Commission for Social Care Inspection, as being the Derby office. The procedure informs the complainants that they are able to contact the Commission at any stage of the complaint if they wish to do so. Discussions with the care staff and minutes of residents’ meetings, confirmed that they are fully informed about the complaints procedure and would have no hesitation in putting their concerns to the manager. The Commission has received one formal complaint about the service since the last inspection. This was investigated under Derbyshire County Councils safeguarding procedures. The home has received no formal complaints from the people who live at the home. Although they are several concerns recorded which should have been looked at in a more pro-active way. This was discussed with the administrator who agreed to take this further. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 16 One person spoken with during the site visit and completed questionnaires we received confirmed that they would speak with the acting manager about their concerns. The home’s policy on protection was examined, although some work has been undertaken in this area the policy requires clarification. The policy needs to reflect the change to safeguarding and include contact details for the lead safeguarding agency. The administrator stated that the majority of the staff had completed training on protection of vulnerable adults however they are aware that further training on safeguarding is required. There has been one incident of safeguarding since the previous site visit. This is being investigated under Derbyshire County Councils Safeguarding procedures. Pendean Nursing Home DS0000002069.V364563.R02.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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and attractive environment which suits the people who live there and their needs Good standards of hygiene are maintained. EVIDENCE: We made a full tour of the building as issues regarding the environment had been raised within the complaint /safeguarding and to establish what work had been undertaken following a requirement made at the previous site visit. The requirement regarding new carpets had partially been met. The carpets had been ordered but not laid. New areas were identified during the tour of the home, mainly on upper stairs landing, this was stained and had lifted. During the visit new carpets were fitted to several of the rooms. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 18 The bathroom on the ground was of a different standard to the others in the home and is designated as needing refurbishment. Following the previous site visit several of the people living at the home have their own room key. People living at the home who wish to have their own key should be risk assessed and outcome recorded in their personal care plan The laundry area was seen and provided sufficient equipment to ensure people’s clothing could be laundered suitably and to meet with infection controls/ standards. People’s clothing appeared well laundered and they were happy with the laundry services provided. During the tour of the home the condition of the upstairs sluice was noted. There was a sign saying not in use and it had not been for a while in addition it was leaking. This was brought to the attention of the administrator who agreed to its immediate removal. Pendean Nursing Home DS0000002069.V364563.R02.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): 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. The skill mix and numbers of staff on duty enabled people’s needs to be met. Staff receive the appropriate training to ensure the safety and welfare is maintained, of the people living at the home. Recruitment procedures ensure further protection. EVIDENCE: During the visit a sample of staff rotas was examined that indicated the home was staffed according to the assessed needs of the people who live there. On the day we visited one registered general nurse, three senior carers, and two assistant carers were staffing the home. In addition the activities co-ordinator and ancillary staff were present. The AQAA indicated a good skills mix and a good percentage of staff holding either a NVQ level 3/ who work alongside qualified nursing staff. The home has a robust recruitment and section procedures are in place to protecting people. Staff recruitment is in line with Schedules 2 and 6 of the National Minimum Standard, Care Homes for Older People. As part of providing a full employment history applicants need to provide an accurate chronology of their employment history with the days date month and Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 20 year. From recent staff recruitment records examined, applicants were only providing the year in one instance. As discussed with the administrators when gaps in employment are investigated this should be fully explored and be formally recorded on interview minutes. The AQAA indicated 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. Information in the AQAA indicated that staff had attended various course relevant to the people they are caring for. Staff questionnaires returned indicated staff were pleased with the level of training offered. Pendean Nursing Home DS0000002069.V364563.R02.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): Standards 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well managed, with staff seeking the views from the people who live there. EVIDENCE: At the time of inspection there was no registered manager in post at the home with interim management arrangements in place. The home has informed us of the management structure. The business manager for the service provides management support with an acting manager having been appointed and a lead clinical nurse as the deputy manager. The business manager visits the home for three days a week and was available by telephone for the remainder of the week if required. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 22 Discussions with the business manager and the acting manager demonstrated they are working hard to improve the service for people living at the home. 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 people living at the home and their 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 first annual report will be published in July 2008. The acting manager is looking to reinstate residents/ relatives meetings as a way of obtaining peoples views. Records of personal monies for people living at the home are kept on computer, and on the day we visited the system was down and we were not able to check these records. No issues were identified at the previous site visit. 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. The AQAA indicated that that safe working practices were in place at the home. Records showed that portable electrical appliance tests, waste disposal contract, bacteriology and legionnaires tests, service certificates for moving and handling equipment and electrical wiring certificates were in place. The gas-heating certificate was out of date. 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. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 23 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 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 3 X X 2 X 2 Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement For people who are self- funding the home must consult more with families about the care they are offering. Care plans for people living at the home must be written in a way and format they can understand and signed by them or their representatives. Care plans must fully reflect the care people are receiving. All care plans for people living at the home must formally reviewed on a regular basis. This is especially important were there is no care manger and the person is self-funding. The home must ensure there are no gaps when recording information on people living at the home. Care staff that administer creams and other external medication must have appropriate training. This is a previous requirement. Medication administration records must be signed accurately following DS0000002069.V364563.R02.S.doc Timescale for action 31/07/08 2. OP7 15 31/07/08 3. 4. OP7 OP7 15 15 31/07/08 31/07/08 5. OP7 17 Schedule 3 13 (2) 31/07/08 6. OP9 31/07/08 7. OP9 13 (2) Schedule 3 31/07/08 Pendean Nursing Home Version 5.2 Page 25 administration of medication. This is a previous requirement. 8. OP9 13 The home must maintain an updated list of names of staff that are authorised to administer medication. This must be available at times. The complaints procedure must be up dated to show the current contact details of the Commission for Social Care Inspection. People living at he home must have their concerns fully recorded and fully. This includes formal and informal concerns. The homes policy on adult protection must fully reflect the change to safeguarding and make reference to local procedures. All staff must update their training on protection to include the safeguarding of adults. Risk assessments must be undertaken on people who wish to have a key to their room and recorded in their care plan. A full time manager must be appointed and an application to register with the commission must be processed. This is a previous requirement. Records of people monies must be available at all times for inspection. Care staff must receive formal supervision. Supervision plan to be put in place. This is a previous requirement The home must have a valid and current certificate for the gas heating system. 31/07/08 9. OP16 22 31/07/08 10. OP16 22 31/07/08 11. OP18 13 31/07/08 12. 13. OP18 OP7 OP19 13 13 31/10/08 31/07/08 14. OP31 9 31/07/08 15. 16. OP35 OP36 16, 17, Schedule 4 18 (2) 31/07/08 31/10/08 17. OP38 23 31/07/08 Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 26 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. 3. 4. 5. Refer to Standard OP3 OP7 OP16 OP19 OP29 Good Practice Recommendations All care needs assessment should be signed and dated by the person undertaking the assessment. The home should develop a uniform style of recording in people care records. Staff should have training on how to record and investigate informal complaints. The home should continue with its planned refurbishment home. In particular the areas identified in the main body of the report. As part of providing a full employment history applicants should provided the days date, mouth and year. Pendean Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Nursing Home DS0000002069.V364563.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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