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Inspection on 02/05/06 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 2nd May 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

It was evident from observations and talking with staff and residents that staff were committed to the residents and cared for them,as well as about them. Both the manager and staff were aware that there were shortfalls at the home, but were keen to improve and develop the service to a good standard. Staff were keen to attend the training that was planned. Residents and visitors spoken with said that the care at the home was very good. One person spoken with said that, "this is not a posh home, and things need renewing, but the care is excellent".

What has improved since the last inspection?

The manager has recently been appointed and was aware that there were a significant amount of issues that need addressing in order to ensure that the home meets the minimum standards. The manager had already taken steps to improve the service. This includes a substantial programme of training for staff and discussions and plans with the owners concerning upgrading the environment. Additional adjustable height beds had been purchased for residents that require nursing care, new commodes have been purchased and carpets have been purchased and were due to be fitted in the communal areas. There was now a choice at mealtimes which is greatly appreciated by residents that were spoken with. Additional moving and handling equipment has recently been purchased in order to assist staff with safe moving and handling of residents. Activities provided at the home have increased with the implementation of an additional 12 hours per week where two care staff have dedicated time to provide activities. Regular monthly outings were planned. Since the manager has been in post she has highlighted some potential institutionalised practice and has ensured that this no longer occurs. New recording systems for care planning have been implemented, although more work is required in this area.

What the care home could do better:

The environment continues to be in need of significant upgrading, renewal and redecoration. This has been an issue for some time., a comment from a resident was that, "the wardrobe is terrible, my drawers don`t open properly" and, "my carpet is thread bare" This inspection has highlighted that the provider had started to consider these issues and make money available for this, although a great deal of work is still required. There have been shortfalls in the training of staff for some time. The new manager has now devised a training plan that will hopefully address the shortfall. The home has several conditions of their registration that had not been met. This includes staff receiving training in caring for residents with dementia. The homes registration only allows for up to seven residents whose primary need is dementia to reside at the home. This number may have been increased, the manager is to review the situation and report to CSCI.

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Derbyshire DE55 5JF Lead Inspector Jill Wells Key Unannounced Inspection 2nd May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 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.V292412.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pendean Nursing Home Address Primrose Hill Blackwell Derbyshire DE55 5JF 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) 01773 860288 01773 860288 mskelley@myway.com Mr & Mrs 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.V292412.R01.S.doc Version 5.1 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. 27th February 2006 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 are between £313- £479.80 depending on the category of resident. Residents that are self funding are charged between £340- £360 negotiable free nursing care charge for residents that require nursing care. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place over a 7.5 hour period. During this time residents visitors and staff were spoken with in private. There was an inspection of the premises. Time was spent with the manager and records were checked including four residents’ files as part of the case tracking methodology used. Pre-inspection information received from the manager was also used and will be reflected within the report. What the service does well: What has improved since the last inspection? The manager has recently been appointed and was aware that there were a significant amount of issues that need addressing in order to ensure that the home meets the minimum standards. The manager had already taken steps to improve the service. This includes a substantial programme of training for staff and discussions and plans with the owners concerning upgrading the environment. Additional adjustable height beds had been purchased for residents that require nursing care, new commodes have been purchased and carpets have been purchased and were due to be fitted in the communal areas. There was now a choice at mealtimes which is greatly appreciated by residents that were spoken with. Additional moving and handling equipment has recently Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 6 been purchased in order to assist staff with safe moving and handling of residents. Activities provided at the home have increased with the implementation of an additional 12 hours per week where two care staff have dedicated time to provide activities. Regular monthly outings were planned. Since the manager has been in post she has highlighted some potential institutionalised practice and has ensured that this no longer occurs. New recording systems for care planning have been implemented, although more work is required in this area. 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 DS0000002069.V292412.R01.S.doc Version 5.1 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.V292412.R01.S.doc Version 5.1 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 the following standard(s): 1, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents have most of information that they need in order to make an informed choice about the home. EVIDENCE: The home had a revised statement of purpose and service user guide. The statement of purpose gave information concerning the registered provider and the manager as well as the care team. There were details of the admission criteria and emergency admission criteria. The statement of purpose and service user guide did not include the homes complaints procedure, although it did give the address of CSCI. The statement of purpose did not clearly set out the physical environmental standards as required. These documents were in large print and were available for residents and prospective residents. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 9 Four residents files were seen as part of the case tracking methods used. Each resident had received a full needs assessment, completed by a care manager from Social Services before they were admitted to the home. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care of residents was generally well met. Recording and care planning has improved although this still requires further development in order to ensure that all aspects of individuals care needs are met. EVIDENCE: The new manager had introduced new documentation for care planning. Staff had just completed the task of transferring the information onto the new documents. The care plans that were seen did not set out in detail the action that needs to be taken by care staff to ensure that all aspects of individuals’ health, personal and social care needs were met. Examples were one resident that enjoyed watching and discussing sport and playing cards and dominos. This information was not recorded on the social care plan. One residents care plan stated that they required one carer to assist with washing and dressing, however the resident and staff confirmed that the resident was able to dress without assistance. It was evident that care plans were being written without Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 11 the involvement of residents or relatives. Care plans were not signed by service users or their representatives. There were records in place showing that relevant health professionals were contacted when appropriate including GPs, dentists and chiropodists. One residents spoken with said that they felt that staff supported them before and after their cataract operation. Pre-inspection information stated that there were no residents with pressure sores at the time of the inspection visit. Nutritional screening was undertaken and weight gain or loss was monitored. One resident had been referred to a dietician due to weight loss. New pressure relieving mattress had been provided and new hoist and slings have been purchased. New commodes had also been purchased. There were generally moving and handling risk assessments and plans in residents’ files, although one residents moving and handling plan was blank. One resident had recently had a review that was chaired by the care manager from Social Services where a behaviour chart was requested. The behaviour recorded indicated that staff may benefit from training in dealing with aggression. Some staff spoken with said that they did not always feel confident when dealing with a resident with aggressive behaviour. Residents’ risks of falls were assessed and any residents at high risk were advised to purchase hip protectors via their families where relevant. Several residents spoken with were wearing them. Although the medication systems were not specifically inspected, the weekly and monthly audits completed by a senior nurse and manager were inspected. These audits were thorough and highlighted that action was taken if any issues were raised as a result of the audits. Staff were observed treating residents with dignity, particularly in the areas of personal care giving. A GP visited the home during the inspection visit and staff took the resident to a private area for the consultation. The manager had recently worked hard to ensure that any potential institutionalisation was removed. An example was the practice of staff queueing residents for the toilet after mealtimes, which has now ceased. One staff member said that, we think more now about what we do and how we do it. One resident at the home first language was not English. Their care plan reflected that the home had highlighted a staff member that had an understanding of the residents cultural and language needs and this worker supported the resident when on duty. Staff were recording daily log entries for each service user. However some staff were not recording, but were merely writing the date time and signing the log. This was not good practice. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities and meals provided had both improved, therefore improving residents’ quality of life EVIDENCE: There were set routines throughout the day, including set mealtimes, however staff were observed trying to be flexible for example offering a resident their meal at a later time as they were not hungry. Staff were observed being very patient in some difficult situations. One resident said that, the staff are wonderful. The homes activities programme had improved since the last inspection visit. There were now two care staff responsible for organising activities for 12 hours per week. Several residents spoken with were looking forward to the outings that were planned. The staff were enthusiastic and had some good ideas, however they were unsure how to provide adequate stimulation for residents with dementia. Residents could choose whether they wished to take part in the activities that were planned. Staff record activities that have taken place, and the notice board advertises planned activities. This includes basket weaving, netball, nail painting, hairdresser, DVDs, foot spa, listening to music and Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 13 reading newspapers. The home had recently organised an Easter party and the celebration of the Queens 80th birthday. Trips were arranged on a monthly basis using community transport. There was little evidence in care plans as to how individuals’ religious needs could be met where relevant. Menus provided showed that there was now a choice at mealtimes. Staff were observed asking residents individually their preferred choice for the following day. Several residents commented that this was a big improvement and much appreciated. At the time of the inspection visit there was not a choice as the cook had been off sick for several days. The manager informed the kitchen staff that this was not acceptable. Several staff had recently attended training on nutrition. This had provided them with useful information concerning supplementing older peoples diet and providing more appropriate liquidised meals were required. Staff spoken with the said that the training had helped them in their work. Several visitors were at the home at the time of the inspection visit. They said that they felt welcomed at the home and knew that they could visit at any reasonable time. Visitors spoken with felt that the care staff cared about the residents. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 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 the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints were thoroughly investigated. The homes written policies and procedures and training concerning protection of vulnerable adults did not ensure that residents were safeguarded. EVIDENCE: There was a complaints procedure displayed at the home. There had been two complaints received by the home. These complaints were received via CSCI and Social Services. Both were responded to within 28 days, and investigated thoroughly. One was substantiated and the second was partly substantiated. The manager had taken steps to improve the service as a result of the complaints received. There was not a system to ensure that residents can understand the complaints procedure and feel confident to use it. Examples were residents that would be unable to read the written complaints procedure had not had procedure read and explained to them. The training records showed that staff had not undertaken protection of vulnerable adults training. One worker spoken with was not aware of a whistle blowing policy. The homes adult protection and prevention of abuse policy was dated 1998 and had not been reviewed. It was therefore unlikely to include the Department of Health guidance ‘No Secrets’ and the Protection of Vulnerable Adults register information. However the manager had spent time talking with Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 15 staff about abuse including institutional abuse. CSCI were not aware of any allegations or incidents of abuse at the home. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment was not meeting the needs of residents at the home. EVIDENCE: There have been a number of issues highlighted at previous inspection visits concerning upgrading of the environment. The timescales set for compliance concerning the physical environment of the home have not been met however an action plan with timescales has now been received by the home. Additional information with timescales was received from the manager at the time of the inspection visit. These were that carpets to be replaced in lounge areas by the end of May, 5 bedrooms per month to be upgraded from June onwards, dining furniture to be replaced by September 06 and bathrooms to be refurbished by end Dec 06. A resident and relative commented about the poor state of furniture in bedrooms. Comments included, the wardrobe is terrible, my drawers dont open properly and, my carpet is thread bare The manager has said that a painter and decorator has been organised to work at the home. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 17 Adjustable height beds for residents that receive nursing care had been purchased. New linen had also been ordered. The manager was advised that residents should be involved in consultation concerning colours schemes etc where possible. Since the last inspection visit there has been a safety gate placed at the bottom of the staircase and safety gate to the step by the dry store. This has improved safety at the home. The manager was planning to change the far lounge into a dining room area. Consideration is also being given to converting a bathroom into a hairdressing room. This change will need to be agreed formally by CSCI. A complainant highlighted the issue of locks on bedroom doors where a resident was unable to open the door without assistance. The lock situation was reviewed at the inspection visit. It was of concern that some Yale locks were not pinned back in a resident’s room that was very confused. This could potentially be used as a form of restraint when the resident is in their room as a resident would be unable to work out how to open the door. Some residents would have a loss of independence due to being unable to manipulate the Yale lock and the door handle at the same time. There were six bathrooms at the home and an additional three toilets. These required up grading and decorating. There were three lounge areas that were connected on the ground floor. These areas were used for dining at mealtimes. Some of the furniture within these rooms were not appropriate, and it had been previously highlighted that the dining room furniture required replacement. A member of staff said that the furniture was very difficult to clean, especially as several residents had their meals sat in the lounge chairs. There continued to be a lack of storage at the home, particularly for wheelchairs and hoisting equipment. Wheelchairs were stored in the hallway, which could be a hazard for residents. Although the premises were generally clean, there were offensive odours in parts of the home. The laundry facilities were not inspected on this occasion. Several comments were received from residents and visitors concerning lost laundry and on occasions residents being dressed in other peoples clothes. Recent review notes of one resident stated that 12 pairs of labelled socks had gone missing. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs were met by the numbers of staff on duty. Further work was required to ensure that staff were suitably trained in order to meet the needs of residents. EVIDENCE: Staff rotas were inspected. At the time of the inspection visit there were 7 staff on duty. 20 residents required nursing care. Rotas showed that there were generally two nurses on duty in the morning and one or two nurses in the afternoon. There was always one nurse on duty at night. The care staff rotas showed that there were generally six care staff on duty in the morning and five or six care staff on duty in the afternoon. Staffing had increased since the last inspection visit as a result of immediate requirements issued. Staff spoken with said that this had made a significant difference to the care provided to residents. Observations of staff evidenced that the number of staff on duty at the time of the inspection was meeting the needs of residents and residents were well supervised. A condition of the homes registration was that they can provide a service for up to 7 residents whose primary need is dementia. The manager was concerned that there may be more than 7 residents admitted to the home with this primary need. She plans to undertake a review of all residents, checking their original assessments and what was their primary need at the time of admission to the home. The manager had recently recruited two registered Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 19 mental nurses.(RMN) to support the needs of residents with dementia. A number of additional new staff have been appointed since the last inspection visit, this includes nurses, care assistants and ancillary staff. It was however of concern that the majority of staff had not undertaken dementia training as this was a condition of their registration. A training record/plan was provided. This showed that some training had been undertaken although more was required in order to meet the requirements and needs of residents. The manager stated that a significant amount of training was booked or planned between May/September 06. The service had not met the requirement of 50 staff trained to minimum NVQ level 2 by 2005. However the new manager was in the process of registering most care staff onto and NVQ 2 Care course. The induction programme presently used for new staff did not meet the requirements, although it was a detailed in house induction. The new manager had recently purchased an induction programme and was planning to start new staff on this programme. Three staff files were seen. Completed application forms, medical questionnaires and two references were in place. Criminal record bureau checks had been applied for but not always obtained before new staff commenced work. The manager stated that she had undertaken protection of vulnerable adults (POVA 1st) checks, but these were not available at the home. Staff had not received a copy of their General Social Care Council code of conduct. There were not photographs of staff at the home, although a worker on duty stated that they had brought in their camera in order to organise this. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is competent to run the service. Significant work is required in order to ensure that the home is run in the best interests of residents and that residents are protected by trained staff . EVIDENCE: The manager had recently been appointed. She has a registered general nurse (RGN) qualification. The manager was in the process of applying to register with CSCI as the registered manager of the home. There were clear lines of accountability within the home. Staff spoken with said that the manager was approachable and would listen to any concerns. She demonstrated a clear sense of direction and leadership, and several people spoken with said that the home had improved. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 21 As previously stated not all of the homes conditions of registration had been met. Some relatives had been sent questionnaires asking their views of the home and service provided. These were in the process of being collected and analysed. The registered provider/owner was now completing monthly reports concerning the conduct of the Care Home. The manager had started a newsletter for residents and visitors, this was appreciated by visitors spoken with. More work was required in order to include residents in the quality assurance process. The manager acknowledged that the focus for improving and developing the home needs to be around the environment. The home held money for two residents. Although there were clear records of transactions, these were not signed by two people as required. The manager had recently undertaken the first audit of these records and found minor errors. The administrator was in the process of investigating these. Residents savings kept on their behalf were in their individual bank accounts. Care staff did not receive formal supervision, although their work was supervised on the day-to-day basis by nursing staff. Hazardous substances were safely stored. Information received from the Preinspection questionnaire was that all required service checks had been undertaken. This includes central heating system, water temperature checks and emergency lighting checks. The home had a number of policies and procedures although not all the necessary policies were in place. Many policies did not have a date and had not been reviewed for a number of years. Many staff were not aware of the homes written policies and procedures. The Fire Officer visited in February. There was a requirement to complete a fire risk assessment. This had not yet been completed. Fire equipment was checked 5 April 2005 and is now due for servicing. Some staff had received fire training in March 2006 although there were still 17 staff that had not received fire training. Approximately half of the staff had undertaken moving and handling training in 2006. Only two staff had undertaken recent food hygiene training. Not all staff that worked in the kitchen had received this training. Four staff had undertaken emergency first aid training in 2004. As stated previously a significant amount of training was planned between May/September 06. Accidents and injuries were recorded. The manager had started to analyse these accidents in order to assess whether accidents could be further reduced. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 3 3 3 x 2 2 2 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 2 3 1 Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15 Requirement The service user plan (care 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. Each care plan must include a moving and handling plan for each resident. Care staff that administer creams and other external medication must have appropriate training. (Original timescale 30 May 2006) All staff must received training in the protection of vulnerable adults.(timescale provided by manager). The homes protection of vulnerable adults written policies and procedures must be revised DS0000002069.V292412.R01.S.doc Timescale for action 30/07/06 2. 3. OP7 OP9 13(5) 15(1) 13(2) 30/06/06 30/08/06 4. OP18 13(6) 30/09/06 5. OP18 13(6) 30/06/06 Pendean Nursing Home Version 5.1 Page 24 6. OP19 23(2b&c) to ensure that they comply with the recent relevant guidance and legislation The registered provider must follow the agreed written programme 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. Replacement of the dining room furniture. (Original timescale March 2006.Work started. New timescale given by manager as a final date for all work to be completed.). 31/12/06 7. OP19 23(2) The agreed plan must be followed in order to ensure that all parts of the home are adequately decorated. 30/08/06 8. OP24 13(4) 12(4) 9. OP25 13(3)(4) 10. OP26 16 (2) (e) Locks on bedroom doors must 30/06/06 be suitable and appropriate for individual needs. A review of this should take place considering individual residents privacy, independence and abilities. Locks should be altered where not suitable for individuals. There must be a system in place 30/07/06 to record that water is being stored at a temperature of at least 60°C and distributed at 50°C minimum to prevent risks from legionella . (Not inspected on this occasion) There must be effective systems 30/06/06 in place to ensure that lost laundry items are kept to a DS0000002069.V292412.R01.S.doc Version 5.1 Page 25 Pendean Nursing Home 11. 12. OP26 OP28 16(2) (k) 18(1)(c) 13. OP29 19 14. OP29 15. OP31 Care Standards Act section 62 (1) Care Standards Act 2000 Part 2 Section 24 minimum and residents are always dressed in their own clothes. The home must be free from offensive odours. There must be a minimum of 50 trained members of care staff (NVQ level 2 or equivalent) (original timescale December 2005) New timescale is date for staff to the registered on a course. There must be evidence at the home that POVA first checks have been obtained for new staff. These records must not be kept at the managers home. Staff must receive a copy of the General Social Care Council code of conduct. 30/05/06 30/06/06 30/05/06 30/06/06 16. OP30 18(1)(a) 17. OP31 9 15/06/06 There must be a review of all residents with dementia to ensure that the home meets their conditions of registration. These are that no more than 7 Residents with dementia will be accommodated. Residents with dementia must be accommodated in the designated areas As agreed by CSCI. CSCI must be informed of the outcome of this review. The service must meet the 30/07/06 condition of registration, which states that staff must receive suitable training in the care needs of those service users with dementia. There must be at least one staff member 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. The new manager must make 15/06/06 and application to register with DS0000002069.V292412.R01.S.doc Version 5.1 Page 26 Pendean Nursing Home CSCI. 18. OP38 23(4) There must be a fire risk assessment undertaken as recommended by the Fire Officer. All staff must receive training in Fire prevention. New staff must receive relevant induction training to National training Organisation specification. 30/05/06 19. 20. OP38 OP30 23 (4) (d) 18(1)(c) 15/06/06 30/06/06 21. OP38 13(5) 22. 23. 24. 25. OP3838 OP35 OP36 OP38 23(4) 16(2) (l) 18(2) 23 Staff must receive training and 30/09/06 refreshers in moving and handling. Relevant staff must receive training in basic food hygiene. Staff must receive training in first aid. (Timescale provided by manager. Date for all to be completed). Fire fighting equipment must be 30/05/06 serviced. Records of residents money 30/05/06 must the signed by two people in order to ensure a safe system. Care staff must receive formal 30/07/06 supervision. Supervision plan to be put in place. The registered person must 30/07/06 check with a qualified electrician whether the fluorescent lighting in the bathroom areas that do not have a cover are appropriate and safe. (Not inspected on this visit) Infection control training must be provided for all staff. Original timescale January 2004,June 2005 and March06 ( new timescale given by manager) 30/09/06 26. OP38 13(3) Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should include the complaints procedure and clearly sets out the physical environment standards met by the home in relation to 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10. Residents of their representatives where appropriate should be consulted concerning their service user plan (care plan). After consultation the plan should be revised and the resident or representative should be notified of any revision. Care plans should be signed by the resident or relative where appropriate. Staff undertaking activities should be provided with appropriate training. Staff should fully complete daily records rather than date and sign with no detail. Staff completing care plans should receive adequate guidance/training. Any residents that are unable to read the written complaints procedure should have the details read or explained to them in order to help them understand the procedure and feel confident to use it. The broken radiator in a residents bedroom should be repaired. (The temporary solution is acceptable until the central heating system as being overhauled in the better weather.) Staff should receive training in dealing with difficult behaviour and aggression. Suitable provision should be made for storage in the home for wheelchairs and hoisting equipment. (Original timescale 31 May 2005 and 31 May 2006) The manager should consider appropriate signage in order to assist residents with dementia. The system for reviewing and improving the quality of care should include consultation with residents. DS0000002069.V292412.R01.S.doc Version 5.1 Page 28 2 OP7 3. 4. 5. 6. OP12 OP7 OP7 OP16 7. OP25 8. 9. 10. 11. OP30 OP22 OP22 OP33 Pendean Nursing Home 12. OP33 The homes policies and procedures should be reviewed and amended. Pendean Nursing Home DS0000002069.V292412.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000002069.V292412.R01.S.doc Version 5.1 Page 30 - 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. 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