Inspection on 23/02/07 for Amberleigh Manor Care Home

This inspection was carried out on 23rd February 2007.

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.

Other inspections for this house

Amberleigh Manor Care Home 06/04/09

Amberleigh Manor Care Home 15/05/08

Amberleigh Manor Care Home 01/11/07

Amberleigh Manor Care Home 02/05/06

Amberleigh Manor Care Home 27/02/06

Amberleigh Manor Care Home 13/09/05

Amberleigh Manor Care Home 07/03/05

Amberleigh Manor Care Home 11/08/04

Amberleigh Manor Care Home 06/08/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Derbyshire DE55 5JF Lead Inspector Angela Kennedy Unannounced Inspection 23 February 2007 10:00 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.V329301.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 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.V329301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No more than 7 DE/E service users can be accommodated, in the designated areas identified for accommodating this category of service user. Staff must receive suitable training in meeting the needs of service users with dementia. There must be a specialist dementia advice and training on an ongoing basis, provided by a Registered Mental Nurse (RMN). To allow two named persons DE(E) to be accommodated in an area outside the designated area for the duration of their stay. 2nd May 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 at this inspection were between £331.60- £482.60 depending on the category of resident. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately 7 ½ hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents. The inspection was focused on assessing compliance with defined key National Minimum Standards. Staff were involved in supplying information during the inspection. On the day of the visit the inspector spoke with three residents to gain their views on the service. There were no residents representatives available to speak with. What the service does well: What has improved since the last inspection? Evidence was in place to demonstrate that some of the requirements left at the last inspection had been addressed. Residents care plans seen provided detailed instructions for staff of the actions that needed to be taken to ensure their health, personal care and social care needs were met. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 6 Out of the 16 care staff employed at Pendean 14 had either achieved a National Vocational Qualification (NVQ) in Care at level 2 or above or were undertaking NVQ training at the time of this inspection. This demonstrated that staff at Pendean have the relevant qualifications to ensure residents needs can be met. A member of the care team is now employed for 16 hours a week to coordinate activities for residents. It was confirmed that these hours were always maintained to ensure a scheduled programme of activities could be provided for the residents. A requirement left at the last inspection related to the safety of fluorescent lighting within bathrooms as no covers were in place. This was assessed at this inspection and lighting provided within the bathrooms now has covers in place. A new full time manager had been appointed and commenced in post from the 26th February 07. This person has been in post as a registered nurse at Pendean and therefore was known to both residents and staff. What they could do better: Following a requirement left at the last inspection, work had taken place to disable the locks on resident’s private accommodation where residents had been assessed as unable or not wishing to use them. Assessments were in place within residents files seen regarding the Yale locks on the doors of residents private accommodation, these assessment looked at the suitability of this type of lock for each individual and included each residents preference as to whether they wished to use the locks or have the locks disabled. However evidence was not in place to suggest that residents had been assessed for or their preference sought on the use of an alternative locking mechanism being used when the present locking mechanism was unsuitable. Some of the requirements left at the last and previous inspections had not been met or evidence was not in place to demonstrate that these requirements had been met. A requirement had been left that care staff that were responsible for administering external preparations for residents such as creams and other external medication must receive the appropriate training. It was stated that this training was ongoing but as yet had not been completed, however there Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 7 was no evidence to demonstrate that this training/ assessment of competency was taking place. There was evidence in place to demonstrate that regular checks were carried out on fire alarm systems and equipment, however the requirement regarding a fire risk assessment had not taken place. To ensure that Section 11(i) of the Care Standards Act 2000 is met, Priority must be given to an application to the Commission for Social Care Inspection (CSCI), for registration of the manager, as this service has been without a registered manager since 2005. 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.V329301.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Resident’s needs were assessed prior to admission to ensure the service could meet their needs. EVIDENCE: Three residents’ files were examined of these three residents two had needs assessments in place that had been undertaken prior to admission. These assessments addressed all areas of health, personal and social care, however it was noted that within one residents assessment the information provided in some areas was not specific in detail. As needs assessments form the basis of residents care plans, detailed assessment will ensure that residents strengths and needs are correctly identified, which in turn will allow the person writing the care plan to identify the level of support required by Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 10 staff to ensure the residents needs are met and their independence maintained. Care managers assessments were also in place for residents who were funded by the local authority. The resident who did not have a needs assessment in place had lived at Pendean for thirteen years and at the time of their admission needs assessments were not required to be undertaken. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 Resident’s health, personal and social care needs were set out within their care plans and in general this was good. However further development is required in some areas to ensure staff receive the correct information to support residents in meeting their needs. Medication practices were in general good but require further development to demonstrate that resident’s safety is maintained. Residents were treated respectfully and their right to privacy was upheld. EVIDENCE: Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 12 Three residents files were looked at and evidence was in place to demonstrate that considerable improvements had been made. The information contained within the majority of care plans and risk assessments seen clearly instructed staff of how the resident’s needs were to be met. Care plans included all areas of health, personal and social care needs and assessment were in place regarding nutrition, mobility, falls, moving and handling and pressure areas. The majority of care plans and risk assessments seen had been completed and reviewed on a regular basis. However one risk assessments and one care plan seen had not been reviewed for over twelve months and therefore it was unclear if these were still valid. One resident’s file seen had a moving and handling assessment and a falls assessment in place that contradicted each other. The moving and handling assessment stated that this resident was ‘independent, walked with a stick but was safe’, whilst the falls assessment stated this resident was a ‘high risk’. This information does not provide staff with clear instructions to ensure this resident’s safety in mobility is maintained. Records of residents weight was maintained within the three files looked at and this had been undertaken on a monthly basis, therefore any sudden reduction or increase in weight could be identified and addressed. Records were kept of doctor’s visits, opticians, dentist and hospital appointments. The administrator confirmed that a chiropodist visited residents on a six weekly basis to provide foot care. Daily information sheets were completed by staff regarding the well being of each resident as were activity sheets that provided information on the activities undertaken by each individual. The medication administration practices of the service were assessed. Medication administration records had been signed correctly to demonstrate that medication had been administered. Resident’s photographs were in place on all but three medication administration records to identify the residents. It was stated that these three residents were new to the service and their photographs had not yet been taken. 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 Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 13 been recorded to ensure this medication was stored at the required temperature. A requirement had been left at previous inspections that care staff that were responsible for administering external preparations for residents such as creams and other external medication must receive the appropriate training. It was stated that this training was ongoing but as yet had not been completed, however there was no evidence to demonstrate that this training/ assessment of competency was taking place. Residents spoken with felt the care and support they received from staff was very good and one resident said, “ the staff are great, they can’t do enough for you”. Staff were observed treating residents with courtesy and respect, such as holding doors open for them and knocking on the doors of resident’s private accommodation before entering. The resident’s right to privacy was upheld, and this was discussed with one resident who stated that they preferred to spend the majority of their time within their private accommodation. This resident confirmed that staff were respectful of their wishes regarding this. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were planned and implemented for residents and contact was maintained for residents with family and friends. Residents were encouraged to exercise choice and control and the meals provided were varied with alternatives available. EVIDENCE: Since the last inspection a member of the care team had been employed for 16 hours a week to co-ordinate activities for residents. It was confirmed that these hours were always maintained to ensure a scheduled programme of activities could be provided for the residents. Activities sheets were kept within each resident’s individual files that recorded the activities that each resident had participated in. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 15 The activities provided for residents included; skittles, dominoes, quoits, netball, target games, ludo, draughts, snakes and ladders and card games. Crafts were also undertaken by residents and this included painting, card making, basket weaving and making mosaic tile coasters. Some of the cards made by residents were seen, and each resident had their name signed on the back of the cards that they had designed. The activities co-ordinater stated that several trips were undertaken each year for residents to places of interest and a vehicle was hired for these events. Discussions took place regarding how the service met the religious and spiritual needs of the residents. It was stated that a Christmas service was held at Pendean and that the local vicar used to visit the residents at Pendean on a regular basis but this no longer takes place, the reasons for this were unclear. None of the residents at Pendean attend any local church services, although the activities co-ordinator felt that one resident might be interested in attending the Salvation Army services. As it was unclear as to why none of the residents attended any religious or spiritual services it is recommended that residents be consulted about their interests regarding this, to ensure that any residents who wishes to participate in religious or spiritual activities are able to do so. Of the three residents spoken with all confirmed that activities were available to them if they wished to join in. One resident who confirmed that she liked to join in with all of the activities said that there was a variety of activities that she was able to participate in, and stated that the range activities and frequency of activities had improved over the recent months. Visiting hours at Pendean were open and residents were able to receive their visitors within the communal areas of the home or within their private accommodation, as they preferred. Residents spoken with confirmed that their visitors were made welcome by the staff when they visited. All of the residents spoken with confirmed that they were able to move freely around the home and were able to choose where they preferred to sit. One resident spoken with chose to spend most of their time within their private accommodation and stated that they had always been a private person who preferred their own company. There was no evidence to demonstrate that Advocacy services were advertised to residents at Pendean. This was discussed with the administrator and it is Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 16 recommended that the services of Advocacy agencies are made known to residents along with their contact details, this will further enhance residents personal autonomy and choice. One cook and four kitchen assistants were employed at Pendean. Staff were available in the kitchen between 7am to 2.30pm and between 4.30pm and 6.30pm each day. Menus ran over a 4-week rota. Alternative dishes were available at lunchtime. The menus seen did not provide a vegetarian option at each lunchtime meal, e.g. roast beef and Yorkshire pudding or turkey slice and stuffing. The administrator stated that although vegetarian options were not always written on the menu they were available to residents who requested them. However it is recommended that to ensure that all residents are aware of the vegetarian option available it is written on the menu for each day. Three residents were spoken with regarding their opinions of the quality and variety of the meals provided. All three residents stated that they were happy with the variety of meals available and stated that the meals were of a good quality. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be can be confident that their complaints will be listened to and acted upon. The policy in place regarding safe guarding adults requires further development to ensure residents are protected from abuse. EVIDENCE: The complaints procedure at Pendean was seen; this was displayed within the entrance and other areas of the home and included the 28-day timescale for response to complaints, and the contact information for the commission for social care inspection. Pendean had received one complaint since the last key inspection, which involved a complaint against staff and residents on a trip out. This complaint had been fully investigated by both the home and the local social services department and, as this complaint was not upheld no further action was taken. The commission had received one complaint since the last inspection and this was regarding requirements not being met from the last inspection and concerns regarding the lack of a full time manager being in post at Pendean. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 18 The details of this complaint were addressed at this inspection and some areas of the complaint regarding some requirements not being met were upheld, these requirements will remain in place and will be assessed at the next inspection. A full time manager was due to commence in post at Pendean on the 26th February 07, and discussions took place with this person regarding the importance of applying for registration within the very near future and a requirement has been made regarding this. All three of the residents spoken with said they had no complaints but felt confident that if they had any concerns they would be taken seriously by the staff team and dealt with. Two Adult protection referrals had been made to Derbyshire social services since the last key inspection. One of these referrals relates to the complaint made against the staff and residents on a trip out, and as stated above no further action was taken. The other referral made remains open and a full investigation is being undertaken. Training in safeguarding adults (Adult Protection) had been undertaken by the staff team in 2006, and this training was planned to take place again in March 2007. The policy regarding adult protection was looked at and requires amendment, as it is not in line with the local authorities safeguarding adults’ policy. As the local authority are the lead agency in investigating any safeguarding adults referrals it is important that the staff at Pendean are aware of the procedures that must be followed regarding any adult protection concerns or issues. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Some improvements have been made to the environment, however further upgrading is required to ensure the building is maintained to a safe standard and provides a comfortable and attractive home for residents. EVIDENCE: A requirement had been made at previous inspections regarding the review and replacement of carpets as necessary on stairs and in hallways, and the review and upgrading of bathrooms including hoisting equipment. A tour of the building was undertaken to assess these areas and establish the works that had been undertaken regarding this requirement. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 20 No evidence was seen to suggest that any carpets had been replaced and it was noted that several carpeted areas seen were either worn, required cleaning or were loose. The corridor carpet in the old building next to room 28 was worn and needed to be replaced. The carpet in room 28A was loose and had the potential to become a trip hazard, if not refitted or replaced. The red carpet near to the food storeroom required cleaning. A new hoist had been purchased which ensured that hoisting equipment was available on both floors. New beds had been purchased for all residents that were height adjustable, this ensured that hoisting equipment could be used if required on all beds. A new call bell system had been purchased, however it was noted that the call bell in one bedroom was attached to the wall and was not within reach of the bed, without the call bell lead trailing across the floor, which would present a trip hazard for the resident and any staff entering the room. Therefore the resident occupying this room would be unable to call for assistance from their bed if they needed to. However there was sufficient space for the bed to be moved to enable the call bell to be accessed safely. The homes administrator agreed that this would be discussed with both the resident occupying this room and staff and action taken as required. The top and bottom of the staircase within the new build part of the building was inaccessible to residents as locked gates were in place, however it was noted that this staircase had a low banister which was accessible to residents on the first floor, this could be potentially hazardous to residents with behavioural problems or confusion. The homes administrator stated that residents with such conditions were accommodated on the ground floor and therefore did not access this area. However it is recommended that a review of this area regarding the potential for harm to residents should be undertaken, to ensure residents’ safety is maintained. A requirement from previous inspections was with regard to the repair of a broken radiator within one resident’s private accommodation. A new radiator is now in place within this resident’s room. Following a requirement left at the last inspection, work had taken place to disable the locks on resident’s private accommodation where residents had been assessed as unable or not wishing to use them. Assessments were in place within the residents files seen, regarding the Yale locks on the doors of resident’s private accommodation. These assessments looked at the suitability of this type of lock for each individual and included each resident’s preference Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 21 as to whether they wished to use the locks or have the locks disabled. However evidence was not in place to suggest that residents had been assessed for, or their preference sought on the use of an alternative locking mechanism being used when the present locking mechanism was unsuitable. It was stated by the homes administrator that one of the passenger lifts was out of order at the time of inspection and confirmed that the engineers were waiting for parts to enable them to undertake the repairs required. It was confirmed by the administrator that residents on the first floor were able to access the other lift to enable them to move between floors. The laundry area was seen and provided sufficient equipment to ensure residents clothing could be laundered suitably and meet with disinfection standards. Two laundry staff were employed at Pendean and these staff were rostered on shift to ensure laundry services were available to residents seven days a week. The residents spoken with were happy with the laundry services provided to them and stated that they had no concerns regarding the laundering of their clothes. Residents were smartly dressed and clothes appeared well laundered. Three domestic staff were employed at Pendean and provided domestic services seven days a week. No offensive odours were noted throughout the building and the general standard of hygiene appeared satisfactory. Residents spoken with said they were happy with the cleaning services provided both within their private accommodation and the communal areas. Some of the furniture and fittings seen appeared worn and in need of repair, this included curtains in one room that had partially come down and some of the furniture seen. The homes administrator stated that the provider had ordered six new dining tables with four chairs to each table and new curtains and bedding for the building. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The skill mix and numbers of staff on duty enabled residents needs to be met to an adequate standard, although further consideration should be given to how staffing levels are determined in order to ensure residents needs are fully met. Staff have the appropriate training to ensure residents safety is maintained and once all of the required recruitment documentation is in place residents protection will be further enhanced. EVIDENCE: Staffing levels at Pendean had improved since the last key inspection, although discussions with some of the staff team did indicate that additional staff on shift would allow staff to spend more time with residents. The staffing rotas were looked at and demonstrated that staff were rostered on shift as follows; five care staff and one or two registered nurses were on shift in the mornings, four care staff and one registered nurse were on shift in the afternoon and at night three care staff and one qualified nurse were on duty. On the day of inspection one member of staff was off sick for the morning shift, which left four care staff and one registered nurse on duty. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 23 It was confirmed that the numbers of staff rostered on shift at the present time were reduced, as although the service is registered for 40 people there was only 30 residents living at Pendean, and on the day of inspection this was reduced to 29 as one resident was in hospital. Evidence was in place to demonstrate that the staffing levels were dependent on the numbers of residents requiring nursing care, which at the time of inspection was set at one member of staff to five residents, and the number of residents requiring residential care, which at the time of inspection was set at one member of staff to eight residents. Although it was stated that this should be the minimum staffing levels worked to, it is recommended that staffing levels be dependent on each individual’s personal needs and dependency levels and not on whether they require nursing or residential care. The residents spoken with felt the staff team worked very hard and all of them indicated that their needs were adequately met. Out of the sixteen care staff employed at Pendean eleven had achieved a National Vocational Qualification (NVQ) in Care at level 2 or above, three staff were undertaking NVQ training at level 2 and one member of staff was undertaking NVQ training at level 3 the time of this inspection. This demonstrated that staff at Pendean have the relevant qualifications to ensure that residents needs can be met. Two staff files were looked at to examine the recruitment documentation in place. Evidence included satisfactory criminal records bureau checks, two satisfactory references, medical health declaration forms, documentary evidence of relevant qualifications and training and details of evidence of up to date registration with the relevant professional body. Also in place were completed employment application forms. Application forms had been amended to request a full employment history and a written explanation for any gaps in employment. The two staff files seen did not have the required identification documents in place, it was confirmed by the homes administrator that this was a working progress, as staff that had been employed for some time did not have these in place. Therefore a checklist had been devised to request the required information from staff. A staff-training matrix was in place, which demonstrated training that had taken place recently, this included training in moving and handling, food hygiene, continence care, infection control, fire safety, stoma care, Care of Substances Hazardous to Health (COSHH) and Safeguarding Adults (Adult Protection). Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 24 Four members of staff had undertaken First Aid training and for three of these staff this training required updating in May 2007. As a qualified first aider should be available at all times, it is unlikely that four staff are sufficient to provide this cover. This was discussed with the homes administrator and agreed that to ensure a qualified first aider was available at all times additional staff would need to attend this training. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. As the new manager was not yet in post relevant information is not yet available to CSCI about them. The opinions of residents and their representatives were sought, and resident’s financial interests were safeguarded. Improvements have been made in the safe working practices of the home. EVIDENCE: A new manager was due to commence in post from the 26th February 07. Therefore this new manager had not applied for registration with the CSCI at the time of this inspection. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 26 A temporary part time manager had been in post at Pendean for the last twelve months. This person was not registered with the CSCI as the registered manager. Evidence was in place to demonstrate that both the acting part time manager and the staff team have worked hard in improving the service for residents. A satisfaction questionnaire for residents and their representatives was undertaken the week prior to this inspection. It was confirmed by the homes administrator that the responses of these questionnaires would be analysed and fed back to residents and their representatives with the next fees invoice. Some of these questionnaires had been returned and these were looked at. The responses given regarding the care and support provided by staff was positive. Comments were noted from a relative regarding the condition of some of the furniture within the communal areas. The system for handling residents’ personal monies was examined and there was confirmation that there are suitable accounting procedures in place, however the practice of these procedures must be undertaken stringently to ensure the records of transactions maintained are up to date. The transaction records of five residents were examined and the figures recorded on the transaction records did not correspond with the monies held for each of these residents. This was due to the fact that monies taken out to pay chiropody fees had not been deducted from the financial transaction records. However evidence was in place to demonstrate that these residents had received treatment from the chiropodist and the administrator amended the transaction records to record the correct amount for each resident before this inspection ended. Some of the safe working practices at Pendean were examined and requirements left at the last and previous inspections were assessed to determine if these had been met. A requirement left at the last inspection related to the safety of fluorescent lighting within bathrooms as no covers were in place. This was assessed at this inspection and lighting provided within the bathrooms now has covers in place. There was evidence in place to demonstrate that regular checks were carried out on fire alarm systems and equipment, however the requirement regarding a fire risk assessment had not taken place. The homes administrator stated that as an up-to-date electrical wiring service certificate could not be located, it had been decided that a service of the Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 27 electrical wiring of the building would be undertaken. The homes administrator stated that quotes were being obtained for this work at the present time. 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. Monthly checks were undertaken on wheelchair maintenance and the nurse call system. Certificates were in place and were up to date for moving and handling equipment, baths and chair scales. As stated in standards 27-30 four members of staff had undertaken First Aid training and, as a qualified first aider should be available at all times more than four staff would need to undertake this training to ensure all shifts are provided with a person qualified in first aid. Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 28 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 29 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, Domiciliary Care Regulations 2002 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14 Requirement Risk assessments must be reviewed regularly to ensure any changing needs of residents can be identified and the correct action taken. Care plans must be reviewed monthly to ensure any changing needs of residents can be identified and the correct actions taken Assessments must clearly and accurately record any health care needs of residents to ensure their safety is maintained. Care staff that administer creams and other external medication must have appropriate training. (Original timescale 30 May 2006, 30/08/06 and 30/11/06) The Safeguarding Adults policy must be in line with the local authority procedure, to ensure that staff are aware of the procedure that must be followed in the event of any safeguarding adults concerns, referrals or investigations. Review and refit, replace or DS0000002069.V329301.R01.S.doc Timescale for action 31/07/07 2. OP7 15 31/07/07 3. OP8 14 31/07/07 4. OP9 13 (2) 31/05/07 5. OP18 13 (6) 31/05/07 6. OP19 23(2 b & 31/07/07 Page 30 Pendean Nursing Home Version 5.2 c) 7. OP24 13 (4) 12 (4) clean carpets identified within this report. Residents must be assessed for and their preference sought on the use of an alternative locking mechanism being used when the present locking mechanism is assessed as unsuitable. Recruitment documents must include evidence of identification including a photograph. The new manager must make and application to register with CSCI. (Previous timescale 15/06/06 and 20/10/06) Care staff must receive formal supervision. Supervision plan to be put in place. Previous timescale 30/10/06. Not inspected on this visit, therefore timescale extended. There must be a fire risk assessment undertaken as recommended by the Fire Officer. (Previous timescale 30/10/06) Sufficient numbers of staff must be trained as qualified first aiders, to ensure a qualified first aider is available on shift at all times. 23/05/07 8 9 OP29 OP31 19 Schedule 2 9 31/05/07 23/05/07 10. OP36 18 (2 ) 31/07/07 11 OP38 23 (4) 31/05/07 12. OP38 13 (4) 31/07/07 Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 31 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 OP3 Good Practice Recommendations Specific detail should be entered onto needs assessments to ensure residents strengths and needs are correctly identified. Residents should be consulted about their interests regarding religious / spiritual activities to ensure any residents wishing to participate in such activities are able to do so. The services of independent advocacy agencies and their contact details should be made known to residents. Vegetarian options should be written on menus to ensure all residents are aware of this option. The banister on the staircase in the new build should be reviewed regarding any potential dangers to residents and action should be taken on any risks identified. Staffing levels should be reviewed to reflect the dependency levels and personal needs of each resident. Stringent practices must be undertaken to ensure the procedure for recording resident’s financial transactions is undertaken as and when transactions are made. 2. OP12 3. 4. 5 6 7 OP14 OP15 OP19 OP27 OP38 Pendean Nursing Home DS0000002069.V329301.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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.V329301.R01.S.doc Version 5.2 Page 33 - 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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