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Inspection on 27/02/06 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 27th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

What has improved since the last inspection?

Both the temporary and the new permanent manager have worked hard in order to implement the requirements made at the previous inspection and the requirements made as a result of a complaint that was made to CSCI. Poor practice that was evidenced during an unannounced evening visit in January has now ceased. This includes bathing residents at night in order to meet the needs of staff not residents, and night staff getting residents out of bed against their wishes there in the morning. Additional adjustable height beds have been purchased, and beds that allow the use of moving and handling equipment have replaced some divan beds. Footrests are now used on wheel chairs. Planned activities have increased and these are now displayed on a notice board. The proprietor is now completing a monthly report concerning the home, evidencing that they have inspected the premises and are talking with staff and residents.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Pendean Nursing Home Primrose Hill Blackwell Derbyshire DE55 5JF Lead Inspector Jill Wells Unannounced Inspection 27th February 2006 09:00 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.V279850.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.V279850.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 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.V279850.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. 13th September 2005 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. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over a 4 .5 hour period. Jayne Ellis the new manager was present throughout the inspection. Mr Kelley was present for some of the inspection. Feedback was given to both parties. The tour of the building was undertaken. Staff members were spoken with in private. Several residents were spoken with during the inspection. The focus of this inspection visit was to assess whether improvements had been made since the last visit and to assess the new managers action plan. What the service does well: What has improved since the last inspection? Both the temporary and the new permanent manager have worked hard in order to implement the requirements made at the previous inspection and the requirements made as a result of a complaint that was made to CSCI. Poor practice that was evidenced during an unannounced evening visit in January has now ceased. This includes bathing residents at night in order to meet the needs of staff not residents, and night staff getting residents out of bed against their wishes there in the morning. Additional adjustable height beds have been purchased, and beds that allow the use of moving and handling equipment have replaced some divan beds. Footrests are now used on wheel chairs. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 6 Planned activities have increased and these are now displayed on a notice board. The proprietor is now completing a monthly report concerning the home, evidencing that they have inspected the premises and are talking with staff and residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 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.V279850.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Adequate information was available for prospective residents. Although the previous assessment was not always adequate, a new document is likely to improve the standard. EVIDENCE: The new manager stated that they had revised the statement of purpose and service user guide. These were not inspected on this occasion. The new manager had developed a new assessment document that will be used for all new residents. Pendean Nursing Home DS0000002069.V279850.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 Poor care practices that had been evidenced has now ceased, however the practices concerning administering medication was not safe. EVIDENCE: The service user plans were generally of an adequate standard, however the new manager had started to implement a new recording tool that if used appropriately would improve the information for individual residents. The initial care plans that had been completed using the new format evidenced that training was required in order to ensure that the plans were individualised, specific and always signed and dated. Staff spoken with said that, there is no time to update care plans. See standard concerning staffing levels. The poor practice evidenced by an evening visit in January 2006 concerning night staff bathing residents and getting residents out of bed in the mornings against their wishes has now ceased. Other poor practice concerning staff ignoring moving and handling plan and failing to use a hoist due to an inappropriate bed has also ceased. The manager confirmed that slide sheets, hoists and banana boards are now used as required. Inappropriate personal care gloves were being provided but more appropriate gloves have now replaced these. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 11 During the same visit staff were observed using wheelchairs without footrests. Staff were now aware of the importance of using footrests on wheelchairs. There were records indicating that GPs and other health professionals were contacted when required. The manager stated that she had requested a dietician visit to meet with three residents that had been assessed as having specific dietary needs or had lost significant weight. Individuals weight was recorded unless an individual was too ill to sit on the scales. The nurse in charge was observed administering medication. It was evident that the nurse signing that they had administered medication had not always done so but had dispensed the medication into a pot in order for care staff to administer out of sight of the nurse. This was not a safe practice. There were gaps in the medication Administration records. Over a 10 day period there had been nine occurrences where medication had not been signed for. The nurse on duty during the inspection visit audited these gaps and found that most of the medication had been given but not signed for. One residents record showed two gaps, an audit of the medication showed that medication had been given on one occasion but not on both. It was impossible to ascertain on which day the medication had been given. This medication was to help the resident sleep. There was no system in place within the home to monitor or respond when medication had not been signed for. Care staff were administering some medication for example creams, although they had not received medication training. Medication records had photos in place for all but four residents. Pendean Nursing Home DS0000002069.V279850.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, 15 Activities were planned but not always implemented. The standard of meals provided was not adequate. EVIDENCE: The manager had implemented a system where activities were advertised on a board in the hallway. Activities included reminiscence, manicure, card games, armchair netball, musical morning, walk to the shop, and dominos. There were monthly outings planned with the use of community transport. There was also a clothing sale and an Easter raffle/Easter bonnet parade planned. It was of concern however as previously stated that the activities planned for the morning of the inspection were not undertaken as staff said that day had been too busy getting residents up and giving breakfast. The manager had stated that activities were provided by two senior care assistants who had protected hours to ensure that the programme occurs. There was a written menu in the hallway. This showed three meals per day. A choice at lunch at times was not provided. As stated previously, due to staff pressures some residents were not having a suitable gap between meals. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 13 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 Complaints received indicated that there had been poor practice occurring within the home. EVIDENCE: The complaints procedure was available around the home. This had been amended to ensure that it included the telephone number of CSCI. Two complaints had been received via CSCI since the last inspection visit. One complaint was concerning poor practice. This included poor moving and handling practices, poor infection control practices and reduction in staffing. Institutionalised practice was also alleged involving assisting residents to bed and up in the morning to meet the needs of staff rather than residents. Bathing residents at night to reduce the work for day staff had also been taking place. Most of the allegations were upheld and requirements were made as a result of the investigation. The new manager has ensured that staff were now following safe moving and handling practices, and infection control practices have improved. Although the manager has discussed with staff the importance of assisting residents into and out of bed at a time to suit them, inadequate staffing levels were still making this difficult. The second complaint was received from Derbyshire Social Services and was concerning lack of criminal record bureau checks for staff. The manager has now ensured that all staff have received or applied for an up-to-date criminal record bureau check. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 14 Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25, 26 The environment was of a poor standard requiring significant upgrading. EVIDENCE: The previous inspection visit had highlighted significant concerns regarding poor quality furniture, and the need to upgrade bedroom furniture, dining room furniture, carpets and décor. A review and upgrading of all bathrooms including hoisting equipment was also required. Although an action plan has been received from the registered provider, work has not commenced in this area. Staff spoken with said that some rooms have had the same furniture for 18 years, nothing gets renewed. The registered provider stated during the inspection visit that due to the cost of agency staff he has been unable to spend significant money on the home. As CSCI have been requiring that the home must be upgraded for some time, the timescale given as a result of this inspection visit is unlikely to be further extended. The registered provider has purchased four adjustable height beds and replaced divan beds with standard beds that allows the use of hoist equipment. This was as a result of the complaint investigation outcome. The dining Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 16 furniture was inappropriate and the tables were unsafe. As a result of a previous requirement made the provider had purchased second-hand wooden dining chairs, which were also inappropriate. There was only one mobile hoist and two stand aids at the home. Staff spoken with said that the mobile hoist has to be moved between floors on a regular basis which is difficult for staff. It was stated that a second mobile hoist had been ordered. One commode was inspected and found to be rusty and in poor condition. There was insufficient storage at the home. Wheel chairs and bedding was stored inappropriately due to lack of storage. Damage around the home that was highlighted at the previous inspection including a damaged radiator cover, a hole in the bathroom ceiling and a bathroom door that would not close have been rectified. Damage in the lounge area caused by a wheelchair usage has not been repaired. Rubber seals coming off windows were highlighted and the manager explained that quotes have been requested. At the previous evening inspection visit, residents were seen unsupervised and unsafe on an open staircase. A requirement was made that a risk assessment must be undertaken which was now in place. The risk assessment states that residents must be monitored and supervised going up and down the stairs. However it was evident that there were insufficient staff on duty to ensure that this occurs safely. There were grab rails and other aids in corridors, bathrooms and toilets to assist residents. There was not a loop system or signs provided to assist residents with hearing impairment or dementia. Call systems were provided. Not all call systems in bedroom areas were placed near to the residents’ bed. The manager believed that the call systems were taken from the wall and placed near the bed every night, although this was not indicated in care plans. There was fluorescent lighting in bathroom areas that did not have a cover and may not be suitable for this area. A bedroom that was highlighted at the previous inspection had a broken radiator and no heating in place. The manager has since placed a temporary electric heater that is safely guarded until the heating system can be overhauled. There was a maintenance person employed at the home for 23 hours per week. His role was general repairs, decorating and testing of a fire alarms, emergency lighting and water temperatures. There was a maintenance book that staff should record any repairs required. This system was not always used, and would often be word-of-mouth with no written evidence of the work requested and undertaken. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 17 There was not a system in place to check that water was being stored at a temperature of at least 60°C and distributed at 50°C minimum to prevent risks from legionella. Bath water temperatures were checked and found to be at a safe temperature. There was not a system to check the call systems other than the annual service. The home now has appropriate personal care gloves as a result of responding to the complaint received. There were areas of the home that were not clean. This included dirty corners in bathroom and toilet areas and cobwebs around the home. The laundry area was not inspected on this occasion. Pendean Nursing Home DS0000002069.V279850.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, 29. There were not adequate staff on duty to meet the needs of residents. Recruitment practices that had been used did not ensure that residents were safe. EVIDENCE: On the day of the inspection visit there was one nurse and five care staff on duty. The manager stated that she was planning to have two nurses and six care staff in the morning and two nurses and five care staff in the afternoon. Plans for staffing for the night shift was to be one nurse and three care staff with an additional care worker between 4 p.m. and 11 p.m. The manager believed that the present staffing levels were adequate but the planned increase would improve the service. However there was adequate evidence during the inspection visit that the present staffing levels were not adequate. As previously stated residents were still being assisted out of bed at 11 a.m. and taken down for breakfast at this time. Activities planned that morning had not taken place due to staff having insufficient time. An immediate requirement was issued concerning staffing levels. Staff training was not inspected on this occasion. Two staff files were inspected. There were not photographs of staff in place or relevant identity documents. There were not full employment histories and one did not have a reference from the most recent employer. The new manager was aware that the recruitment practices had not been of a good standard. A Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 19 new application form had been created and would be used for all new applicants. Criminal record bureau checks were now being undertaken. The home was short of staff, particularly nursing staff. As a result, the new manager had taken steps to recruit new staff and was in the process of doing so. She hoped that the home would be fully staffed by the end March 2006. Pendean Nursing Home DS0000002069.V279850.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, 34, 38. As the manager was new in post, relevant information is not yet available to CSCI about them. The promotion of safe working practices has improved. EVIDENCE: As stated previously the manager was very new in post. Contact had been made between the manager and CSCI before appointment and she was aware of the concerns identified during previous inspection visits. An application to become registered manager had not yet been received by CSCI. The accounting and financial procedures were not inspected, however the registered provider was asked whether there were any concerns regarding financial viability of the home. The registered provider stated that there were none. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 21 There had been previous concerns regarding unsafe moving and handling and infection control, however this had improved. There had been a previous requirement to make the sluice areas safe. Although there were bolts on the doors, these rooms were unlocked and vacant during the inspection visit. Domestic staff were decanting chemicals into containers that did not have appropriate safety information on the container. The kitchen was not inspected on this occasion. There had been a high number of accidents recorded and a requirement had been made that these accidents must be analysed and risk assessed in order to minimise further accidents. The manager stated that this work had been undertaken, however it was not inspected on this occasion. Pendean Nursing Home DS0000002069.V279850.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 1 X X 2 X 2 2 2 STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 3 X X X 2 Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP24 Regulation 16(2c) Requirement Adjustable height beds must be provided for service users receiving nursing care in accordance with assessed needs. Original timescale was to complete a rolling programme by 31 August 2005. 4 additional beds have been purchased but it has not been made clear whether other nursing care residents have been assessed as requiring adjustable beds. Clarification required. Timescale for action 30/03/06 2 OP38 13(3) Infection control training must 30/03/06 be provided for all staff. Original timescale January 2004 and June 2005 (not inspected on this occasion) The sluice room must be locked for safety of residents. A loop system must be provided for the benefit of residents using hearing aids. Original timescale 30/12/05 01/03/06 30/06/06 3 4 OP26 OP22 13(4) 23(2n) Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 24 5 OP27 18 Staffing levels must be increased in order to meet the needs of the residents and ensure the health, safety and welfare of residents are met. Immediate requirement issued. After consultation with individual residents there must be a record in their care plan stating their preferred times to go to bed and get up in the morning. If consultation is not possible with the resident, guidance should be sought from their family/representative. original timescale 28/02/06 Care plans should also state whether call systems need to be placed near to residents. After consultation with individual residents there must be a record in their care plan stating preferred times for a bath. If consultation is not possible with the resident, guidance should be sought from their family/representative. original timescale 28/02/06 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. 01/03/06 6 OP7 24(3) 30/03/06 7 OP7 24(3) 30/03/06 8 OP19 23(2b&c) 31/03/06 Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 25 9 OP22 23(2) Suitable provision must be made for storage in the home. Original timescale 31 May 2005 The statement of purpose and service user guide must be revised to ensure that it is accurate and up-to-date. (Not inspected during this visit) The service user plan must include in detail the action which needs to be taken by staff to ensure that all aspects of individuals health, personal and social care needs are met. This must include dietary preferences social interests, stimulation and ways that staff need to promote individuals independence. Care plans must be reviewed on a monthly basis. original timescale 30/11/05 31/05/06 10 OP1 4&5 28/02/06 11 OP7 15 30/04/06 12 OP12 16(2) (m) ( n) 13 OP19 23(2) The activities programme must 30/03/06 be followed unless there is a good reason to change the programme. Staff must be given adequate time to provide activities. A dedicated activities co-ordinator should be considered. The registered provider must 30/06/06 follow the agreed plan in order to ensure that all parts of the home are adequately decorated. The nurse responsible for administering medication must be the person that administers the medication. There must not be gaps in the medication administration records. There must be an initial or appropriate code used. Where the code ‘other’ is used, there must be an explanation for this. DS0000002069.V279850.R01.S.doc Version 5.1 14 OP9 13(2) 02/03/06 15 OP9 13(2) 02/03/06 Pendean Nursing Home Page 26 16 OP9 13(2) There must be a safe system for monitoring and reporting any gaps in the medication administration records. Care staff that administer creams and other external medication must have appropriate training. There must be a photograph of residents in order to identify them during the administration of medication. There must be a choice at all mealtimes. Staff must ensure that there is an appropriate gap between meals for each resident. If any residents request a late breakfast then they should be offered a late lunch. The registered person must check with a qualified electrician whether the fluorescent lighting in the bathroom areas that do not have a cover are appropriate and safe. The broken radiator in a residents bedroom must be repaired. (The temporary solution is acceptable until the central heating system as being overhauled in the better weather.) There must be a system in place 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 . There must be a system in place to ensure that call systems are checked and a record is made of the checks. The home must be clean and hygienic at all times. (this refers to dirty areas in the corners of bathrooms and cobwebs around DS0000002069.V279850.R01.S.doc 30/03/06 17 OP9 13(2) 30/05/06 18 OP9 13 (2) 30/03/06 19 20 OP15 OP15 16 (2) (i) 16 (2) (i) 30/03/06 02/03/06 21 OP38 23 30/04/06 22 OP25 23(2) (p) 30/06/06 23 OP25 13(3)(4) 30/04/06 24 OP38 16 30/04/06 25 OP26 16(2) 30/03/06 Pendean Nursing Home Version 5.1 Page 27 26 OP29 19 27 28 OP22 OP38 13 13(3)(4) 28 OP31 9 the home. Recruitment procedures must include obtaining two written references, one from the most recent employer, evidence of identification including a photograph, and a full employment history. The manager must check all commodes. Any that are in poor condition must be replaced. Cleaning chemicals that are decanted into separate containers must have the required warning and procedures for accidental spillage etc The new manager must make and application to register with CSCI. 30/03/06 30/04/06 30/03/06 15/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP12 OP38 OP7 OP22 OP19 Good Practice Recommendations Staff undertaking activities should be provided with appropriate training. The risk assessment concerning the open stairs should be reviewed. Staff completing care plans should receive adequate guidance/training. The manager should consider appropriate signage in order to assist residents with dementia. The system for recording maintenance/repair work to be undertaken by the maintenance person should be used on all occasions rather than occasionally. Pendean Nursing Home DS0000002069.V279850.R01.S.doc Version 5.1 Page 28 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.V279850.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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