Inspection on 03/07/07 for Pendlebury Manor Care Home

This inspection was carried out on 3rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Pendlebury Manor Care Home 27/01/10

Pendlebury Manor Care Home 04/08/09

Pendlebury Manor Care Home 05/08/08

Pendlebury Manor Care Home 10/01/08

Pendlebury Manor Care Home 09/05/06

Pendlebury Manor Care Home 10/01/06

Pendlebury Manor Care Home 07/06/05

Pendlebury Manor Care Home 16/12/04

Pendlebury Manor Care Home 30/07/04

Pendlebury Manor Care Home 24/05/04

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

CARE HOMES FOR OLDER PEOPLE Pendlebury Manor Care Home Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD Lead Inspector Denis Coffey Unannounced Inspection 3 July 2007 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 Pendlebury Manor Care Home DS0000018805.V335314.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. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendlebury Manor Care Home Address Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD 01260 253555 01260 253041 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) Pendlebury Healthcare Limited Susan Ann Bellamy Care Home 61 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (61) of places Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 61 service users to include * Up to 61 service users in the category of DE(E) (dementia over the age of 65 years) requiring personal care only * Up to 5 service users in the category of DE (dementia, aged between 50 and 65 years) requiring personal care only Date of last inspection 20 March 2007 Brief Description of the Service: Pendlebury Manor is a care home providing care for up to 61 people with dementia who require personal care only. The premises are divided into two units: the Villa and the Manor. Accommodation comprises of 53 single rooms and 4 double rooms. There are dining and lounge areas in each unit and two passenger lifts for access to the first floor. The weekly fee charged to the residents is from £462.24 to £515.16. Additional costs may be charged dependent on the bedroom occupied. The home manager provided this information on 25 June 2007. Information regarding the fees can be obtained by telephoning the home. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of the home looked at events that have occurred since the last inspection. The inspectors (Denis Coffey & Helena Dennett) visited the home unannounced on 3 July 2007. They toured the building, looked at care and general records, spoke with people who live at the home and staff. A pharmacy inspector from CSCI looked at the management, storage, administration and records of medicines. People who live at the home were positive in their comments about the care they received, the support provided by the staff and the services provided by the home. CSCI comment cards were sent out before the inspection visit took place to people living at the home; none were returned. A random inspection of the home was carried out on 19 October 2006 to check up on the progress made in relation to the findings of the key inspection that was carried out on 9 May 2006. Some of the requirements made had been satisfactorily met and some had not. What the service does well: What has improved since the last inspection? The arrangements for the storage of medicines have improved so they are now kept more securely in the home. There is an adequate supply of hot water to the baths around the home so that the people who live at the home can now use any of the bathrooms as needed. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 6 Storage arrangements around the home have improved so that the sluice rooms no longer have to be used for storage. What they could do better: A statement of terms and conditions should be provided to all people live at the home so they know what their rights and responsibilities are whilst living at the home. Full assessments need to have been done before staff from the home agree that a person can move in so that it is clear that the person’s needs can be met at the home. The care plans should include information about what staff need to do to meet peoples needs to make sure that all their needs are met in the way they prefer. The medicine administration records must be kept accurately so it is clear that people who live at the home have been given their medicines as prescribed. The fitment attached to the handrail leading to the garden of the Villa Unit should be repaired to make sure that people can use it safely. Other problems that create risks for people living at the home should be attended to for the same reason. Whilst the standard of cleanliness in the kitchen has improved, further improvements are needed to make sure that all the equipment used in the kitchen is kept clean. The number of hours available for cleaning and laundry needs to be increased so that the cleanliness of the home is improved. Staff records should include information about each member of staff’s contracted hours and two references must be obtained for all staff who are recruited to work at the home to make sure that they are suitable to work in a care home. Regular unannounced monthly visits to the home should be undertaken by a representative of the company that owns the home to check on the quality of the service being provided there. The quality assurance system being used at the home needs to improve to make sure that action is taken as a result of the feedback provided. Please contact the provider for advice of actions taken in response to this Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 7 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. Pendlebury Manor Care Home DS0000018805.V335314.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 Pendlebury Manor Care Home DS0000018805.V335314.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): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of people’s care needs are carried out before they move into the home to show that their needs can be met there. EVIDENCE: The care records of two people who had recently moved into the home were checked. One record was of a person who had been referred by their social worker as an emergency. The assessment contained all the relevant information, including a mental health assessment and a falls risk assessment. The person’s religious beliefs had also been recorded. This person’s contract identified that they had chosen a single room and what the weekly cost of would be. There was nothing to show that they had been given a statement of terms and conditions. The deputy manager said that this was because the person’s placement was initially temporary. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 10 The second set of records contained an assessment of needs. There was a copy of an assessment done by a care manager from the local authority although this was not received at the home until three weeks after the person had moved in. There was a statement of terms and conditions in place. The home does not provide intermediate care, so Standard 6 does not apply. Pendlebury Manor Care Home DS0000018805.V335314.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 poor. This judgement has been made using available evidence including a visit to this service. Plans of care were in place but did not show what staff must do to provide appropriate care so people who live at the home were at risk of not having their needs met. Medicines were not well managed so people who live at the home may not be receiving these as prescribed. EVIDENCE: The care plans of three people were looked at in detail. These contained assessments for falls, nutrition, moving and handling, and skin care needs. Plans of care were in place that identified specific needs/problems and the care that was to be given to meet these. However, there was no plan of care in place for one person who had a pressure sore. District nurses were visiting the home to dress this person’s sore, but there was no guidance for staff on how to provide appropriate care for this problem. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 12 There was specific information in the files about the nutrition/fluid needs for two people but the cook did not know about the nutritional needs of one person living in the home and the information about fluids was not identified in a plan of care. Only some of the care plans were dated to show when they had been put into place. The pharmacy inspector inspected the medicines and medicine records for the Villa and the Manor because of concerns about these arising from the last inspection at the home. There are two medicine storage rooms in the home; the floor of one was very sticky and the other was damaged. The facility at the Manor did not have enough space for the medicines. They were piled up and some fell out of the medicines trolley when it was opened. This may cause damage to the medicines. In both rooms the dressings storage was untidy and there were irrigation solutions that may not be fit for use as they were almost passed or passed their recommended shelf life. Many of the medicines had been dated when opened to show they were fit to use. In the trolley in the Villa some tablets and some dressings were in a resident’s box of laxative sachets. This may damage the sachets or cause the other things to be mislaid. The medicine administration records for forty-four people who live at the home were checked. Twenty-nine of these had no significant problems. Three peoples’ records did not include the amount of medicine available at the start of each new sheet. Including this information helps to show that the medicines have been given properly. For example, when a person’s sedative medicine could not be found, the records did not help. Nobody had noticed that it had gone, nor ordered more. The record sheets for nine people did not have the dose given recorded when they were prescribed variable doses of medicines, and there were four omitted records of giving a medicine. On both units there were doctors’ letters offering support where people did not take their medicines willingly. Generally records of controlled drugs were an accurate description of their use but some had been altered to correct arithmetical errors, and one record of receipt was not complete. During the inspection the arrangements for the security of controlled drug cabinet key were changed. On the Manor a person’s medicine to thin the blood had not been recorded clearly. Three people were not having their medicines to the doctor’s directions and some eye drops were being given twice daily even though no directions were included in the record. In one person’s daily care record there was a record that clearly stated, “accept all medications”, yet the medicine administration record sheet showed that all medicines for that day were refused. Quality in this area is poor because people are at risk of medicine errors that are not identified by the home’s audit system. A list of staff responsible for administering medicines was in place, and evidence was seen of all but one of these receiving training in this procedure. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 13 The deputy manager said that the person there was no such record for had received training, and reference to this was included in their personnel file. However, there were no records available that demonstrated these staff had had their competencies assessed before they were given responsibility for giving out the medicines. In light of the observations made about the management of medicines it would be advisable for all of these staff to attend refresher training in medicines and have their competencies assessed following the training. Staff were seen to respond to people living at the home in a positive and supportive manner, addressing them appropriately, and ensuring that their privacy and dignity were not compromised when providing personal care for them. However, during the course of this visit the inspector observed one person being taken to a dining table at eleven am, put into a chair that was pushed up to the table and left there for over an hour before lunch was served. The member of staff who did this did not give the person a reason for doing so. Pendlebury Manor Care Home DS0000018805.V335314.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. There are social and leisure activities available for the people who live at the home to help them stay active and stimulated. EVIDENCE: A full time activity co-ordinator is employed at the home. She helps in the morning with meals and provides activities for people for the rest of her time in the home. There was evidence of crafts, painting, etc around the home and at the time of this inspection visit she was seen carrying out a manicure with a person who lives at the home. The co-ordinator said that she has a planned programme of activities, and a copy of this was on display. Two people visiting the home were spoken with. Both said that they were happy with the care provided for their relatives, and that staff treat everyone in an open and friendly manner. One visitor said that they liked to take their relative out several days a week and that the staff enabled them to do this. A weekly religious service is held at the home, and peoples’ religious beliefs are identified in their care records. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 15 Menus seen appeared varied and nutritious in content. People living at the home said that they enjoyed the food and that they ‘get well fed’. Lunch on the day of inspection was liver and onions, chips and broccoli followed by a dessert of cheesecake. Alternatives to the main courses are available. There was a good stock of food products in the kitchen storeroom that included fresh fruit and vegetables. People were seen to eat their food in a dignified way and staff appeared attentive at this time. There was a notice board in the dining room with a list of people’s names and their dietary needs. This appeared institutional and the deputy manager said that she would make arrangements for this information to be kept more discreetly. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Complaints are responded to appropriately giving an assurance to people that their concerns will be dealt with. There is a policy and staff receive training on protection of adults so that the people who live in the home can be safeguarded from possible abuse. EVIDENCE: The complaints log for the home shows that three complaints have been received since the last inspection, all of which had been made by the same person. Records were seen of meetings being held with the complainant and of the complaints being responded to by the home manager. Policies and procedures on protecting vulnerable adults are available at the home for staff to refer to. Records were seen of some of the staff receiving training on this, and a further training day has been organised for those staff that did not attend this. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general standard of the environment could be improved so that people live in safer and more comfortable surroundings. EVIDENCE: A maintenance person is employed at the home to carry out general repairs and upkeep of the building. During the course of the inspection visit it was noted that a number of toilet seat fittings were loose and therefore presented a hazard to people using them. It was also noted that the restraining chain fitted to a bathroom window on the first floor of the Villa was broken. When these were pointed out to the deputy manager she arranged for these issues to be attended to, which they were before the inspection was completed. There are gardens available for use by people on both units at the home. There is a ramped pathway into the garden on the Villa, with a handrail for Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 18 people who are unsteady on their feet to use. The door leading to the garden was open and the post holding the handrail in place was not firmly embedded into the ground, a result of which was that the handrail was loose and not secure. There are toilets and bathrooms in each unit, close to bedrooms and communal areas. There was a problem with the supply of hot water to baths at the last inspection which has now been resolved. Two of the baths on the Villa have floor mounted bathing chairs fitted by them for use with people who are unable to get into or out of a bath unaided. These chairs had drainage holes in the seating area and present an entrapment hazard to males when being used. The floor in the toilet next to the medicines storage room on the Manor was uneven and badly marked, and the flooring in the medicines storage room was torn and raised along the tear. The state of the flooring in both rooms presents a trip/fall hazard to anyone using them. It was also noted that a number of wash hand basins did not have plugs supplied, and therefore it is difficult to see how people could wash their hands adequately after using the toilet. The deputy manager she said that these are replaced but continually go missing. It was suggested that an alternative method of storing these be looked into. A number of bedrooms were visited on both units. These were seen to be comfortably furnished, and in a lot of cases personalised by the person occupying the room or by members of their family. During the inspection visit a family member of one person had brought in a display cabinet for their room and had filled this with mementos and personal items belonging to them. Domestic staff are employed to work on both units and the deputy manager said that the number of hours allocated for this would increase the week following this inspection as a new member of domestic staff was due to start work then. It was suggested that the cleaning routine on the Manor be reviewed as bedrooms were being cleaned in the morning before the dining room which was not being cleaned until just before lunch was served. During this time, on the day of the inspection visit, there was a noticeable amount of food from breakfast on the tables and carpet. People living at the home were using this area during this period. The standard of cleanliness in the kitchen has improved but there are areas that still require attention. The microwave needed thoroughly cleaning, and the large chest freezer had a build up of ice in it that was stained. The freezer was seen to be in this condition at the last inspection. The freezer also needed cleaning and the top was scored and stained. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Although there are sufficient care staff on duty to provide care for the people who live at the home, the recruitment process needs to be improved so that all the required checks on new staff are obtained. EVIDENCE: There is a team of care staff employed at the home, together with catering, domestic and maintenance staff. The rotas for the care staff showed that for most of the time there were six care staff on duty in the morning, and five in the afternoon. The rotas also showed that there are four staff on duty at night, and that there is a senior carer on duty at all times. One person is employed in the laundry who works 8 am to 5 pm five days a week. This person works alternate weekends when they also carry out general cleaning duties on one of the units. When this person is not working, a member of the domestic staff works in the laundry for approximately three hours each day. At 10.30 on the morning of the inspection the inspector visited the laundry and noted that both washing machines were in use, and that there were fourteen large skips of clothing, etc waiting to be laundered. The person working in the laundry at this time said that they did not think they would be able to get through all of the washing to be done that day. This arrangement is not satisfactory as the reduction in available hours to both Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 20 laundry and domestic duties results in a delay in processing laundry and inconsistent cleaning routines. A total of eighteen staff are employed to provide care; six of them have achieved an NVQ level 2 in care. One other person was currently undertaking training leading to this qualification and the deputy manager said that she was doing the training course leading to an NVQ level 3. The personnel files of four people employed at the home were examined. All contained completed application forms and satisfactory protection of vulnerable adults checks. Two did not have the information regarding the number of weekly hours the people were employed for, and three did not contain health declarations. The application forms ask the person to fill in minimum information regarding their health that needs to be expanded on. Requests for references had been sent out for all staff but the previous employers of two of the staff had responded that it was their company’s policy not to supply references. In such circumstances, the manager would be advised to ask for the contact details of a third person who could supply a reference. Staff training files showed that training had been provided within the past twelve months on: diabetes, safe moving and handling practices, adult protection and dementia. Further training sessions have been booked for infection control, dementia, adult protection, and safe moving and handling. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There is a quality assurance system in place but it needs to be improved to make sure that the home is being run in the best interests of the people who live there. EVIDENCE: At the time of inspection the home manager was on annual leave. The deputy manager was in charge of the home in her absence and was not included in the care hours being provided so she could carry out management duties. Surveys have been sent out to families from the home to find out what they thought about the standards of care provided at the home. Some have been Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 22 completed and returned, but the information from these has not been collated, and there was no overall plan devised to address the issues raised. A representative of the company is required to carry out an unannounced inspection visit to the home each month, during which they are expected to tour the premises, speak with people living at the home and members of staff, inspect the home’s records, and write a report on their findings/observations. Records were seen of such visits taking place in February, April and June of this year only. Small amounts of money are held at the home for the people who live there. A balance sheet identifying all transactions is kept for each person, with two staff signatures are obtained for each transaction, and where possible receipts are kept. The records and cash balances were examined for one person and found to be correct. A sample of maintenance records were looked at and found to be satisfactory. There was evidence that the gas system had been checked. There were records to show that fire safety tests had been carried out and that staff has taken part in fire drills. During the inspection visit a member of staff who was helping people who live in the home to move was seen to be wearing high-heeled shoes. This footwear is not appropriate and could compromise the health and safety of people living at the home and the member of staff. Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 2 2 2 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 5A Timescale for action All people living at the home 31/07/07 must be provided with a statement of the terms and conditions of living at the home to ensure that they are aware of their rights. The plans of care for each person 31/07/07 living at the home must accurately reflect their needs, and demonstrate how these needs are to be met to make sure that appropriate care is given to meet all the person’s identified needs. Medicine storage facilities must 31/07/07 be safe, clean, secure, kept at the appropriate temperature and have enough space to store medicines in an organised way so that they are not mislaid, depriving people of their medicines. Records of the receipt, giving 31/07/07 and disposal of medicines must be clear, accurate and include the date, quantity/dose and signature of the person doing it to show that people have been given their medicines properly, DS0000018805.V335314.R01.S.doc Version 5.2 Page 25 Requirement 2 OP7 17(1)(a) Schedule 3 3 OP9 13(2) 4 OP9 13(2) Pendlebury Manor Care Home 5 6 OP9 OP19 13(2) 13(4)(a) 7 OP21 13(4)(c) 8 OP38 23(2)(b) 9 OP26 13(3) 10 OP29 16(2)(e) & (j) 19(1)(b) 11 OP29 12 OP33 26(3) and that medicines have been managed securely. Reference to medicine care records must be accurate. The handrail leading to the garden on the Villa Unit must be made secure to reduce the risks of falls/trips by people using this doorway. The seating provided to the floor mounted bath chairs in the Villa Unit must be replaced as these present an entrapment hazard when used by men who live at the home. The flooring in the rooms identified in the main body of the report must be replaced as these present a falls/trip hazard. The large chest freezer and microwave in the kitchen requires thorough cleaning to reduce the risk of cross infection occurring. Sufficient and suitable staff must be employed for cleaning the home and laundering peoples’ clothing and the home’s linen. Full recruitment/employment records must be kept to ensure that suitable people are working at the home. Monthly unannounced visits must take place at the home by a representative of the company to review the quality and standards of care provided. 31/07/07 31/07/07 15/08/07 15/08/07 31/07/07 15/08/07 31/07/07 15/08/07 Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 2 3 Refer to Standard OP9 OP9 OP9 OP19 Good Practice Recommendations Counting triangles should be provided to enable staff to check amounts of medicines, particularly controlled drugs, hygienically. Updated training in the management of medicines should be arranged for all staff who carry out this procedure to ensure that they are competent. Consideration should be given to providing enough facilities to store controlled drugs to the correct specification. Window restrictor fastenings should be checked regularly to make sure that people are safe. It is recommended that stronger window restrictors are fitted to all the first floor windows so these do not get broken so easily. More care staff should be encouraged to undertake NVQ training in care to develop their skills to provide good quality care for the people who live in the home. Staff should be directed to wear suitable footwear for the work they carry out to reduce injury both to themselves and people living at the home. 4 5 OP28 OP38 Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Pendlebury Manor Care Home DS0000018805.V335314.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!