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Inspection on 05/08/08 for Pendlebury Manor Care Home

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

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Adequate service.

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

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

What the care home does well

People living in the home said they are treated well. They said `staff are nice` and look after them. Relatives spoken with said they were happy with the care and service provided. An assessment of needs is carried out before a person moves into the home so that they can be confident that staff at the home have the skills necessary to meet their needs. People living in the home continue to benefit from a wholesome nutritious diet so maintaining their health and well being.

What has improved since the last inspection?

Recording in care plans has improved since our last inspection. All of the care plans seen were well written, up to date and contained the information required to make sure that staff could meet people`s needs.The outside of the building looks more attractive and welcoming. Work continues on the interior to ensure that the home is a safe and comfortable place to live in. A representative from the company that owns the home visits unannounced once a month and monitors the quality of care and facilities provided there. A report is written and made available to the manager. This means that any issues regarding the quality of care provided should be identified quickly and action taken so that people living in the home are provided with good care. Since our last inspection the new manager has identified several areas of poor practice. Some of these issues have been dealt with through disciplinary procedures so promoting good practice and ensuring that people`s needs are met.

What the care home could do better:

A more robust management structure is needed to ensure that the manager has the support and time to deal with all aspects of running a care home. Staff need to make sure that people living in the home are not put at risk of cross infection by poor practice. Some areas of the home need to be cleaned more thoroughly to ensure people live in a safe and comfortable environment. The temperatures of hot food and fridge/freezers temperatures should be taken and recorded. This is to ensure that food is stored and served at the correct temperature to avoid any health related problems. Recruitment practices need to improve. Records of any issues that are identified during the process and records of any conversations/exploration of issues during interviews should be kept so that it is clear how a decision to employ staff is made. The health and safety of people living in the home must be promoted and maintained. Risk assessments must be carried out where there is any identified risk to people. Products classified under Control of Substances hazardous to Health (COSHH) Regulations must be placed in a locked cupboard to ensure that they cannot be accidentally ingested by someone living in the home.

CARE HOMES FOR OLDER PEOPLE Pendlebury Manor Care Home Pendlebury Manor Care Home, Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD Lead Inspector Helena Dennett Key Unannounced Inspection 5 August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendlebury Manor Care Home DS0000018805.V366164.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.V366164.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendlebury Manor Care Home Address Pendlebury Manor Care Home, Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 0LD 01260 253555 01260 251641 pendlebury.manor@virgin.net 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 Care Homes Ltd Manager post vacant 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.V366164.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 10 January 2008 Date of last inspection Brief Description of the Service: Pendlebury Manor provides care for up to 61 people with dementia who require personal care only. It is situated on the outskirts of Macclesfield. The home is divided into two units: the Villa and the Manor. Accommodation comprises of 53 single rooms and 4 shared rooms. There are dining and lounge areas in each unit and two passenger lifts for access to the first floor. There is adequate car parking facilities at the home. The weekly fee charged to the people living in the home ranges from £ 446.39 - £546.00 per week. The home manager provided this information. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced visit, part of our major inspection, took place on 5 August 2008. Two inspectors visited Pendlebury Manor Care Home and spent 6 hours there. During this time we looked around the home, spoke with people who were living in the home and two relatives. We also spoke to two members of staff and the manager about the care and services provided. We looked at five people’s records at in detail to see the care they were given. We also looked at medication records, care plans and training records. A new manager has recently come into post at the home. Since beginning work at the home she has identified some poor practice and seventeen members of staff have left the home. During this time she has been unable to find some records including the fire log and maintenance contracts. These will be looked at on the next key inspection. What the service does well: What has improved since the last inspection? Recording in care plans has improved since our last inspection. All of the care plans seen were well written, up to date and contained the information required to make sure that staff could meet people’s needs. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 6 The outside of the building looks more attractive and welcoming. Work continues on the interior to ensure that the home is a safe and comfortable place to live in. A representative from the company that owns the home visits unannounced once a month and monitors the quality of care and facilities provided there. A report is written and made available to the manager. This means that any issues regarding the quality of care provided should be identified quickly and action taken so that people living in the home are provided with good care. Since our last inspection the new manager has identified several areas of poor practice. Some of these issues have been dealt with through disciplinary procedures so promoting good practice and ensuring that people’s needs are met. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. People considering moving into Pendlebury Manor Care Home have a full assessment of needs before moving in to ensure that staff at the home can meet their needs. EVIDENCE: Information about the home and the services provided is available for people who are thinking of moving in. This has not been updated to reflect the changes in the management. This needs to be done to make sure that people living in the home and people considering moving in know who to approach if they have any queries. The manager or a senior member of staff visits the person in their own home or hospital to do an assessment of needs before they move. This is to ensure that staff at the home have the skills to care for that person. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 9 Intermediate care is not provided so standard 6 does not apply. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. The care plans provide guidance so that staff can meet the health and personal care needs of people living in the home and the dignity of the people living in the home is maintained at all times. EVIDENCE: During our visit, we looked at the care plans of five people who live in the home. They all contained an assessment of the person’s needs. The information gained in this assessment is transferred to a plan of care so making sure that these needs are met. All of the care plans had been evaluated regularly and updated when the person’s condition changed. This means that all staff are aware of the care to be provided so that the health of the person is promoted and maintained. Some minor issues relating to the care plans were noted and these were discussed with the manager at the end of the visit. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 11 People living in the home have their weight checked regularly. This is recorded in the plan of care. Advice is sought from the district nurse or general practitioner if there are any concerns about a person’s health. People living in the home told us they were happy living there. They appeared relaxed in their environment and said that staff were ‘very good’. We spoke with two relatives who were visiting the home. Both were very happy with the home and the care provided. One person told us, ‘The staff are very good; they always let me know if there are any problems with my relative’. The person went on to say that their relative always looked nice and appeared happy in the home. We spoke to a health care professional who was visiting the home. She said that she had noticed improvements in the care being delivered. She thought that the staff were able to deal with any issues that arise. The manager observed some poor practice when she first came into post. She told us she has dealt with this and as a result some staff have left the home and new staff appointed. Some of those issues related to the management of medicines which have been dealt with satisfactorily. We looked at the management of medicines within the home. The records showed that people living in the home receive their medicines as prescribed by the doctor. Staff have had training on the management of medicines. We noticed that some of the staff interacted very well with the people living in the home. On the Manor one member of staff is always present in the lounge area. One of the carers was seen sitting and talking to most of the people in there, engaging them in conversation. Other staff were seen treating everyone with respect and explaining their actions to them in a calm, relaxed way. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to the service. There is an adequate range of social activities so people living in the home can keep active and stimulated. People living in the home receive a good balanced diet so promoting their health and well being. EVIDENCE: An activity co-ordinator was employed until recently. She provided several different activities for people to take part in including some outings. The position has been advertised and the manager is hopeful that the will be able to recruit someone soon. Photographs of recent events are displayed in the reception area. The manager told us that she will continue with visits from entertainers and that staff will make sure that people take part in activities. There is a pat a dog scheme, with a member of the scheme visiting the home on the day of our visit. People living in the home seemed to enjoy this and were seen interacting with the dog and its owner. The person’s life history is recorded in some of the care plans. This gives staff a better insight into the person’s likes, dislikes and social needs so they can adapt the care provided to ensure that it meets the person’s expectations. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 13 Visitors can come at any reasonable time. Visitors told us they are made feel welcome and find the staff friendly. According to the information received before our visit, staff ensure that people living in the home have the choice of a carer of the same sex if they express this preference. The information also states that staff have made made flash cards to enable people living in the home who have difficulties with communication to express their needs and preferences. People living in the home can follow their religious beliefs as they wish. Members of the clergy visit regularly and a weekly religious service is held in the home. Information about a person’s religious beliefs is gained during the assessment process and this is written in the care documentation. Since our last visit to the home we received a complaint from a person who did not wish to give their name. They said that there is not enough food available in the kitchen to meet people’s needs and that staff have to go to the local supermarket to purchase essential items. A new chef has been appointed since the last inspection. She explained that she is an ‘old fashioned cook’ and liked to cook everything from fresh. There is a menu in place and the chef explained that at times the meals have to be switched around if the butcher or fishmonger has not delivered their supplies in time. We visited the kitchen and looked at food stocks and records. There was plenty of food available in the kitchen and a large store of fresh vegetables and fruit. In addition there were seveal large tins of fruit, lots of packets of flour and cake mix on the sheves as well as the usual stocks of food found in a kitchen. One of the freezers contained lots of meat that had been frozen by the chef. Two large trays of homemade lasgane which were dated and labelled were also in the freezer. The chef told us she had made too much the day before and so decided to store them in the freezer. The chef told us she monitors food temperatures and the temperature of the fridges and freezers. These are not recorded and past records were not available. Both units of the home have a separate dining area. The tables on the Manor are chipped and in need of replacement. This has been identified on previous inspectons. They are covered with tablecloths during mealtimes. The dining room on the Villa is satisfactory. People were seen to enjoy their lunch of beef stew and dumplings and homemade bakewell tart for dessert. Alternatives are available if required. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. Although people living in the home have access to a good complaints procedure the lack of recording of action taken means that there is a risk that complaints may not be acted on. EVIDENCE: There is a complaints procedure, which is in the service user guide. A log of complaints received is kept. This showed that the previous manager had received two complaints but there were no details of the action taken to address either complaint. One complaint has been made recently to social services regarding the care of a person living in the home. There was no record made of this complaint. The manager told us that this was due to the fact it was being dealt with under the local authority’s safeguarding procedures; however, any action taken following this incident should have been recorded. There is a policy on safeguarding people in place at the home. The last training for staff on safeguarding adults took place in 2007. One member of staff told us she had not done training although she has worked at the home for about eight months. The manager told us that she is in the process of arranging this training with the local authority. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 15 Some recruitment practices are in need of improvement to ensure that only people suitable to work in care are employed. There is further detail about this in the section of the report on staffing. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. The planned refurbishment of the building should mean that, once complete, people will live in a pleasant a safe environment. Poor infection control practices mean that people living in the home may be placed at risk of cross infection. EVIDENCE: Improvements have been made to the outside of the building in the past year. The windows have been painted and a new gardener employed so the garden has been improved. A new walk in shower facility has been provided on the Villa and a new bath on the Manor. Two double bedrooms have been altered into single rooms, each with an en-suite facility. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 17 On the day of our visit a team of decorators were in the home. They were carrying out work on the corridors on the Villa. There were problems for the people who live at the home and these are recorded in more detail in the section of this report on management. Work was also in progress on some of the upstairs rooms on the Manor. The manager told us she has recently purchased several pillows and duvet covers for the bedrooms. We walked around part of the home and visited some bedrooms. Two rooms had a bad odour and the carpet required deep cleaning. The cupboards in the kitchenette on the Villa required cleaning and foodstuffs stored there should be decanted into a sealed container. The freezer part of the fridge required defrosting. Fridge temperatures are not monitored. The corridor from the outside of the home to the kitchen and laundry requires cleaning. The paintwork around the door leading to the main building was marked and stained. The flooring requires replacement. Several toiletries with no names on were left in some of the bathrooms. These should be removed so that people living at the home do not use or misuse them. In a bathroom on the Villa the temperature of the water was cool and not conducive for bathing. One of the carers told us this bathroom is not used. We noticed some poor practice in relation to infection control. We discussed this with the manager who agreed to address it with the person concerned. Protective clothing is available for non-essential visitors to the kitchen. Blue aprons are also available for staff when serving food. The laundry was visited and found to be clean and tidy. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. There are enough staff working in the home to meet the needs of the people living there. The recruitment processes used at the home need to be improved to make sure that staff are suitable to work with the people who live at the home. EVIDENCE: There were thirty-eight people living in the home in total on the day of the site visit, sixteen in the Manor unit and twenty-two on the Villa. One senior carer and two carers were working in each unit. The manager was also present in the home. Since the manager has been appointed a large number of staff have left the home. The manager told us that she had discovered some poor practice that has been dealt with through disciplinary procedures. The manager has managed to recruit several staff in replacement and agency staff are used. The manager told us the same agency carers are used so there is continuity of care for the people living in the home. We looked at the personnel files of three members of staff. All contained an application form, two references and a Criminal Record Bureau disclosure. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 19 Records of interviews are not kept and so it is difficult to judge how the decision to employ a person has been made. In one person’s file a reference from their last employer had not been obtained. Some issues relating to the employment of one person had not been followed through and recorded to ensure that the person was suitable to work with vulnerable people. Photographs were not available in some of the files. There were no contracts of employment in the files. The manager said these have not yet been issued. The manager told us that staff follow an induction programme; however there were no records to evidence this. There were no records of competency in any of the files to show that staff had the skills and knowledge to perform care duties. The manager told us that checks had been carried out by the deputy manager who has since left her employment. The last supervision records are dated December 2007 and these were done by the previous manager. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to the service. The management structure does not ensure that the home is run in an efficient and effective way. The health, safety and welfare of people living in the home is not always promoted and protected and so people may be at risk of injury and harm. EVIDENCE: A new manager has been appointed since our last inspection. She has worked in the care home environment previously and is an experienced manager. The deputy manager has also left which means that support for new the manager when undertaking her management duties is limited. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 21 The owner of the home and the manager discussed the possibility of replacing one deputy with two head of units. However there is a need to ensure that staff become familiar with the home and the policies and procedures before embarking on management duties. The manager of the home is also responsible for administration duties such as answering the telephone and collating information for the accounts department with regard to staff wages. This means there is less time to organise the office and spend on the ‘floor’. As a result the office was disorganised and some paperwork could not be found. The manager told us that some paperwork has gone missing recently. This includes the record of fire safety checks. There is a quality assurance system in place. The manager has started to conduct internal audits to monitor the quality of the care provided. According to the information sent to us before our visit questionnaires are sent out regularly to gain the views of the people living in the home and their relatives. These could not be found on the day of our visit. Since the last inspection the owner of the home has employed a person to visit the home unannounced every month to monitor the quality of the care and services provided. A report is prepared and given to the manager of the home following these visits. The manager told us she has held a staff meeting since coming to the home. However minutes of this meeting were not available. Staff hold small amounts of money belonging to people living in the home. Good records are kept and receipts gained for transactions. Some health and safety issues were found during our visit. Painters were working on the rear corridor on the Villa. Equipment such as stepladders and paint were placed in this corridor. Four people were in their rooms whilst painting work was going on in the corridor. The back door was open, which means that people living in the home could have left the building undetected. A mattress was being stored in one person’s bedroom. This was being used to prop the door open as the person was still in bed. The manager was told of this and it was dealt with immediately during our visit. One person living in the home was seen walking up and down the corridor into the main building and back. Although mobile this person used a walking aid which means they were sometimes unstable and at risk of tripping or falling. Risk assessments had not been carried out on the building and the areas where the painters were so people living in the home were at risk of injury. During the morning staff placed a table by the door leading to the corridor area to try and prevent the person walking down the corridor. However this meant Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 22 that if anyone who was in their room decided to go to the main building they would not have been able to do so. We noticed some items classified under Control of Substances Hazardous to health (COSHH) regulations were stored in unlocked rooms. This means that people living in the home may have been able to access them and would have been at risk should they decide to drink the liquid. Tubes of tooth cleaning tablets were seen in some bedrooms. Risk assessments should be done on this as these tablets contain harmful substances that could cause harm if eaten, for example by a person with dementia. The manager told us that a fire safety inspection had been carried out. We found some problems with fire precautions in the home. Although the report of the fire safety inspection had not yet been issued, the fire officer had told the manager what the problems were. The manager said she is addressing this. Records of the tests of fire safety equipment had gone missing. A new logbook has been set up and tests are now recorded. The manager told us that all staff have had moving and handling training. However all staff have not yet had fire safety training and action needs to be taken to address this. The manager told us that the lift and the hoists have been serviced recently. Records of the hoist service were seen. All other records pertaining to servicing of essential equipment could not be found. However we looked at a sample of these records during our major inspection in January 2008 and found them to be satisfactory. Pendlebury Manor Care Home DS0000018805.V366164.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Pendlebury Manor Care Home DS0000018805.V366164.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 OP38 Regulation 23(4)(d) & (e) Requirement The manager must; after consultation with the fire authority, make adequate arrangements for staff working at the care home to receive suitable training in fire prevention and take part in fire drills. This is to make sure that people living in the home are not put at unnecessary risk in the event of a fire breaking out. Timescale for action 05/11/08 2 OP38 13(4)(a) All parts of the home to which 06/09/08 service users have access must be so far as reasonably practicable free from hazards to their safety. Risk assessments must be carried out when there is a risk to people living in the home and action taken to minimise any risk so they remain as safe as possible in the home. Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The statement of purpose and service user guide for the home should be reviewed to make sure they contain accurate information for people considering using the service or who currently live in the home. A summary of the complaints made during the preceding twelve months and the action taken in response to the complaint should be kept sp that people living in the home know their complaints are listened to and acted on. Steps should be taken to make sure that staff adhere to infection control guidelines including; • monitoring hot food temperatures • monitoring fridge/freezer temperatures • replacing dining room tables on the Manor This is to make sure that people living in the home are not placed at risk of cross infection. All parts of the home should be kept clean and tidy and that carpets are cleaned regularly so minimising odours. This will ensure that the home is a pleasant place to live in. All information including a recent photograph should be obtained for a person before they start work in the home. Details of interviews and of any issues explored during the process should be kept. This is to make sure that only people suitable to work in the care industry are employed. Records of staff competency should be kept so that the manager knows the member of staff has the skills to carry out their role. 2 OP16 3 OP26 4 OP26 5 OP29 6 OP30 Pendlebury Manor Care Home DS0000018805.V366164.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Region Unit 1, Level 3 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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.V366164.R01.S.doc Version 5.2 Page 27 - 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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