Inspection on 09/05/06 for Pendlebury Manor Care Home

This inspection was carried out on 9th May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 03/07/07

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 OLD Lead Inspector Denis Coffey Unannounced Inspection 9th May 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 Pendlebury Manor Care Home DS0000018805.V289554.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. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pendlebury Manor Care Home Address Lyme Green Park London Road Lyme Green Macclesfield Cheshire SK11 OLD 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.V289554.R01.S.doc Version 5.1 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 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 10th January 2006 2. 3. Date of last inspection 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 50 single rooms and 6 double rooms. Dining and lounge areas are provided on each unit, and two passenger lifts are provided for access to the first floors. The weekly fee charged to the residents is between £417 to £477. Additional costs can be charged dependent on the bedroom occupied. The registered manager provided this information on 12th May 2006. Information regarding the fees can be obtained by telephoning the home or the local authority. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place on the 9th May 2006 and was carried out by Denis Coffey and Helena Dennett, CSCI Regulation Inspectors. The last inspection took place on 10th January 2006. This visit considered events that have occurred since then, e.g. notifications of accidents and incidents, and other information received by CSCI, as well as findings of the site visit. The visit took place over a 6-hour period and included a tour of the premises, speaking with residents, visitors and members of staff. Care records and the home’s general records were also inspected. What the service does well: What has improved since the last inspection? The residents care records now more accurately reflect their needs/problems and how these are to be met. Daily entries about each resident’s and welfare give more accurate information about their health and needs. Activities are now planned in advance rather than being provided on an ad-hoc basis as they were previously, and residents were seen to benefit from this. Substances that could prove harmful to the health of the residents are now stored securely and labelled appropriately. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 6 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. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 The quality of the way the home met the standards assessed was found to be adequate. Assessments of potential residents’ care needs are carried out before they move into the home so they know their needs can be met there but minor improvements are needed to the written statement of terms so that residents and their families have all the information they need about the conditions for living at the home. EVIDENCE: The care records of two people who have moved into the home since the last site visit were examined. Both of which contained satisafactory pre-admission assessments that had been carried out by a senior member of staff employed at the home. The written statement of terms and conditions for these two residents did not state the weekly fee payable. They did however identifiy additional costs and what these were for. The statement is one that is used by the company and had been amended to reflect that this referred to Pendlebury Manor by including the homes address at the top of page 1. It contained details of nursing and personal care. References were made to the laundering of clothes Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 9 in this statement, one of which stated that the home assumed no responsibility for mislaid or spoilt clothes. The home does not provide intermediate care therefore Standard 6 does not apply. See Recommendation 1 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality of the outcomes for these standards was found to be adequate. The care records of the residents were well documented, reflecting their care needs and how these were being met. The security of medicines needs improving to ensure the safety of the residents. EVIDENCE: The care records of three residents were examined at this visit. Resident 1 Care plans were in place that were comprehensively written and contained the details of this resident’s admission to the home. Risk assessments with regard to safe moving and handling and skin care were included. The resident has been identified as being at high risk due to falls and a risk management programme for this was in place. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 11 Plans of care dated 25th October 2005 were in place for the management of falls, continence, dementia, social and personal care, wandering and skin care. The care records identified that the resident liked to dance, enjoys music, benefits from one to one discussions, and attending church meetings which are held regularly. Most of the care plans have been regularly reviewed, and daily records were in place with regard to the residents health and well-being. Monthly weights were recorded that showed the resident had lost some weight for a few months but is now gaining weight. This resident had sustained a fall at the home and required treatment in hospital for a fractured femur as a result of the fall. Upon return to the home, the resident’s plans of care had not been updated to reflect the fact that she suffers from high blood pressure and that a district nurse was visiting to monitor this. However, there was evidence in the daily records and by looking at the resident that her condition has improved, and that staff are meeting her needs. This resident has been identified as being allergic to a particular type of medicine which was logged in the transfer document from the hospital. This should be identified in a more prominent place in her care records. A member of staff was able to identify this resident’s care needs in detail, and was aware of the associated health problems. The staff member discussed the treatment being given by the district nurse, and confirmed that the resident can now move around more independently, but that staff are monitoring this closely. The resident was seen walking around the home, and she appeared happy and content. Accident records were completed and stored with the care records, and evidence was seen of these being checked by a senior member of staff. Records were also seen of other healthcare professionals being involved in this residents care, e.g chiropody. A chiropodist visits the home every six weeks, and the resident was receiving treatment to her feet at the time of this visit. Resident 2 This resident was admitted to the home from outside the United Kingdom and evidence was seen of liason between the home and her country of origin to make sure that her needs could be met at the home. Risk assessments were documented for nutrition (records showed that she has gained 6kg since moving into the home), skin care, safe moving and handling and falls. Plans of care were in place that set out her individual needs and how the staff were going to meet them. Adequate daily records were kept in relation to the residents health and well-being. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 12 The inspector spoke with this resident at length. She said that she was happy with the care provided, but that she was very lonely. She added that she receives visits from members of her family. The resident went on to say that she liked her room, that the food was good, and that the staff were kind. A member of staff spoken with displayed a good awareness of this resident’s needs. The medicine administration record (MAR) sheets for this resident were in the main satisfactory. It was noted however that one of the medicines identified on her MAR sheet was to be given three times a day, but was recorded as being given four times a day. The senior care staff said that the consultant had altered the frequency of this medicine on the previous MAR, but this information had not been transferred to the current MAR sheet. Advice was given that this be done as soon as possible, and that future prescriptions for this medicine be checked to ensure that the frequency of administration was identified correctly on them. Resident 3 There was no written statement of terms and conditions regarding the services provided and the weekly fee payable found in this residents care records. Assessments of need were in place, and risk assessments for nutrition, safe moving and handling and falls were documented. Plans of care identifying the residents needs and how these are to be met were in place, and evidence was seen of these being reviewed regularly. Good daily records were kept, and staff spoken with displayed a good awareness of the residents needs. When spoken with, the resident said that they were happy with the care and services provided. Records were seen of the district nurse being involved in this residents care, and of visits to her by her social worker. All of the residents accommodated at the home are registered with a doctor and have access to the facilities of the NHS. During the course of this visit, staff were observed administering medicines to the residents on both the Manor and Villa Units. This was carried out in an unhurried and supportive manner, and residents who needed it were seen to be helped to take their medicines. However, it was observed that when administering medicines to residents away from the medicine trolleys, the staff left medicines out on top of the trolleys, and the keys in the door. There were occasions when the staff had their back to the trolleys and residents wandering around could have taken medicines without the staff being aware of this. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 13 Residents were seen to be assisted by the staff in a calm and supportive manner and for their dignity and privacy to be maintained when being helped with their personal care needs. Staff were heard to address the residents appropriately. All of the bedrooms at the home are used as single rooms and their doctor, or anyone else wishing to meet with them in private can see residents in their own rooms. Residents were dressed in their own clothes that appeared smart and well cared for. See Requirement 1 and Recommendation 2 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The quality of the way in which the home met these standards was found to be good. Social and recreational activities are provided so that residents can stay active and stimulated. Choice is offered to the residents so they can make decisions about their everyday lives. EVIDENCE: The provision of activities for the residents has improved since the last visit. The home now employs a full time activities co-ordinator whose role is to plan and deliver a range of social and leisure activities for the residents. Evidence was seen of residents being involved as much as possible in activities. An example seen at this visit was a large mural in the dining room of the Villa Unit where residents were observed to paint parts of this in. Examples of other pieces of art work completed by the residents was on display in various parts of the home. The activities co-ordinator discussed her intentions to develop activities to meet the individual needs of the residents, and has arranged themed days to coincide with significant days in the year. Several photographs of residents taking part in crafts, gardening etc, were on display. Relatives spoken with said that they appreciated the input given by the activities coordinator. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 15 At the time of this visit one of the residents was getting ready to spend the day at home with her family. Two sets of visitors present were spoken with. They said that they are made to feel welcome when visiting the home and that they are kept informed of any significant events affecting their family member. The visitors went on to say that they were happy with the care provided, and that they found the staff to be caring and supportive. Residents were seen to be dressed in their own clothes, and residents spoken with said that they are able to choose what the wear. One lady had decided to have a lie in bed, and when she got up she was given a hot drink and something to eat. Lunch on the day of this visit was meat pie, chips, carrots and cabbage, followed by a dessert of chocolate and rhubard crumble and custard. All of the vegetables prepared for the residents are fresh, and meat is delivered to the home daily. Residents spoken with were complimentary about the standard and quality of food provided, and one visitor remarked that the food was good and appetising. Alernatives are available to the main courses at each meal. These tend to be a choice of sandwiches, baked potatoes or omelettes. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality of the outcomes for the standards assessed was found to be good. There is information available to residents and visitors to the home on how to make complaints and how these will be dealt with so they know that their concerns will be listened to. Staff have received training on protecting people from abuse so that residents are protected from harm. EVIDENCE: The homes complaints records showed that one complaint had been recorded as being received at the home since the last visit. A letter from the companys administrator to the complainant was seen that stated the complaint had been investigated, and that the complaint was unfounded. A shortened version of the homes complaints procedure is contained in the written statement of terms and conditions. The full complaints procedure is kept in the homes procedure and policy file. A copy of the procedure was not on display to inform anyone visiting the home on how to make a complaint if they wished to. The home manager agreed to display a copy of this. The home has a policy on protecting vulnerable adults that defines abuse, who abusers may be, and the action to be taken if abuse is witnessed or suspected. A whistle blowing policy is also in place advising staff as to how they can make their concerns known if they suspect or witness poor practices taking place. The home manager said that all members of staff are given a copy of this upon commencement of employment. Most of the staff have received training in protecting vulnerable adults, and those that have not are due to receive this training in July 2006. Staff spoken with displayed a good awareness of their role in these issues. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 &26 The quality of the outcomes at the home of these standards was found to be poor because although the home has generally been well maintained, providing comfortable accommodation for those people living there, there are problems with bathrooms, with storage and with other matters that create risks for the residents. EVIDENCE: All areas of the home were inspected at this visit. Structural and redecoration work is continuing in the Villa Unit, some of which has been completed since the previous visit in January this year. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 18 The Villa Bedrooms were comfortably furnished and personalised by the residents or members of their families with photographs, ornaments, and in some instances small pieces of furniture brought in from home. There is a large sitting room and a smaller sitting area for use by residents, and dining facilities are provided. Floor mounted hoists were fitted to the baths for use with residents who are unable to get into and out of a bath unaided. There are a total of four baths and one newly installed shower room on the unit. There was no hot water available to three of the baths, despite the hot water tap being run for two minutes, and there was no hot water available for the shower. When asked how they bathed the residents, the staff said that they used a bathroom on the first floor. This bath did have a satisfactory supply of hot water, but staff have said in the past that they dislike using this bathroom as there were no curtains or blinds at the window and they feel this compromises the dignity of the residents. When reported on at previous visits, an assurance was given that suitable window coverings would be supplied to this window, but this has not been acted upon. A number of communal toilets did not have grab rails fitted for use by residents who may experience difficulty in using a toilet without such aids being present. This was particularly noticeable in one toilet where the toilet was raised off the floor At the previous visit a number of issues were identified in relation to reducing the risk of cross infection occurring. Evidence was seen of these matters being addressed satisfactorily. However, at this visit, wheelchairs were seen being stored in the sluice room on the first floor. This type of equipment for use by residents should be stored in a clean area, as storing them in a sluice room increases the risk of cross infection occurring. The Manor Bedrooms were comfortably furnished and personalised by the residents and members of their families. The standard of decor on this unit is looking worn and in need of attention. The manager said that plans have been made for the unit to be redecorated once the refurbishment schedule on the Villa has been completed. Residents have the use of two sitting rooms and seperate dining facilites are provided. The hot water temperature of the water supplied to the baths was within acceptable limits, but the water pressure to one of the baths on the first floor was inadequate, and the water just dribbled out of the tap after being run for a couple of minutes There are two enclosed gardens leading off the Villa that can be accessed by all of the residents at the home. One of the gardens has garden tables, chairs and benches. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 19 All areas of the home accommodating residents were found to be clean and free from unpleasant smells. However, when visiting the main kitchen it was noted that the cleaning schedule in there had not been followed, and that the kithcen was in need of a general clean. See Requirements 2, 3, 4, 5 & 6 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality of the way in which the home met these standards was adequate. There were sufficient staff on duty to meet the needs of the people living at the home. Staff receive a range of training to enable them to provide appropriate care for the residents but residents would benefit from staff undertaking further, more structured training. Recruitment procedures need to be improved in order to ensure that residents are safe from possible harm and poor practice. EVIDENCE: At the time of this visit there were forty people living at the home. The duty rotas showed that there are normally five staff on duty during the day and four at night. The home manager is not included in these figures. A total of sixteen care staff are employed, four of whom have attained an NVQ level 2 in care, giving a figure of 25 of staff with such a qualification. The home manager is aware of the need for 50 of care staff to have this qualification or an equivalent and said that more staff would be starting such training through the Cheshire Training Consortium. Six of the staff have recently completed training in medicines and have been awarded certificates of proficiency in this. Staff training files were examined and records were seen of staff having received training in safe moving and handling procedures, adult protection, dementia care, basic food hygiene and first aid at work. Those staff that have not as yet received training in adult protection are due to undertake this in July 2006, and arrangements are being made for a nurse from the Primary Care Trust to provide further training in dementia. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 21 The personnel files of two members of staff were examined at this visit. Both contained completed application forms, equal opportunities questionairres, interview assessment forms, a written statement of terms and conditions of employment, and Criminal Record Bureau disclosures. One of the files contained two satisfactory written references, but the second only had one written reference in it. The need to ensure that two satisfactory references for prospective staff was discussed with the manager. See Requirements 7 & 8 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 33, 35 & 38 The quality of the outcomes for the standards assessed were found to be good. The home is managed in an open manner that encourages staff, residents’ and their families to express their opinions. Safety measures are in place that promote the health and welfare of the residents and the staff but need minor improvement to ensure that all service records for equipment in the home are current. EVIDENCE: The registered manager is a trained nurse who has been in post for one year. She is currently undertaking training leading to a registered managers award and has completed five of the nine learning units involved in this course. She expects to have successfully completed the whole course by September this year. Staff spoken with said that they find the manager approachable and willing to listen to them Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 23 A representative of the company carries out unannounced monthly visits to the home when they tour the building, speak with residents and staff, and review the homes records. The home manager devised quality assurance survey forms and sent these out to the relatives of 50 of the residents in December 2005. The responses to these forms were seen at this visit. The majority of the responses were positive, and all stated that they would recommend the home to others. The negative comments centred around the lack of provision for activities, but since then a full time activies co-ordinator has been employed. The home manager said that she plans to repeat this exercise to the remaining 50 of relatives in June this year. The home holds small amounts of personal money for the residents from which services such as hairdressing, chiropody and aromatherapy are paid for. A balance sheet is maintained for each resident that identifies the amount of money paid in, what has been withdrawn and the reasons for the withdrawals, and the balance of money left. Records were seen of signatures being obtained for all cash withdrawn. The records and cash balances of three residents were examined and found to be correct. Materials covered by the Control of Substances Hazardous to Health legislation were found to stored securely and to have appropriate labelling attached to them. Records were seen of the fire alarm and emergency lighting systems being tested on a regular basis, and current satisfactory test certificates for these were in place. There have been thirteen fire drills held at the home since January 2006, and records were seen of the majority of the staff having received fire safety training within the past twelve months. Those that have not had this are new employees, and the home manager said that she was in the process of arranging this training for them. A fire safety officer from the local brigade visited the home on 10th February 2006, during which time he made a number of requirements regarding fire safety. These were with regard to fire doors and equipment. A follow-up visit by this officer is due to take place on 16th May 2006. The home manager said that all of the required work has been carried out. The home is required to obtain a satisfactory gas safety certificate on an annual basis. The current certificate held at the home expired in April 2005 and the manager was informed that this needs to be addressed as a priority. The cold water system was disinfected in March 2006 and the passenger lift serviced in January 2006. Records were seen of the hoists at the home being serviced, with a renewal test date of September 2006 identified. See Requirement 9 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 24 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 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 3 3 2 2 X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 25 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. 2. Standard OP9 OP21 Regulation 13 23 Timescale for action The registered person must 31/05/06 ensure that medicines are kept securely stored at all times. The registered person must 31/05/06 ensure that there is an adequate supply of water at the home for bathing, and that the pressure of the hot water is sufficient for bathing. The registered person must 31/05/06 arrange for the supply and fitting of window covering to the bathroom on the first floor of the Villa Unit. The registered person must 20/06/06 make provision for safety rails to be fitted close to the toilets on the Villa Unit. The registered person must 31/05/06 ensure that personal equipment used for the care of the residents’ is not stored in sluice rooms. This requirement remains outstanding, and the timescale of 15/02/06 for meeting this requirement has not been met. Requirement 3. OP25 16 4. OP22 13 5. OP26 13 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 26 6. OP26 13 7. OP28 18 8. OP29 19 9. OP38 13 The registered person must ensure that the main kitchen is thoroughly cleaned, and that the kitchen remains in a clean condition. The registered person must ensure that qualified and competent staff are working at the home in such numbers as are appropriate for the health and welfare of the residents’. This requirement remains outstanding, and the timescale of 31/03/06 for meeting this requirement has not been met. The registered person must ensure that two satisfactory written references are obtained for all people employed at the home prior to them commencing employment. The registered person must obtain a current gas safety certificate for the home, and ensure that this is renewed annually. 31/05/06 30/06/06 31/05/06 20/06/06 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 Refer to Standard OP2 OP7 Good Practice Recommendations The home’s written statement of terms and conditions given to residents and their families should include the weekly fee payable to the home. Staff should ensure that care plans are updated and new ones put in place when residents’ needs change. Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Pendlebury Manor Care Home DS0000018805.V289554.R01.S.doc Version 5.1 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!