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Inspection on 28/06/05 for Pendleton Court Care Centre

Also see our care home review for Pendleton Court Care Centre for more information

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

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

What the care home does well

Prospective residents have a pre admission assessment to ensure the home can meet the individual needs. Prospective residents were encouraged to visit the home prior to making a decision to stay at the home. Residents` remarks were generally that the staff were caring and kind and one relative stated that she always felt she could raise any concerns with the staff or management. House keeping in the home was being undertaken well despite some staff shortages. The home was generally clean throughout and the residents` clothes were well laundered.

What has improved since the last inspection?

Since the last inspection there has been minimal improvement in the care planning documentation and the requirement from the previous inspection has been reiterated. The appointment of a new enthusiastic manager and a care manager to assist the home to deal with the concerns raised had been made.

What the care home could do better:

Residents were not being provided with appealing, wholesome nutritious food.Requirements made following an Environmental Health inspection in the kitchen must be addressed. Medication administration practices and the recording of medication were not always as accurate as they should be. Organising the home`s system for managing complaints could be better. Training for staff, particularly in relation to the Protection of Vulnerable Adults required addressing. Improvements in ensuring all staff files contain appropriate references and Enhanced Criminal Records Bureau Disclosures must be made to safeguard the residents. Clearing up some kitchen waste and rubbish externally was required to minimise a risk to the health and safety of individuals.

CARE HOMES FOR OLDER PEOPLE Pendleton Court Care Centre 22 Chaplin Close Salford Manchester M6 8FW Lead Inspector Elizabeth Holt Unannounced 28 June 2005 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 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. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pendleton Court Care Centre Address 22 Chaplin Close Salford Manchester M6 8FW 0161 743 9798 0161 737 8080 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Highfield Home Properties Ltd CRH N 58 Care home Care home with nursing Category(ies) of OP Old age 57 registration, with number PD Physical disability 1 of places F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The number of persons requiring nursing care at any one time shall not exceed 25 older persons, aged 65 years and over. That the number of persons requiring accommodation for personal care only at any one time shall not exceed 38 older persons aged 60 years and over within the overall maximum occupancy of 58. The service users requiring personal care only may be accommodated on the first and second floors and rooms 7, 8, 9, 14 and 15 on the ground floor. The service users requiring nursing care may be accommodated on the ground floor only. 1 named individual requiring nursing care as a result of physical disability is accommodated in a designated room on the ground floor. The registration will revert to older people (OP) once the service user leaves the home. That the home complies with the Staffing Notice issued on 28th May 2003 in relation to those service users that are in receipt of nursing care. That dependency levels of service users are assessed on a continuous basis and staffing levels are adjusted where appropriate to ensure continued compliance with the Residential Forum Guidance for Staffing in Care Homes for Older People on the unit providing accommodation for service users receiving personal care only. That in addition to care staffing hours a minimum of 20 hours per week will be provided exclusively for activities. The home must at all times employ a manager who is registered with the Commission for Social Care Inspection. Date of last inspection 4 November 2004 F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Pendleton Court Care Centre is a care home registered to provide accomodation for up to 37 older people requiring nursing care and 21 places for older people requiring personal care only. The home is owned by Highfield Home Properties Limited. The home is a converted mansion house situated in an elevated position at the rear of a residential estate. The home provides accomodation on two floors in single en-suite bedrooms. A passenger lift provides access to each floor. The home is within walking distance of a local park and shops. The home is close to the local bus routes into Manchester city centre and Salford/Eccles and is close to the motorway network. The home has a temporary manager however a former manager has been nominated to return to manage the home, supported by a care manager. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, conducted by 2 inspectors, which took place over 7 hours on 28 June 2005. During the course of the inspection, time was spent talking to the home’s acting manager, residents, relatives and members of staff to find out their views of the home. Time was spent examining records, documents and residents’ care plans. Not all the requirements and recommendations from the previous inspection had been addressed and these have been included in this report. During the inspection only a selection of the key National Minimum Standards were assessed, therefore, in order to gain the full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well: What has improved since the last inspection? What they could do better: Residents were not being provided with appealing, wholesome nutritious food. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 7 Requirements made following an Environmental Health inspection in the kitchen must be addressed. Medication administration practices and the recording of medication were not always as accurate as they should be. Organising the home’s system for managing complaints could be better. Training for staff, particularly in relation to the Protection of Vulnerable Adults required addressing. Improvements in ensuring all staff files contain appropriate references and Enhanced Criminal Records Bureau Disclosures must be made to safeguard the residents. Clearing up some kitchen waste and rubbish externally was required to minimise a risk to the health and safety of individuals. 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. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. Service Users’ Guides were available for residents. Relatives/friends are able to visit the home before making the decision to stay at the home. EVIDENCE: The Service Users’ Guide provided prospective residents with information to enable them to make an informed choice about possible admission to the home. It was pleasing to see that a requirement made at the previous inspection for all residents to have evidence of a thorough pre-placement assessment had been addressed. The recommendation made at the last inspection for all Care Management assessments to be held on the residents files had not been addressed. Copies of pre admission assessments were available, however, these were available held altogether in a separate file. Where possible prospective residents and their family were encouraged to visit the home prior to making a decision about their admission. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 10 Care plans did not always demonstrate that they had been discussed with the resident or their next of kin. Residents and or their relatives must be involved in the care planning process. These records were not always signed, dated or have review dates recorded. The home did not offer intermediate care. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Each resident had an individual plan of care. Shortfalls within the recording of these care plans have the potential to place residents at risk. Residents’ health care needs were not always evidenced as being met due to lack of detailed information being recorded within the care plans. The homes medication policies and procedures were detailed, however, some shortfalls in the procedures may lead to residents not always being protected. EVIDENCE: There was evidence of some improvement in the care planning since the last inspection, however, the care plans examined did not always accurately reflect the changing health care needs of the residents accommodated. One example included a resident who had sustained an injury following a fall and his care plan did not reflect his changing needs. From the care plans examined it was difficult to establish where the most up to date information was held due to the large amount of information held. It is strongly recommended these files are streamlined. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 12 Detail showed a pressure sore had been reported and the treatment regime was recorded. The evaluation stated ‘care plan remains relevant’, however the nurse in charge informed the inspector that a dressing was not required any longer. It is required that care plans are regularly and appropriately reviewed. Limited evidence was seen of the involvement of the resident and their representatives’ involvement in the drawing up of the individuals care plan. Where it is not possible for residents and their relatives to sign, it is recommended this is recorded. The residents’ records did include evidence of involvement by other healthcare professionals e.g., dentists, opticians, chiropody and speech and language therapy. It was pleasing to see that the recordings of catheter changes and care in the care plans included appropriate detail and information. The daily recordings in the care plans of residents on the first floor, (personal care only) contained some inappropriate recordings, for example; ‘blatantly refused to get up’. Daily statements within care plans on the nursing floor included comments like; ‘fair day’, ‘good night’. Daily nursing reports must indicate the actual care given. Plans of care in relation to the equipment required for the promotion of tissue viability and the prevention of pressure sores recorded ;’regular pressure area care required’ and ‘nurse on the appropriate mattress’. A requirement was made accordingly. Observation of a number of residents accommodated showed them to be in need of nail care and oral hygiene care. Risk assessments available included: falls, moving and handling and nutrition, however, these were not reviewed regularly or clearly integrated into a plan of care. A specialist pharmacy inspection was carried out on 27 April 2005 where a number of issues including some in relation to the administration of medication were raised. The home provided an action plan on the 6 July 2005 showing where they had addressed the requirements made. The requirements will be followed up at the next inspection. Medication Administration Record Charts (MAR charts) were examined and some were found to be inappropriately completed with gaps. Controlled drugs storage and recording was found to be satisfactory. The staff at the home appeared to treat residents with respect and dignity, however, an incident was observed which raised serious concerns regarding the attitude and approach of one staff member towards a resident. This was F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 13 discussed with the manager of the home immediately and requested to be appropriately dealt with. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 standard(s) 15 Meal times appear to be a relaxing occasion, however, the food served was not appealing or well balanced leaving residents potentially at risk nutritionally. EVIDENCE: The inspectors observed lunchtime to be a relaxed, social occasion with the staff promoting a friendly atmosphere. Staff was observed to be pleasant and courteous to residents and sensitive when additional support was required during the mealtime. A number of concerns in relation to residents receiving a ‘wholesome appealing balanced diet’ were raised including the following : 1.The food served at lunchtime was observed to be dry and unappetising. 2. The soft diets observed seemed inappropriate for the individual residents. 3. Vegetables were peeled and pre-prepared for the following day. 4. Two residents complained that breakfast was toast and porridge on a regular basis. A comment regarding the lunch was that it was “not very tasty, there was nothing about it”. One of these residents also complained that he was “ushered out of the dining room when he did enjoy sitting there after his meals” and another resident stated “they were rushed at mealtimes”. 5. Food was observed being placed in the bain marie at 3.30pm by the cook. The bain marie did not appear very hot and this seemed early pre teatime. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 15 A letter of serious concern was sent to the home on 29 June 2005 and an action plan was received by the Commission on 18th July 2005. A new 4 week menu was to be discussed at the relatives meeting on 2 August 2005. An inspection was carried out by the Environmental Health Services on the 19 May 2005 where a number of concerns and subsequent requirements were made. An action plan must be forwarded to the Commission to demonstrate how these requirements and recommendations are to be addressed. The kitchen was clean and tidy at the time of the inspection and records of fridge and freezer temperatures were available At the time of the inspection 7 residents were on a holiday in Southport accompanied by care staff. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 A complaints procedure was in place and residents knew how they could make a complaint. Updates in staff training are required to protect residents from abuse more fully. EVIDENCE: A detailed complaints procedure was available, however, it is disappointing to note that the home’s response to the last inspection report indicated that all references to the NCSC in the complaints information had been addressed. The complaints procedure displayed in the entrance hallway referred to the NCSC. The home’s system for organising complaints was disorderly. The acting manager stated she had ordered a book to log complaints, however, this was not yet available. There was evidence that some complaints had been responded to in writing within appropriate timescales. The Commission For Social Care Inspection has received 6 complaints which were found to be partially upheld or upheld since the last inspection. Two further complaints remain under investigation. Requirements have been made in relation to personal care, inappropriate manual handling, inappropriate activities and some environmental issues. The home had an Adult Protection policy and a copy of Salford’s Multi-Agency policy for the Protection of Vulnerable Adults from abuse. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 17 It was clear from discussions with a number of staff that they had not actually read the policy and three staff members stated they had not received any specific training. Some of the staff spoken to could, however, explain what action they would take if a resident alleged that an incident of abuse had occurred in the home. The home is required to ensure all staff have received appropriate training in adult protection procedures. It is recommended that the home retain a tracking sheet to record the staff’s signatures when they had read the policy. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 19, 24, 25 and 26 The home was fit for its stated purpose and was clean. Residents’ bedrooms were clean, adequately decorated and comfortable. A risk assessment to the rear of the property is required to minimize the risk of hazards to safety. EVIDENCE: The bedrooms inspected were clean and tidy. The decor and the furnishings were of an acceptable standard. There was evidence that residents were encouraged to personalise their bedrooms with their own effects. During a tour of the home a bathroom was found to contain furniture and personal effects. These were removed during the course of the inspection. The home has a number of communal lounges and a smoking room that were appropriately furnished. Discussions were held highlighting that the dining F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 19 area on the first floor may be relocated nearer to the main lounge area on that floor. The home has a pleasant outside seating area to the side and front of the home. Several residents and their visitors were seen to be enjoying the warm weather on the day of the inspection. At the rear of the home, a certain amount of kitchen waste and rubbish was seen. This should be removed as it created a poor impression of the home and may pose a risk to the health and safety of individuals. The management of the home said this would be dealt with immediately. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated, however, the recruitment procedures of the home must be reviewed to protect and safeguard the residents. EVIDENCE: At the time of the inspection, the home accommodated 49 residents. This number included 3 residents who were in hospital. Twenty residents were in receipt of nursing care and 29 in receipt of personal care only. Seven residents were on holiday with care staff in Southport. The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. The staff duty rotas need to demonstrate in full the name of the agency nurse or carer for whom the shift has been allocated to. A sample of staff’s files were examined during the inspection. These files did not contain all the information listed in Schedule 2 of The Care Homes Regulations 2001. It is of serious concern that not all staff files held an appropriate Enhanced Criminal Records Bureau Disclosure including a satisfactory POVA first check prior to taking up employment. This was followed up in a letter of serious concern dated 29 June 2005 and a requirement made. This requirement was made at the last inspection with a short time scale and it is of serious concern that this has needed to be reiterated. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 21 There was evidence that newly appointed staff members had received induction training. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 38 An acting manager was in post to manage all the areas of practice required to promote the health, welfare and safety of residents. EVIDENCE: The acting manager was focusing on specific areas for development, however the home requires a registered manager and a period of stability in order to progress the requirements made in this report. The inspectors were introduced to the prospective manager who had managed another home within the group and she is proposing to be the registered manager. A deputy manager was appointed on 27 June to be the ‘care manager’. This change in managerial structure is to assist the home deal with the concerns raised. Care staff confirmed in discussion that they received supervision on a 3 monthly basis, however, these records were not examined at this inspection. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 23 The accident book was not in line with the requirement of the Data Protection Act 1998. Examination of the accident book showed this book to not be in line with the requirements of the Health and Safety Executive requirements. Accidents/incidents were recorded however a number of these lacked detail, for example; ‘found on bathroom floor behind door’, ‘Cut to back of head’. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x 3 x 2 F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 25 yes Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 Requirement Timescale for action 21.11.05 2. OP8 15 The service user plans of care, where possible, must be drawn up with the involvement of the service user in a style accessible to the service user. Once agreed it must be signed for by the resident whenever possible and/or their representative. 28.11.05 Service user plans must demonstrate that the home is able to meet the residents needs. They must reflect all the residents assessed needs and provide current, relevant information regarding the interventions required in order to meet those needs effectively. The previous timescale of 10.01.05 had not been met. Risk assessment review dates must be checked to ensure the risk assessments are being reviewed and updated on a regular basis. Care plans must be ammended in line with the review and integrated into the plan of care. The previous timescale of 14.12.04 had not been met. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc 3. OP8 15 30.10.05 Version 1.30 Page 26 4. OP9 13(2) 5. OP15 16 6. OP16 22 7. 8. OP18 OP19 18 23 The Medication Administration Records must be completed with codes used appropriately when medications are omitted. An audit of MAR charts must be carried out. The timescale of the 14.12.04 was made at the last inspection and the timescale has not been met. The home is required to provide adequate quantities , suitable, wholesome and nutritious food which is varied and properly prepared. It is required that the homes complaints policy contains the correct information and that complaints are addressed as per the procedure. It is required that all staff receive training in Adult Protection. It is required that the rubbish and kitchen waste at the rear of the home is removed. All staff files must contain the information specified in the Care Homes Regulations. No staff must be employed without obtaining an appropriate Enhanced Criminal Records Bureau check and 2 satisfactory written references. The home is required to supply the Commisssion for Social Care Inspection with an action plan to demonstrate how they intend to meet the requirements and recommendations made during the Environmental Health Services visit in May 2005. It is required that all accidents are recorded in detail in an accident book meet the requirements of the Data Protection Act 1998. 30.10.05 Within 1 day of receipt of this report. 10.11.05 10.12.05 Within 1 day of receipt of this report 1.11.05 9. OP29 19 10. OP38 23 10.11.05 11. OP38 23 10.11.05 F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP18 Good Practice Recommendations It is strongly recommended that care management assessments are held with the relevant plans of care. It is strongly recommended that staff sign a tracking sheet to demonstrate they have read the homes policies and procedures. F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 F55 F05 S6726 Pendleton Court Care Centre V229880 210605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!