Inspection on 19/09/06 for Pendruccombe House

This inspection was carried out on 19th September 2006.

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

Pendruccombe House 06/12/05

Pendruccombe House 20/04/05

Pendruccombe House 05/10/04

Pendruccombe House 10/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Pendruccombe House (Nursing) 23 Tavistock Road Launceston Cornwall PL15 9HF Lead Inspector Kerensa Livingstone Key Unannounced Inspection 19th September 2006 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 Pendruccombe House (Nursing) DS0000009244.V304932.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. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendruccombe House (Nursing) Address 23 Tavistock Road Launceston Cornwall PL15 9HF 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) 01566 776100 01566 775700 pendruccombe@btconnect.com A J & Co (Devon) Limited Mrs Lynda Anne Winston Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (27), Terminally ill (27) of places Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 27 adults of old age (OP) Service users to include up to 27 adults with a physical disability (PD) Service users to include up to 27 adults with a terminal illness (TI) some of whom may have nursing needs. Total number of service users not to exceed a maximum of 27 Date of last inspection 6th December 2005 Brief Description of the Service: Pendruccombe House (Nursing) provides accommodation and nursing care for 27 people in need of care due to old age or physical disability over the age of sixty-five. Pendruccombe House is a large purpose built home on the edge of Launceston town. Also owned by the same company and on the same site is Pendruccombe Residential Home. This report relates to the Nursing provision only. The accommodation offered is on two floors, with a lift access to the first floor. Service users have a choice of two lounges, one of which also has a dining area and a separate dining room. Service users are encouraged to take their meals in the dining areas, but may eat within their private room if that is their choice. There is a large conservatory with comfortable seating which leads outside to a patio area, accessible to wheelchair users as well as those more mobile. Activities are arranged within the home as well as outings for Service users who wish to partake in these trips. For those who do not wish to visit or are unable to get into Launceston, hairdressing, opticians, chiropody and dental services are arranged at Pendruccombe on a domiciliary basis. There is a hairdressing room with specialist equipment, which is operated once a week. There is a small parking area to the front of the home and parking to the rear. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over on full day by one inspector. The nurse in charge was extremely helpful throughout the inspection and the inspector had the opportunity to meet the Registered Manager towards the end of the inspection when they came on duty. The inspector had the opportunity to inspect the environment, meet staff and service users. Records were inspected including care documentation. The inspector met with visitors and relatives to the home. Observation and case tracking was used during the inspection. What the service does well: What has improved since the last inspection? Training for staff has improved in certain areas such as Protection of Vulnerable Adults, Fire, Moving and Handling. The care documentation has been reorganised and demonstrate that the service user is central to this Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 6 process. There is evidence of a comprehensive range of assessment tools that are used and reflect the complexity of needs. These are reviewed regularly, as required. Staff report that the running of the home has benefited from clear leadership since the new Manager arrived. A lockable space has been provided for service users, in their private accommodation. 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. Pendruccombe House (Nursing) DS0000009244.V304932.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 Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users are provided with information to enable them to make an informed choice and a full assessment is completed prior to them moving in to the home. EVIDENCE: Since the last inspection the Statement of Purpose and Service User’s Guide, which is a combined document, has been reviewed. This is a comprehensive document illustrated with photographs. This document is available in the reception of the home with a copy of the most recent report. A copy is provided to each service user in their room. The inspector observed evidence that Service users are assessed prior to admission to ensure that the home can meet their needs. Detailed information is gathered and this forms the basis for the care plan. New service users are able to visit and/or move in on a trial basis if they wish. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 9 Standard 6 was not assessed, as this home does not provide Intermediate Care. Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The staff work very hard to meet the Service user’s health and personal care needs, whilst ensuring the service user’s dignity is respected. Medicines are stored and administered safely. EVIDENCE: Since the last inspection the documentation used for the planning and directing care has been reviewed and noticeably improved. After the initial assessment a Service user profile is developed to include life story, preferred social events and activities. A plan of care is compiled service users and/or their representatives must be involved in this process. There is evidence that this plan of care is reviewed at least monthly as required. In addition to this nutritional, moving and handling assessments and tissue viability assessments are reviewed monthly. The Primary Healthcare teams and Home have established links e.g. tissue viability, continence viability, community physiotherapist. In each service user’s room there are individual plans of how to meet the individual needs of the service user e.g. ‘how to meet the personal hygiene needs’. Carers sign to confirm they have delivered the care that is Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 11 planned. The inspector was impressed with the comprehensive documentation and high standard of recording that is undertaken. The home aims to promote service users’ health and ensures access to health care services to meet assessed needs. All service users are registered with a General Practitioner, in fact seven different ones. Nursing care is provided within the home, with input from other professionals sought as and when required e.g. Tissue Viability/Continence Nurses, Speech and Language Nurses. Risk assessment and management tools are utilised for example these cover falls, manual handling assessment, Barthel assessment, bed rails, scalding. Records are kept of healthcare related visits. A Chiropodist visits the home six weekly and dental services are arranged as required. An optician visits the home regularly. Physiotherapy and audiology is available at the local Launceston Hospital. Continence assessments had been reviewed recently. The home has policies and procedures with regard to medication. All medication is administered by a qualified nurse, who are required to work to Nursing and Midwifery Council guidelines. Medicines are stored in a secure cupboard. A ‘blister pack’ system is used for the medication. A fridge is available specifically for the storage of medication. Each service user has their photograph contained within the medication file to aid identification. A new drugs trolley has been purchased since the last inspection; this can be manoeuvred more easily. There is a designated Controlled drugs (CD) cupboard. The inspector observed a drug round; medicines were administered and stored safely. Medication administration records were seen to be in order and signed appropriately. Service Users confirmed that they are free to make choices about whether to eat in the dining room or in their room. There are two dining rooms to choose from. Staff were observed to knock on Service Users doors and use preferred names. The Service User’s wishes, choices and routines for activities of daily living are recorded. All rooms are single occupancy, the home does have the facility to open a door to convert two singles into two adjoining rooms for a couple. Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are able to make choices about how they live their lives. Activities need to be provided to meet the service user’s needs. A nutritious, varied diet is provided supplemented with home baking. EVIDENCE: Individual accommodation is personalised and homely. Activities of daily living records detail the support or help needed. The records in the service user’s rooms are personalised to the individual. On the day of the unannounced inspection the hairdresser was visiting, she is provided with a designated hairdressing room and service users informed the inspector, it was like going to the salon. Service users are able to choose whether to have meals in their room or one of the two dining rooms. Service users’ interests are recorded. On the duty rota a carer is designated to coordinate activities on some afternoons, however the service users said that this is sometimes cancelled due to staffing. Several service users and a visitor commented on the need for more activities. The Manager was aware of the need to target this area and had arranged to meet with the Registered Manager in the adjoining residential care home to decide what action needs to be taken. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy; with visitors welcome at any reasonable time. Visitors confirmed that they are made to feel welcome, ‘I am offered a cup of tea and a biscuit, when Service users are having theirs’. The service users are encouraged to maintain links with the community if they so wish, and confirmed that there are no restrictions on visiting. A Visitors Book is maintained. Service users informed the inspector they could make choices about how to spend their time. The inspector observed evidence that the service users were able to make choices about when to get up. A varied, nutritious diet is offered to the Service Users, there is a choice at all meals. There is a choice of dining room to have lunch, whilst some Service Users prefer to take lunch in their room. Menus are changed on a four weekly cycle, this is due to be reviewed in November. This is posted in the reception area of the home, although on the day of the inspection a different week was posted than the one available. On the day of the Unannounced Key inspection, the menu was Meat and potato pie with seasonal vegetables or turkey steak, tomato, chips and peas. There was Peach Upside Down cake and custard or cheese and biscuits. The kitchen is spacious and ventilated. On the day of the unannounced inspection the Cook had made cakes and scotch eggs. Fresh fruit and vegetables are included on the menu. At the previous inspection the inspector and Manager discussed how the food records need to be able to demonstrate that all Service Users have had a nutritious diet and include any special diets, this still needs to be done. Cleaning schedules are maintained and fridge temperatures checked. The Inspector was informed that all staff working in the kitchen has a Foundation Food Hygiene certificate. The Head Cook has an Intermediate Food Hygiene certificate. There is access to snacks at all times. Homemade cakes were being made on the day of the inspection and always provided for birthdays. The Head Cook is planning to undertake further specialist training with the Chefs Award Scheme. Pendruccombe House (Nursing) DS0000009244.V304932.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are aware of whom to speak to if they have any concerns and staff are provided with training on safeguarding service users from abuse. EVIDENCE: The Commission for Social Care Inspection has not received any complaints or concerns about this home. The home has a complaints procedure, this is displayed within the entrance hall and distributed to all service users within the Service User’s guide. The complaints log was observed to be empty, as the inspector was informed that no complaints had been received and concerns are dealt with promptly by the Manager. The inspector and Manager discussed the usefulness of recording low-level complaints and concerns. It should include that the Complainant should contact the Department of Adult Social Care if they have any concerns about contractual issues. Service Users were aware of who they would speak to if they had any concerns. Written policies are in place to safeguard service users. This includes a whistle blowing procedure, Department of Health (DoH) guidance No Secrets and reference to the passing on of information to other appropriate professional bodies in line with the Public Interest Disclosure Act 1998. This included the Commission for Social Care Inspection and Social Services. Service users said that they would feel able to voice any concerns. Staff are receiving training in the Protection of Vulnerable Adults facilitated by the Registered Manager. The training records must reflect the training that staff have completed. Two staff Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 15 have attended the externally provided training and two more are booked to attend. Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 24 & 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service Users live in a safe, well-maintained and comfortable environment. The Service Users who spoke to the Inspector stated that their accommodation meets their needs. EVIDENCE: The home is well maintained, well decorated and accessible. There is wheelchair access. There is evidence that there is a programme of renewal and routine maintenance. The home is centrally heated, with each room heated by a covered radiator that allows the temperature control to be adjusted as required. There is plenty of natural lighting and opportunities for ventilation. There are lovely countryside views from the communal rooms and some of the Service Users rooms. The home was tidy and clean on the day of the Unannounced Inspection. Storage is provided for equipment. The home is clean, hygienic and free from odours on the day of inspection. Housekeeping staff are on duty on each floor daily and were evident during the inspection. Protective clothing is available for staff. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 17 There are choices of seating areas, which are pleasantly furnished and spacious. There is a welcoming reception area with seating provided, a lounge, dining room and additional lounge/dining room on the lower floor. These areas are furnished comfortably and in a homely way. There is an accessible large patio area to the rear of the home and a passenger lift, which services the home. The inspector was informed that redecorating had taken place since the last inspection e.g. service user’s rooms, the dining room, porch and corridors. Recarpeting for communal areas is planned. Service users informed the inspector that they liked the environment, including their personal accommodation. Service Users informed the Inspector that they liked the accommodation and felt that it met their needs. All rooms are single and one can be converted to a double by removing a door. Most rooms are ensuite with a toilet and a sink. Rooms individually and naturally ventilated. Adjustable beds are provided and furnishings as required. The inspector was informed that all rooms have been provided with a lockable space since the last inspection, however no doors are provided with a lock. The inspector has been informed that door locks are due to be installed. The registered person shall make arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. It is recommended that keys be provided unless a risk assessment suggests otherwise. All rooms should be fitted with these facilities. Lighting in service users rooms is domestic in nature. Rooms individually and naturally ventilated. The call bell system was malfunctioning on the day of the inspection and the inspector was informed that it had been doing so for sometime. This was disturbing service users and their visitors, as well as placing an additional burden on staff. The home is clean, hygienic and free from offensive odour on the day of inspection. Domestic staff are on duty on each floor daily; and were evident during the inspection. There is an Infection control Policy. The laundry appeared industrial, well managed and clean with an appropriate floor covering. A sluicing facility is available on the washing machines. Washing is ironed and sorted into baskets (labelled for each service user) and then returned to the rooms. Protective clothing is available in the laundry for the staff. Sluicing facilities are provided on each floor. Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The individual needs of the service users are met by the skills and knowledge of the staff, although role specific training should be improved and records need to reflect the training completed. The recruitment procedures must be tightened up to safeguard service users. The staff presented as hardworking and motivated. EVIDENCE: The staff member informed the inspector that the current staffing levels are in the morning 1 trained nurse plus 6 carers and in the afternoon 1 trained nurse plus 4 carers and at night 1 trained nurse plus 2 carers. 2 domestic staff and 1 general assistant are also on duty each day. On the day of the inspection there were six carers and two qualified nurses as one was undertaking their induction. There is a duty rota and this reflects the hours that are worked. Staff were observed to be very professionally presented in uniform. An induction programme is in place for all new staff, however it was not possible to inspect this as staff had their own records off the premises. The inspector and Registered Manager discussed the importance of being able to evidence that staff are provided with a comprehensive induction, which complies with Skills for Care requirements. One staff member confirmed that they were being provided with a comprehensive induction and commented on the high level of support for a new staff member. Ten out of twenty four care Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 19 staff have completed their National Vocational Qualification level two training, more staff are due to complete this training to meet the minimum 50 per cent of trained care staff. Staff are given a copy of the General Social Care Code of Practice. The recruitment and selection procedures are organised. Prospective staff are required to complete an application form, two written references, a satisfactory CRB and interview. It is recommended that the application form include the dates of previous employment to enable the interviewer to explore any gaps in employment. Interview records are kept by the respective manager, rather than in the recruitment files. However, on inspection three staff files were noted to include only one reference. One included a reference from a family member. A staff member due to commence unsupervised working did not have a CRB or POVA First check. All staff are provided with a Job description and contract. The recruitment procedures must be thorough to protect service users, these have been reviewed since the last inspection. The inspector discussed with the Registered Manager that the training records demonstrated that staff had undertaken mandatory training such as First Aid, Moving and Handling and Fire, however there was little evidence of staff attending professional development and role specific training. The inspector observed that the number of trained nurses may make it difficult to access training available due to there not be adequate cover. The Registered Provider must ensure that the persons employed receive training appropriate to the work they are to perform and suitable assistance, including time off for the purpose of obtaining further qualifications. Protection of Vulnerable Adults training was yet to be recorded. Staff reported that they were supported to undertake training and enjoyed working at the home. Pendruccombe House (Nursing) DS0000009244.V304932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Manager is very experienced, there is clear evidence of leadership and lines of accountability within the home. There are some issues relating to health and safety that require organisation. EVIDENCE: The Manager is a Registered Nurse, has completed the Registered Manager’s Award and has sixteen years of experience of working with the Older Person. The Manager has worked at Pendruccombe Nursing Home for almost a year and there is clear evidence of leadership and efficient management. This is endorsed by the staff and visitors to the home, who report that ‘things have improved’ since the Manager’s arrival. Staff spoke highly of the support that they are offered enabling them to continue with their roles. Staff meetings are held and feedback gathered from service users, relatives and staff. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 21 A survey was conducted to gather views from relatives, staff and visitors on the running of the home and a report compiled. This included personal care and support, catering, premises, management and information sharing. This was a detailed and comprehensive piece of work. It is recommended that other stakeholders are included next year. The evaluation and actions to be taken as a result of the survey were clearly identified. There is evidence that all the home’s Policies and Procedures are reviewed annually. Service Users and their family/or representative are encouraged to maintain control of their money. Written transactions are maintained and receipts provided for all dealings with Service Users monies. The administrator for the home is responsible for this area. Invoices are provided for payments, if service users do not have the resources. There is a facility for the safe keeping of valuables on behalf of the Service User, a receipt is provided. Supervision has been taking place, there was evidence that staff had received it twice this year and staff meetings are held. As discussed at the last inspection the Manager plans to increase their frequency to ensure that supervision takes place bimonthly and to include an appraisal, this is yet to be done. The home’s Administrator takes responsibility for the health and safety within the home is the First Aid trainer and assessor too. There is a comprehensive Fire risk assessment. The Fire Officer visited the home on the 21.11.05, no action was required. The Inspector was informed that all water is regulated, all windows restricted and all hot surfaces covered. Since the last inspection, the Registered Manager has arranged for staff to receive suitable training in fire prevention, the inspector was informed that all staff had received the required training. Seven staff are qualified First Aiders. Staff are provided with moving and handling training. Some environmental risk assessing has been undertaken by the Administrator and the Registered Manager, these do not include clear information about the risk management strategies and require further development. A health and safety audit is due to be undertaken by an external agency. Electrical portable appliance testing had not been undertaken at the time of the inspection, evidence has been supplied since the inspection that this has been done, a gas certificate is required. There is evidence that appliances and equipment is generally maintained. The inspector and Registered Manager discussed the importance of ensuring this is up to date. Legionella testing is undertaken. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 3 17 X 18 3 3 3 X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 2 Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 17(2) Sch 4. Requirement Timescale for action 01/12/06 2. OP24 3. OP29 4. OP38 The Registered Person must keep food records in such detail to enable any person inspecting to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual Service Users. Previous timescales not met 01/03/06. 12(3) (4) The registered person shall make 01/07/07 arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. E.g. Door locks are fitted suited to service user capabilities and accessible to staff in emergencies. Service users are provided with keys unless their risk assessment suggests otherwise. 19, 17(2) The Registered person shall not 01/12/06 Sch. 2 & 4 employ a person to work at the care home unless he has obtained the information and documents detailed in Schedule 2. 13(4) The Registered Provider must 01/12/06 DS0000009244.V304932.R01.S.doc Version 5.2 Pendruccombe House (Nursing) Page 24 ensure that unnecessary risks to health or safety of Service Users are identified and so far as possible eliminated e.g. environmental risk assessments. Previous timescales not met 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP29 OP36 OP38 Good Practice Recommendations For the application form to include dates of employment to enable the interviewer to explore any gaps in employment. For staff to receive formal supervision at least six times a year. For evidence of gas certification and PAT certification to be forwarded to the Commission for Social Care Inspection fao K. Livingstone. Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Pendruccombe House (Nursing) DS0000009244.V304932.R01.S.doc Version 5.2 Page 26 - 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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