Inspection on 05/10/05 for Pennine Centre

This inspection was carried out on 5th October 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pennine Centre 07/01/10

Pennine Centre 27/01/09

Pennine Centre 06/11/07

Pennine Centre 14/11/06

Pennine Centre 08/02/06

Pennine Centre 03/12/04

Pennine Centre 30/06/04

Pennine Centre 27/02/04

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

CARE HOME ADULTS 18-65 Pennine Centre Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH Lead Inspector Angela Sizer Unannounced Inspection 5th October 2005 09:30 Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 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 Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 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 Adults 18-65. 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. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pennine Centre Address Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH 01482 839311 01482 839021 pat.walker@hullcc.gov.uk 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) Kingston upon Hull City Council Mrs Patricia Mary Walker Care Home 12 Category(ies) of Physical disability (12) registration, with number of places Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the intended work as stated in the action plan in regard to the premises is carried out. 3rd December 2004 Date of last inspection Brief Description of the Service: The Pennine Centre is a modern purpose built building situated on a large housing estate on the outskirts of the city of Hull. It is operated by Kingston upon Hull City Council, social services department. There is an adjacent day centre. The Pennine centre is in the midst of restructuring it’s stated purpose and it is intended that the home will cater for up to 12 younger adults with a physical disability on a respite/short term basis. The home is secure and has it’s own well tended grounds. Public transport is accessible adjacent to the home. Although local facilities are limited, a large retail centre can be reached by a short journey. The home has a ground and first floor with a passenger lift connecting the two. There is ample communal space for the service users to access including three lounges, a visitor’s room and a large dining area. Due to current building works the home has reduced their occupancy level to a maximum of seven service users until the work is complete. There is currently one assisted bathroom and four communal toilets available for use. One of the seven bedrooms has en-suite facilities. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours. Pat Walker, Registered Manager and Julie Tomlinson, Shift Leader helped with the inspection. A tour of the premises was undertaken and a number of records were looked at. Two of the service users, four of the staff and one visitor were spoken to find out what people thought of the home and their comments have been included in this report. The home is undergoing major refurbishment and has one half of the downstairs and the whole of the first floor accommodation out of use. The home has decided to care for 7 people at the most whilst the work is being done, currently there are 3 service users in the home. One additional visit had been made in July 2005, but this is the first inspection for 2005. Some serious concerns were highlighted the home’s one bathroom was out of order this meant that people could not get bathed also staff were carrying dirty laundry through the dining/kitchen area and this is unhealthy. An official letter was left at the home to tell the registered manager and registered provider that these must be put right straight away. The registered manager contacted the CSCI the following day to inform the Commission that the bathroom would be working from Friday 7.10.05, also that the Environmental Health Officer had told them the procedure for taking the dirty laundry through the kitchen/dining area until the work is finished, evidence of this is to be sent to the Commission. What the service does well: Service users and a visitor spoken to all confirmed that the staff and management are “kind and caring”. Also that visitors are made “very welcome”. One person said “all of the staff speak to me and are there when you need something”. The home is kept clean and tidy even though there is a lot of building work and there were no offensive smells in the home, making it a nice place for people living in the home. Meals are nicely presented and nutritious. Service users said that they have a choice and the food is “good and the cooks will prepare anything you wanted”. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 6 The home has a welcoming atmosphere and staff spoke to the service users in a caring manner. Visitors were welcomed at any reasonable time. One relative confirmed that staff always made her feel welcome, also that refreshments were offered. Staff at the home chat to service users and offer support when necessary. All of this helps service users to feel relaxed and at home. The home has a good level of staff with varied experience, knowledge and skills, which helps them to look after the service users well. What has improved since the last inspection? What they could do better: The refurbishment of the home could have been planned better, making sure that there were bathing facilities at all times. The Environmental Health Department should have been consulted and approved a plan and risk assessment with regard to the transporting of dirty laundry/soiled incontinence pads. The manager, staff and a service user said that sometimes people were admitted into to the home who caused problems for the other service users living there. One service user said that on a few occasions another service user had been “noisy and drunk and shouting at everyone, I was glad to go home”, this had affected the other service users and staff said that “I did not feel confident when dealing with this person, no-one has received training with regard to this area”. The registered provider and registered manager must make sure they only take service users whose main problem is their physical disability this will mean that the staff have the skills to look after them. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 7 To make sure that staff are doing a good job of looking after people, the home is supported to spend regular time meeting with them and talking about what they are doing. A written record must be kept of this meeting. This did not happen as much as it should and this meant that the written records of care provided were different to what really happened. This could end up with service users not getting the care they need. The way the home deal with medication is not safe and could lead to the wrong medication being given. The systems need to be checked regularly to make sure that this is recorded and given accurately and staff are trained appropriately. 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. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Progress has been made with regard to the statement of purpose and service user guide, these now fully meet the standard. The homes admission procedure is not always adequate and does not provide individuals with the assurance that their needs can be met prior to the coming into the home. EVIDENCE: The home’s statement of purpose and service user guide gives clear information about the home and what it can offer to people. The contract covers all areas required, but there is one paragraph that states the manager can reserve the right to move service users during their stay. This was discussed during the inspection and it was advised that this should be removed or made clear to people in the statement of purpose and contract so they know what to expect. The home does undertake an assessment of need by way of a community care assessment. A care plan is formulated from the information gathered and on the whole these are very good with clear direction to the care staff. There are risk assessments in place for most areas, one issue that was not covered was in relation to PEG feeding (see Standard 9). From speaking to service users and relatives it was clear that wherever possible prospective service users have the opportunity to visit the home. This Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 10 is not always achievable due to the high numbers of emergency admissions. There have been some incidents where people admitted to the home as an emergency have not been appropriate to the service either because of their primary need not been physical disability or due to some aspect of their behaviour that impacted on other people staying at the home. The manager and several of the staff spoke about this stating that often “pressure is placed upon the home to take admissions from the Care Management teams as there is a shortage of beds across the city”. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Service users individual needs and choices are on the whole well supported, however one risk assessment and care plan lacked the required information and could result in adverse effects on the service user. EVIDENCE: Service user files contain a community care assessment, care plan and risk assessments covering most areas. The care plans which are drawn up are of good quality and on the whole provide staff with sufficient guidance to ensure service users needs are met consistently. Service users coming into the home are enabled to be as independent as possible. Staff try hard to maintain the level of independence they exercise at home, unless the risk assessment indicate otherwise. One service user administers his own medication at home, but he did say he “preferred the staff to give it “ when in the home. There was one risk assessment relating to PEG feeding that did not have sufficient information regarding what the staff should do in an emergency. From speaking to staff it was evident that they knew what the needs of the service users were, but it was senior staff who undertook the actual administration of the PEG feed and although they had received training there was no written confirmation that they had been observed as competent in this procedure, Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 12 some training took place over 4 years ago. Also information from a family member regarding calorie intake and what was required as a supplement was incorporated within the actual administration of the PEG feeding plan, this requires support from a medical professional. These informal arrangements rely on communication between staff. Two of the three service users were spoken to during the inspection, one of which could communicate and stated that they were aware that information is kept about them. In the lounge and bedroom areas information was displayed with regard to what support and care is available. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 and 17 Service users are supported to maintain family links and relationships. A healthy and nutritious diet is offered. EVIDENCE: One service user confirmed that he is enabled to maintain links with his family and friends whilst staying at the Pennine Centre. He stated that “my family and friends can come and visit me whenever they like”. A relative who was visiting the home said that her relative had recently been admitted for a twoweek respite stay and confirmed that “staff have made me feel very welcome and if I had any concerns which I don’t I would have no hesitation in approaching them about it”. Lunch was observed and consisted of either chicken with fresh vegetables or minced meat and dumpling with vegetables. There was a variety of sweets on offer including rice pudding and chocolate mousse. Two of the service users confirmed that the food was “good” and “there was a choice if you didn’t like anything on the menu”. The home has a well-trained and separate staff group in place for the kitchen. All of the staff have undertaken the basic food hygiene and some have completed the intermediate food hygiene. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 14 The dining room is bright and airy, the decoration is homely and there was a pleasant atmosphere during meal times. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Service users personal care needs are well met, however flaws in the medication practices could put their health needs at serious risk. EVIDENCE: Service user files indicated that healthcare needs were attended to whilst staying in the home. The remit of the home is to offer short-term respite; staff confirmed that if there are any queries regarding a person’s physical, emotional or mental health then this would be discussed with senior staff. From speaking to two service users and a relative it was evident that all physical and emotional needs are met. A service user stated “staff always offer personal care the way that I want it, they always knock on my door before entering and treat me right”. A relative stated that she was “very happy with the care offered”. The home has a medication policy and procedure and on the whole this is adhered to. From inspection of records it was identified that one new admission did not have a photograph on file and medication had been taken out of the prescribed boxes in order to take this to the GP to obtain a new prescription. This meant that there was no instruction from the pharmacy about how much or how often to administer. One of the drugs was in foil packs and the name was a brand name so it was possible to match this to the hand-written MAR sheet. The medication had been entered onto the homes Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 16 medication sheet, but this had not been double signed which it needs to be. Temazepam was not being stored as a controlled drug. The home has a selfadministering policy and risk assessments were seen in relation to this. One service user was assessed as able to take responsibility for his medication yet was not doing so. The senior on duty said that he chose not to but there was no evidence on the service users file that this had been discussed with him. The home has a policy with regard to the death of a service user. Staff who were spoken to had a good understanding of loss and bereavement. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People feel able to complain and are provided with the information to take this further should they not be happy with the response from the home. EVIDENCE: The home has a thorough complaints policy and procedure and one service user spoken to stated that this was displayed within the home and he would know what to do if he had any issues. A complaint was received by the Commission in May 2005 this was passed to the Registered Provider (Local Authority) for them to investigate, at the time of writing this report no response had been received and some of the areas were investigated during the inspection itself. There is a protection of vulnerable adults policy and procedure in place and all staff spoken to were fully aware of their role and responsibilities, they also had a good understanding of what constituted abuse. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,29 and 30 Despite major refurbishment service users generally live in a comfortable environment, however poor planning of building works did result in service users choices around bathing being limited. EVIDENCE: During the inspection a tour of the premises was carried out and it was identified that the first floor and one half of the building was closed off to service users, the half that was in use has reduced the capacity to 7 service users. There are currently seven bedrooms, one having an en-suite shower and one assisted bathroom, the bathroom was out of order and an immediate requirement was issued. A service user confirmed that he had been having a bath when the hoist arm broke off causing an injury to a staff member. A letter from the registered provider was received on 12.10.05 confirming that this had been repaired and was in use. It was observed that dirty laundry and soiled incontinence pads were been transported through the dining/kitchen area, a discussion with the registered manager took place and this was included on the immediate requirement notice stating that the home would need to contact the Environmental Health Department with regard to this practice. A letter from the registered provider on 12.10.05 confirmed that since the inspection they had consulted with the Environmental Health Department who had confirmed an agreeable practice with them and an Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 19 updated risk assessment would be required. The home are double bagging the dirty laundry and only taking it through the dining/kitchen area once per shift. The immediate requirement was closed on 12.10.05. The dining area, lounges and bedrooms were all decorated and maintained to a good standard. Also having sufficient aids and adaptations to help the service users mobility. There are four communal toilets, one assisted bathroom. There is a call system throughout the home and staff responded quickly to the buzzer. The carpet in the main entrance and hallway will require replacement in the near future, it is worn and stained in parts. It is difficult to assess the suitability of the environment until the whole of the refurbishment is complete which will not be until around February 2006. Since the previous inspection the premises have been assessed by a qualified occupational therapist, once the report has been received a copy will need to be forwarded to the Commission. The home was clean and hygienic throughout, there were no offensive odours. A discussion with the registered manager occurred regarding the provision of communal space and the proposed reduction in communal space once the refurbishment is completed. The home must provide the same amount of communal space it had when it was first registered with the CSCI. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Service users are supported by staff in sufficient numbers and who have the required skills to meet their needs, however, there was a lack of evidence with regard to their competence to administer PEG feeds. EVIDENCE: Three staff files were looked at confirming that usually all employees have a CRB check and two references in place prior to employment commencing. However, one long standing employee had been missed when undertaking the retrospective CRB checks on existing staff, the registered manager stated that once she had realised a CRB was sent off immediately, this has not yet been returned. There wasn’t a photograph or proof of identification in place for each staff member. The home has a very good training programme in place, since the last inspection most of the staff have now undertaken infection control and food hygiene training. From speaking to staff it was evident that they discuss their training needs in their supervision and any requirements are recorded. They also receive an annual achievement and development interview. From looking at records it was clear that not all staff receive regular and consistent supervision. Some specialist training is offered with regard to various topics. One service user who has regular respite stays in the home requires a PEG feed to be administered. All staff who administer the PEG feed have received training, Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 21 but there was no written evidence to state that they have been deemed competent by a qualified medical practitioner, nor was there a written statement that staff agree to undertake this responsibility. Three staff members were spoken to with regard to their role and responsibilities and confirmed that they feel “well supported by senior staff and the manager”. The staff team is experienced and has various skills to offer. Service users who were spoken to talked about the staff as being “caring and friendly”. From observation it was noted that staff interacted in a professional but caring manner, offering support when needed. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 On the whole the home is well run and there are appropriate record keeping systems in the home. Service users’ health and safety is not always safeguarded. EVIDENCE: The registered manager has been at the home for two years and is qualified and experienced. Staff commented that the manager is always available and has an open door policy, but also stated that the shift leaders offer help and advice in addition to the manager. Many of the issues highlighted within this report relate to the environmental changes and the building work which is ongoing until February 2006. The home has a quality assurance system, but still requires further expansion to include all stakeholders and an annual report that should be forwarded to the Commission. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 23 Regulation 26 visits are not currently taking place, the registered manager stated that it has been agreed with the Commission that three registered managers employed by the Local Authority are going to undertake these in the near future. The care staff are having to walk through one corridor where the refurbishment is taking place in order to access the laundry. The electricity is switched off in the area where work is being carried out and extension leads were found close to the laundry room. These had not been fastened down and were posing as a health and safety risk. The inspector spoke to the site manager who rectified this and this must be maintained. As stated earlier in the report during the inspection it was identified that the only bathroom available was out of order. An immediate requirement was issued giving the home 24 hours to put this right, on 12.10.05 a letter was received from the registered provider confirming the bathroom had been repaired. Dirty laundry and soiled incontinence pads were been carried through the dining/kitchen area, which could potentially spread infection. A discussion occurred with the registered manager and it was identified that the Environmental Health Department must be contacted for them to give advice. This was also included in the immediate requirement notice. A response was received on the 12.10.05 from the registered provider confirming that the procedure now in place is acceptable to them, a risk assessment is to be updated with regard to this. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 3 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 1 X 1 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pennine Centre Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 1 X DS0000034637.V255910.R01.S.doc Version 5.0 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 2 3 Standard YA3 YA9 YA20 Regulation 14 13,14 13 Timescale for action See Standard 9 05/01/06 Risk assessment documentation 05/01/06 must cover all areas including PEG feeding. Medication must have a printed 05/01/06 label detailing the service users name, date of dispensing, name and strength of medicine and dose and frequency of medicine. Complaints must be dealt with 05/11/06 within timescale and outcome forwarded to the CSCI. The registered person must 05/03/06 ensure that the premises are fit for the stated purpose. (Previous timescale not met – July 04) Heating which is capable of 05/03/06 been individually controlled is required in service users bedrooms. (Previous timescale not met – July 04) Appropriate lighting is required 05/03/06 in service users bedrooms. (Previous timescale not met – July 04) The registered person must 05/11/05 ensure that all staff files contain a photograph and proof of DS0000034637.V255910.R01.S.doc Version 5.0 Page 26 Requirement 4 5 YA22 YA24 17,22 23 6 YA26 23 7 YA26 23 8 YA34 17,19 Pennine Centre 9 YA28 10 YA34 11 YA35 12 13 14 YA36 YA37 YA42 15 YA42 identification. (Previous timescale not met – 03.03.05 23 The registered person must ensure that the home provides the same amount of shared space as it did when first registered. 13,18,19 The registered person must ensure that all staff files contain a photograph and proof of identification. (Previous timescale not met – 03.03.05) 18,19 Training in relation to PEG feeding is kept up to date and a qualified medical practitioner confirms that the staff are competent is this procedure. An agreement is required that staff are willing to undertake this procedure. 17,18 Supervision must be offered to all staff at least 6 times per year. 26 Regulation 26 visits must be undertaken and reports forwarded to the CSCI. 12,13,16, The registered person must 23 ensure that there are sufficient bathing facilities for service users at all times. 12,13,16,23 The registered person must seek advice from the Environmental Health Department with regard to carrying soiled articles/clothing through the dining/kitchen area. 05/03/06 05/11/05 05/11/05 05/11/05 05/11/05 06/10/05 06/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 27 No. 1 2 3 Refer to Standard YA5 YA20 YA24 Good Practice Recommendations The contract should be amended and not specify that the registered manager reserves the right to move service users during their stay. Temazepam should be stored as a controlled drug and it would be deemed good practice to also record it as one. The carpet in the main entrance hall and hallway will require replacement. Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Pennine Centre DS0000034637.V255910.R01.S.doc Version 5.0 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!