Inspection on 08/02/06 for Pennine Centre

This inspection was carried out on 8th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 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 05/10/05

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 8th February 2006 09:30 Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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.V263740.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V263740.R01.S.doc Version 5.1 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.V263740.R01.S.doc Version 5.1 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. 5th October 2005 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 five service users until the work is complete. There is currently one assisted bathroom and a disabled access shower room and four communal toilets available for use. One of the five bedrooms has en-suite facilities, the remaining four have a wash-hand basin. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted for 6 hours, prior to the visit 2 hours preparatory work was undertaken. Several of the key standards were looked at and progress on the requirements and recommendations made during the last inspection visit. Eve Featherstone, Shift Leader assisted with the inspection process as the registered manager was away on training. A tour of the premises was undertaken, three residents files were case tracked, this involved meeting the residents, visiting their rooms and reading about their assessed needs and how the home planned to meet them, also talking to them about what the home was like and whether any improvements could be made. At the residents request the inspector joined the residents for lunch. Two staff members were interviewed and practice observed, also some policies and procedures were inspected. The home is undergoing major refurbishment and has one half of the downstairs and the whole of the first floor accommodation is out of use. The home has decided to care for 5 people at the most whilst the work is being done, currently there are 4 residents in the home. Some of the requirements made in relation to the environment will remain outstanding until the refurbishment is completed, the projected date of completion is towards the end of March 06. Three additional visits have been made on 1, 23 and 30 of November 2005 to monitor progress and to ensure that the registered provider was adhering to and working towards achieving the outstanding requirements and one immediate requirement. It should be noted that the immediate requirement was actioned within two days of the inspection and a substantial amount of the outstanding requirements and recommendations have been implemented. What the service does well: The home continues to offer a very good standard of care to the residents. Residents stated that, “the home couldn’t be any better, I have been to a few but this is the best and I don’t want to go anywhere else”, “the staff are smashing, nothing is too much trouble”. Although the refurbishment is still ongoing, the half of the building that is operational and has already being refurbished is presented in a tasteful and homely manner, it is clean and hygienic. Again the comments made by the Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 6 residents confirmed this, “the home is like a 5 star hotel, it is lovely”, “there is nothing more I could wish for the home is beautiful”. Staff were observed when speaking to residents and this was carried out in a sensitive and caring way. Staff receive an excellent range of training courses that would enhance their skills and knowledge. The menu offered is varied and nutritious, all residents confirmed that the food was of a very high standard and that a good choice was offered. Some comments included, “the food is wonderful, if I don’t like anything the cooks are very good they will do something else”. The home continues to have a good staffing level and the residents needs are fully met. Staff when interviewed were able to display extensive knowledge about the needs of the residents and could describe in detail what intervention would be necessary in order to implement the care plan. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? 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. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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.V263740.R01.S.doc Version 5.1 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): 3&5 Prospective residents know that the home will meet their needs prior to admission. Each resident is issued with a statement of terms and conditions, this requires amendment to ensure that the residents’ rights are maintained. EVIDENCE: From speaking to staff and some of the residents it was clear that information is given to individuals about whether the home can meet their needs. One person stated that he had been in hospital prior to coming to the Pennine Centre and had undergone assessments in the hospital and from the home’s staff to ensure that they could look after him properly. Another resident stated that, “I came to visit before I decided to come here, also two members of staff came to see me at home to make sure that they could look after me”. There was written evidence that residents are informed when their needs can or cannot be met by the home. A contract or statement of terms and conditions is issued to all residents upon admission; this clearly states the room to be occupied, facilities, fees and notice to be given. One paragraph states “in some cases it may be necessary to allocate another room to you during your stay. The Registered Manager reserves the right to carry out this action as and when necessary”. It is recommended that this paragraph be re-worded to ensure that this procedure is only carried out in exceptional circumstances and the decision is clearly documented. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 10 Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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 The residents are very well cared for, but this would be enhanced by care plans and risk assessments being more specific and greater consistency being achieved. EVIDENCE: Three residents’ files were case tracked during the inspection and on the whole were in very good order. For each person a detailed community care assessment, care plan, regular reviews and daily notes were in place. Risk assessments had been developed for various areas including bed rails, peg feeding, mobility. There were regular entries made by care staff regarding the what part of the care plan had been achieved, but not specific information as to how this had been achieved. The care plans lacked specific detail about the actual need and the regularity of any action required. From speaking to the staff it was clear that they had a good understanding of all of the residents’ needs, but particularly those whom they were key worker to. Staff talked about having access to relevant training including Parkinson’s, Huntington’s, epilepsy, dealing with aggression and many more. They confirmed that the manager encourages learning and fully supports the staff on a day-to-day basis. From speaking to the care staff it was evident that they do not attend any of the reviews even though they may be either key worker or link worker Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 12 to the resident. The staff confirmed that they would pass on their views, but would not partake in the review itself. The home has a thorough risk assessment procedure and on the whole is of a good standard, documentation is in place, but not always completed in a way that would give specific direction to staff. One risk assessment looked at in relation to PEG feeding had been updated, but still did not contain specific details about timescales in emergencies. During a previous visit to the home it was highlighted that medication was being administered in the food of a resident and the care plan in did not contain a multi-disciplinary agreement with regard to carrying out the covert administration of medication within the resident’s food, during this inspection the inspector was informed that a multi-disciplinary meeting had been arranged for 14.2.06 and until that time the home would not undertake this procedure. A number of other requirements in relation to PEG feed and medication training have now been met. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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): 11,12,13,14 & 17 Residents are fully supported to take part in appropriate activities, have opportunities for personal development remain part of the local community. The food offered is of an excellent standard, wholesome, nutritious and plentiful. EVIDENCE: Throughout the inspection process the residents were spoken to about ‘what life was like for them’ in the care home. Three of the four residents were interviewed and all gave a glowing report for the Pennine Centre, stating that “this home is the nicest I have ever been to” and “it is lovely here, I don’t want to leave”. During a group discussion with the residents it was identified that regular activities are offered and are usually on an individual basis as residents only stay for short respite periods. The residents explained that “sometimes we do things together like quizzes and pool, it depends upon how able the other people are”. The home caters for adults and the age group can vary between 18 and 65, it was observed that the home has lots of board games and quiz books and games, also play stations for the younger residents. There is a variety of videos and DVD’s available for use. Some of the residents if they choose to can attend the Pennine Day Centre which is adjacent to the Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 14 home, others go out to community centres or take part in other activities that they would do if they were at home. Throughout the day the residents spoke highly of the home and staff confirming that dignity was maintained at all times, by staff asking if they required any help and talking to them in a non-judgemental way. Staff were observed interacting with the residents and this was carried out sensitively and respect was shown to the residents. Residents also confirmed that any relationships they have are supported by staff, family or friends are welcome to visit at any reasonable time. The home has developed a newsletter to inform the residents of activities, facilities, staff, stories or events that may be taking place, it was very well presented and easy to read, but also offered a variety of information that was interesting. The menu offered to residents is varied, healthy, nutritious and plentiful. The inspector joined the residents’ for lunch and enjoyed chicken breast, mashed potato and peas, the option for the day was home made fish and chips or steamed fish. Dessert was jam sponge and custard or jelly and ice cream. One resident spoke about being a diabetic and said that the cooks talk to him everyday about what he would like and alternatives options to dessert. He stated, “the cooks are great they talk to me about what I would like and they make it”, another resident said, “nothing is too much trouble, the staff and cooks always talk to us about the menu for the day, the food is excellent and first rate”. The home has a picture menu for those with communication difficulties and has achieved the Heartbeat Award. The dining room is spacious and nicely presented, the food was also well presented and appealing to the eye. All staff who either prepare, cook or serve the food have obtained the basic food hygiene certificate. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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): 20 The home has a medication policy and procedure and on the whole is adhered to, however an issue regarding covertly administering medication could affect the resident’s human rights and choice. EVIDENCE: During the inspection the medication records were inspected and found to be up to date and accurate, there were no errors in the recording upon the Medication Administration Records. Since the last inspection the medication procedure has being improved and various requirements that were made during that inspection and in subsequent visits to the home and now been achieved, these included ensuring that the quantity of medication is recorded upon admission, the medication administered correlates to the prescribed amount displayed on the printed label, any changes to come via the GP or Pharmacist and all medication must have a printed label detailing the persons name, date of dispensing, name and strength of medicine and dose and frequency of medicine. Temazepam is now stored and recorded as a controlled drug and there is a controlled drug register, there are two staff signatures for each entry. The one outstanding requirement is in relation to one resident being administered medication covertly in food, although there was evidence that Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 16 this was the families choice there was nothing from a medical practitioner or a multi-disciplinary agreement that this was the most appropriate form of action. All staff who administer medication have either already attended or booked on to the new accredited medication training course offered by the Local Authority. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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 The home has a complaints procedure, which meets the needs of residents who feel their views are listened to. EVIDENCE: Since the last inspection there have been several complaints mainly in relation to the environment being too cold or the heating not working properly, these have been resolved and recorded appropriately. There was one in relation to the newly refurbished bathroom and toilets not having any signage on the doors, this has yet to be resolved, but the inspector was informed that the signs had been ordered for the doors. With regard to the slow response from the local authority in dealing with a complaint forwarded to them by the CSCI, an action plan received stated that timescales will be adhered to in the future. From speaking directly to the residents it was clear that they did not have any complaints and spoke very highly about the home. During discussion all of three residents stated that they were aware that they could complain and would do so to the manager if there was a problem. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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 & 30 Although the refurbishment is ongoing the residents live in a clean, comfortable and homely environment. Bathroom/toilet doors did not contain any signage causing difficulties to residents. EVIDENCE: A tour of the building was undertaken, the newly refurbished half of the building accommodates up to 5 residents. It is well presented and decorated and furnished to a very high standard. Each bedroom has an electronic sink which enables people with a physical disability to maintain their independence, one bedroom has an en-suite shower. There is a bathroom and disabled access shower room both are assisted, there are four communal toilets available to the residents. None of the bathing rooms or toilets had clear signage on the doors and some residents stated that this had caused some confusion. The hot water temperature is taken on a regular basis and recorded, the previous problem of the water being too hot has now being corrected. An Occupation Therapist has assessed one half of the building that has been refurbished and there are suitable aids and adaptations in place including grab rails, assisted walk-in shower room and an assisted hydro-bath. There is a ceiling-tracking hoist fitted in most of the bedrooms and bathrooms. Once the Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 19 refurbishment is completed an occupational therapist will need to re-assess the whole of premises. It is difficult to assess the suitability of the environment until the whole of the refurbishment is complete which will not be until the end of March 2006, it had previously being estimated that the work would be finished in February 2006. The home was clean and hygienic and there no malodour was detected. Three of the residents were spoken to about the environment and some of the comments were; “it’s like a 5 star hotel, the living area is really nice and my bedroom is lovely”, “it is nice and homely in here” and “it is very clean”. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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): 33, 34 & 36 A well-trained and experienced staff group supports residents. The home has adequate staffing levels that ensure the needs of the residents’ are fully met. The home has a supervision policy and procedure and is offered to all staff, unfortunately this is not carried out as regular as it should be. EVIDENCE: The home is supported by a well-trained staff group, there knowledge is varied and covers areas such as the protection of vulnerable adults, Parkinson’s’ disease, Huntington’s disease and many more. From speaking to two staff members it was clear that they had a good understanding of the residents’ needs and could express what care was offered and the way in which the care tasks were undertaken, ensuring the privacy, dignity and independence of the residents. It was clear that the ethos of the home is to offer a very high standard of care in a sensitive and has adapted a person centred approach. The staffing levels are adequate for the current residents. Since the last inspection staff who administer medication and PEG feeding have updated their knowledge by attending training courses in these areas, there was written evidence to confirm this. Unfortunately, on the day of the inspection the registered manager was away from the home undertaking the medication training, none of the shift leaders had access to the staff files and this meant that these records were not available for inspection and the requirements highlighted in the previous report Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 21 regarding photographs and identification of staff and supervision records will remain unmet. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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): 39 & 42 The home’s quality assurance programme is comprehensive and qualitymonitoring systems are based on seeking the views of all stakeholders. Residents’ health and safety is not always safeguarded as maintenance is not always up to date. EVIDENCE: The home has developed a very good quality assurance system, this incorporates regular liaison with residents, family/friends, other professionals, the completion of surveys and the correlation of this information throughout the year. At the end of the year all of the information is brought together in an annual report, a copy of which is made available within the home and a copy forwarded to the CSCI. A newsletter has been produced informing the residents of events, activities, stories and staff news, it is well-presented, colourful and interesting to read. All complaints and compliments are recorded. On the whole the health and safety of the residents is promoted, unfortunately there was no evidence of the water being tested for Legionella, the last check Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 23 was in December 04. Since the inspection the home has forwarded written confirmation that this procedure has now been carried out and the results have not yet been returned. Some other maintenance documentation were inspected and there was no evidence of a Landlord’s gas safety certificate, although there was a evidence to state that the boiler had been tested. All of the mandatory training is offered to the staff including moving and handling, fire safety, first aid, health and safety, the protection of vulnerable adults and infection control. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 X 2 X 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 2 30 4 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 x X X 4 X X 2 x Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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 YA6 Regulation 15,17 Requirement Timescale for action 08/04/06 2 YA9 13,14,17 3 YA20 12,13,17 4 YA24 23 All care plans must be kept up to date and reviewed regularly, these must give clear direction to care staff with regard to all areas including PEG feeding. (Previous timescale – 05/01/06) Risk Assessment should be 08/04/06 made more specific, detailing any action to be taken and regularity of intervention. When medication is 08/04/06 administered covertly there must be a multi-agency agreement with the medical practitioner taking responsibility for this decision and documentation evidencing this. (Previous timescale – not met 23/01/06) The registered person must 08/04/06 ensure that the premises are fit for the stated purpose. (Previous timescale not met - July 04) Heating which is capable of been individually controlled is DS0000034637.V263740.R01.S.doc 5 YA26 23 08/04/06 Pennine Centre Version 5.1 Page 26 required in service users bedrooms. (Previous timescale not met - July 04) 6 YA26 23 Appropriate lighting is required in service users bedrooms. (Previous timescale not met - July 04) All bathroom/toilet doors must be clearly identified with appropriate signage. Once the refurbishment is completed, an occupational therapist or similar will need to assess the building. The registered person must ensure that all staff files contain a photograph and proof of identification. (Previous timescale not met – 03/03/05) Supervision must be offered to all staff at least 6 times per year. (Previous timescale not met – 05/11/05) 08/04/06 7 8 YA27 YA29 16,23 12,13,16,23 08/04/06 08/04/06 9 YA34 17,19 08/04/06 10 YA36 17,18 08/04/06 11 YA42 12 YA42 12,13,16,17,23 The registered person must be satisfied that the gas has been tested by a qualified technician and a landlord’s gas safety certificate held in the home, a copy of which to be forwarded to the CSCI. 12,13,16,17,23 The water system must be checked for Legionella. 08/04/06 08/04/06 Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 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 YA5 YA6 YA24 Good Practice Recommendations The statement of terms and conditions/contract should be amended (point 10) to state in exceptional circumstances a resident may need to move rooms. Care Assistants who are also key worker or link worker to residents should attend reviews. The carpet in the main entrance hall and hallway will require deep cleaning or if unsuccessful will need replacing. Pennine Centre DS0000034637.V263740.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 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.V263740.R01.S.doc Version 5.1 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. 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