Inspection on 16/04/07 for Pensby Hall Residential Home

This inspection was carried out on 16th April 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pensby Hall Residential Home 16/10/07

Pensby Hall Residential Home 05/06/06

Pensby Hall Residential Home 27/02/06

Pensby Hall Residential Home 15/01/06

Pensby Hall Residential Home 03/02/05

Pensby Hall Residential Home 04/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Pensby Hall Residential Home 347 Pensby Road Pensby Wirral Merseyside CH61 9NE Lead Inspector Helen Carton Key Unannounced Inspection 09:30 16th April 2007 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 Pensby Hall Residential Home DS0000059534.V332062.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. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pensby Hall Residential Home Address 347 Pensby Road Pensby Wirral Merseyside CH61 9NE 0151 648 9730 0151 648 6520 vicoakden@aol.com 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) Snow Peak Ltd T/A Pensby Hall Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2007 Brief Description of the Service: Pensby Hall is a large three-storey building, situated on a main road in Pensby, Wirral. The home is in a residential area, close to shops and other community facilities, including a library. Residents bedrooms are situated on all three floors, all rooms are single occupancy with five having en-suite facilities the first and second floor are serviced by a passenger lift. The two lounges and separate dining room are situated on the ground floor. The home has sufficient bathing including specialist equipment and toilet facilities for the residents living at the home. Pensby Hall has a pleasant patio and garden area at the rear of the home and a small patio to one side. Car parking is available at the side of the building and on the main road at the front of the home. The weekly accommodation fee for the home is £365.73 per week. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process the Commission sent the home a pre inspection questionnaire to be completed prior to the site visit to provide information about the service. A site visit was made to enable the inspector to examine documentation and to discuss how the service supports residents’ in all aspects of their lives. Part of this process involved speaking with the manager, members of the staff team and spending time talking with residents’ to find out their views on living at Pensby Hall. The inspector spent approximately eight hours at Pensby Hall. What the service does well: What has improved since the last inspection? Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 6 The owners’ employed a new manager in January 07 she has a lot of experience of supporting and caring for people who live in care homes. What they could do better: Assessments that are carried out before a person comes to live in the home do not provide a lot of information about the type and level of support and care residents’ need to live their lives as independently and safely as they can. Because this information is not documented in the care plans and risk assessments the home produces once a person comes to live in the home peoples care and social needs are not included. The plans do not consider residents’ expectations of living in the home, emotional or social needs resulting in their mental and emotional wellbeing not being supported. The manager has begun to review these documents and acknowledges further work is needed to create a fuller picture of each resident and the needs and expectations. The home keeps daily records on all residents’, which should help staff to offer the best type of care and support to individual residents’. However these records provide very little information to assist the staff team to do this. The staff team are provided with training opportunities to attend National Vocation Training (NVQ) schemes. However the home does not provide more specialised training this type of training is important because it enables the staff team to understand and support residents’ with specific conditions or illnesses in the best possible way. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s pre admission assessments lack sufficient detail to ensure they can meet the holistic needs of prospective residents’ and provide them with the type and level of services detailed in the statement of purpose. EVIDENCE: The home’s statement of purpose provides basic information regarding the type and level of service provided at Pensby Hall. Contracts of residency provide residents’ with the necessary information to make an informed choice as to the suitability of the home and outline what they can expect. The contracts indicate if residents have concerns or complaints about the services being provided to raise them with the manager or registered provider. The manager was advised to ensure contact information of advocacy organisations are also included to allow residents’ or their supporters to access this type of support if they choose. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 10 The inspector examined pre admission assessments for five people who have moved into the home since the last site visit. The inspector noted there were a number of different assessment documents being used. However they were not fully completed and information gained only identified basic health and physical care needs. This information had not been transferred to care plans or risk assessments. The manager was advised to ensure pre admission assessments seek information about the holistic needs of prospective residents’ including past life experiences and significant people in their lives. This is to ensure the home can meet prospective residents needs and can provide the lifestyle choices a detailed assessments would identify. The registered persons are advised to ensure the skill mix, knowledge and expertise of the staff team form part of the assessment process. To ensure placements’ are offered when the home is confident it can meet all identified needs appropriately and safely. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no clear or consistent care planning system or risk management strategies in place to adequately provide staff with the information they need to satisfactorily meet service users needs and aspirations. EVIDENCE: Samples of residents’ care plans were viewed. The inspector noted they do not provide detailed information about residents’ care needs, preferred routines, likes/dislikes or past life experiences including significant people in their lives. This leaves residents’ at risk of receiving generalised care rather than care and support tailored to them as individuals. Care plans do not show the type and amount of support residents’ need with their personal care or who they would prefer to support them either male or female care staff. The plans provide little information about the activities and lifestyles residents’ enjoyed prior to moving into the home. There was no information about preferred daily routines. The inspector was unable to find a Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 12 care plan for one resident admitted in January 07 however a review of the person’s care needs had taken place in March 07 indicating the care plan and risk assessment should be kept up to date. Care files had many different documents in them, which had not been fully completed. Resulting in medical information detailed in the pre admission assessment not being transferred and expanded upon in the care plans. Leaving residents at risk of not receiving appropriate care, support and medical interventions. Mental and emotional wellbeing issues were highlighted in pre admission assessment documentation however they had not been transferred onto care plans or risk assessments. This leaves residents’ at risk of receiving inappropriate care and their mental health needs not being effectively monitored. A sample of daily records for five residents’ their accompanying care plans and other records such as weight charts were examined. The daily records provide only generalised comments and in many instances the same phrases are used. Resulting in significant health and emotional wellbeing issues not being identified and monitored effectively. Discussions took place with the staff team about the care needs of residents’ they described their daily routines and the routines of the home. Residents’ said the staff team were kind and looked after them well however felt they would like them to spend more time with them but they were very busy. Records show the home identifies some risks however plans or strategies to support residents’ are not provided. This includes plans to support residents’ with significant mental health and medical care needs. A sample of residents’ medication and the accompanying Medication Administration Records (MAR) were examined the following issues were discussed with the manager; The home uses a monitored dosage system however the blister packs do not have a commencement date on them. It is important to know the date and time medication is delivered to the home and the actual commencement date of the medication. One tablet from a full blister pack to be used for the following week of the inspection was missing there was no documented explanation as to why. The manager told the inspector a tablet had been dropped and to ensure the resident received the correct medication a tablet had been used from the new pack with a replacement being ordered from the dispensing pharmacist. The Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 13 inspector advised the manager to ensure information is fully recorded to ensure there is a clear audit trail for the administering, storage and recording of residents’ medication. Residents’ have refused specific medication for a significant period of time however the home had not contacted the prescribing GP to inform them of the situation. This would allow GP the opportunity to review the residents’ medication regime and look at alternative forms of treatment more acceptable to the individual. The inspector observed a strip of tablets with just the first name of a resident on it. The manager looked for the dispensing information and found it on the medication box stored in a different medication trolley. All information about residents’ medication should be held in the same place to ensure those administering medication have all available information to assist them and to ensure residents’ safety. Medication is stored securely in locked medication trolleys and cupboards within a locked room. Senior staff members within the home administer medication and all have received training provided by an external trainer. The manager is advised to ensure information sheets on each medication prescribed to residents’ is held with the MAR sheets. This is to allow the staff team to be aware of any side effects of medication and to allow medical advice to be sought. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of information held in care plans about residents’ personal lifestyles indicates residents’ views and wishes are not sought and acted upon to ensure they are living the lifestyles of their choice. EVIDENCE: The home employs an activities co-ordinator the pre inspection questionnaire completed by the home prior to the site visit lists the following activities as regularly taking place in the home; bingo, book club, painting, board games, floor games and trips out. During the site visit residents’ took part in a game of bingo. However there is very little information in care plans about residents’ past life experiences or activities enjoyed prior to coming to live in the home. This indicates there is a lack of value placed on residents’ being central to decision making and being involved in planning their care and daily activities. This approach leaves residents’ at risk of receiving a generic care service that does not acknowledge their diversity and individuality. Care files do not provide information about the significant relationships in residents’ lives such as life partners, children, other relatives and friends. Daily Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 15 records do not show if residents’ are going out of the home being visited or are enjoying planned activities. This approach leaves residents’ vulnerable to inappropriate care and staff not acting proactively to changes in residents’ emotional and mental health wellbeing. Discussion with residents’, members of the staff team and examination of residents’ files indicates on the whole the home is task orientated and focuses on residents’ physical care needs. One resident said “ I would like to go out more but they say I will have to wait till someone can go with me all I do is wait”. Residents’ said they enjoyed most of the meals provided by the home. The manager told the inspector she intended to review the menus and involve residents’ in the formulation of new menus. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 17 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure however care practices within the home indicate residents’ views are not routinely sought or acted upon. Arrangements for protecting residents’ not always being robust with particular regard to the staff teams knowledge, training and understanding of this issue. EVIDENCE: The manager told the inspector no complaints had been made about the home in the last twelve months the inspector viewed the home’s complaints logbook. The manager discussed with the inspector her understanding of the home’s complaints procedure and her commitment to act proactively and sensitively to all complaints and concerns raised about the home. The complaints procedure provided information of processes and timescales. The home has a copy of Wirral social services revised ‘No Secrets’ document. This details the local procedures regarding the raising of concerns including to who and where the responsibilities regarding the investigation of allegations of abuse or poor practice lie. The inspector spoke to three members of the staff team and discussed adult protection issues with them. Their knowledge and understanding of their roles and responsibilities were mixed. These issues were discussed with the manager Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 17 who told the inspector training had been arranged for members of the staff team who have not received protection of vulnerable adult training this was confirmed by members of the staff team. This training is vital to ensure all members of the team are fully aware and able to identify the different forms of abuse including poor and neglectful practice. Further examination of staff files indicated a risk assessment had not been carried out where specific issues of concern had been highlighted during the recruitment process. The manager was advised all issues of concern must be risk assessed and an open and honest discussion entered into with each individual. This is to ensure the home’s selection and recruitment processes offer residents’ confidence in the management of the home and protection against possible abuse and neglect. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24 25, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home provides a clean homely environment for residents to live in. Residents’ are supported and encouraged to personalise their bedrooms to enable them to view Pensby Hall as their home. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 19 EVIDENCE: The last report indicated the registered persons had a programme of redecoration, which had commenced. The manager told the inspector the registered persons intended to replace the most damaged windows within a short timescale. The following issues were identified during this inspection visit: Ground floor bathroom- the bath chair is rusty and could pose a health and safety risk to residents’. The tiles had recently been re-grouted however excess grout had not been removed. The bathroom was not clean. The hall patio doors- lead to a patio area but does not provide level access and could potentially be a tripping hazard to residents’. Bedrooms- all rooms viewed where highly personalised and pleasantly decorated however the damaged paintwork on bedroom doors needs to be addressed. The small front lounge- the inspector noticed not all residents’ sitting in this lounge have an unobstructed view of the television. This issue was discussed with the manager. Most areas of the home were clean and tidy however there was a pungent smell in the entrance hall. Examination of the staff rota indicates there are 36.5 hours allocated by the home for cleaning. Due to the size and layout of the building the number of hours being provided should be reviewed. The garden and patio areas are well maintained and provide pleasant and comfortable areas for residents to enjoy. Overall the home is pleasantly decorated and homely in appearance providing a welcoming environment for residents’ to live in. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 using available evidence including a visit to this service. The home’s recruitment and training processes do not always promote residents’ safety or a person centred approach to their holistic needs. This leaves them vulnerable to receiving a generalised care service that does not meet their individualised needs. EVIDENCE: The pre inspection questionnaire completed by the home prior to the site visit provided the following information: The home employs a manager, assistant manager, five senior care assistants, six care assistants and three night staff. 78 of the care staff have gained National Vocational Qualification (NVQ) level 2 or above in care. With ten members of the staff team holding current first aid certificates. This shows a commitment by the registered providers to support the staff team to access NVQ training. During the site visit the manager told the inspector protection of vulnerable adults training had been booked members of the staff team confirmed this information. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 21 The inspector discussed with the manager the need to ensure the staff team have the appropriate training, expertise and knowledge of medical and mental health needs of residents’ as detailed in pre admission assessments. This is to ensure residents’ receive appropriate and safe support at all times. As detailed earlier in the report an issue regarding the home’s recruitment process with regard to protecting vulnerable people is raised. The home is currently advertising a kitchen assistant post for six hours per day. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the staff teams’ practices do not reflect their policies and procedures and leave residents’ vulnerable to possible poor practice or unsafe situations. EVIDENCE: The manager was appointed in January 07 she has approximately 15 years experience in the care sector with eight of them in management positions. She has successfully completed the registered managers award and has been registered with the Commission as a manager supporting adults with a learning disability. The manager told the inspector it was the registered providers and her intention to apply to the Commission to become the registered manager of the home. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 23 During the site visit the manager told the inspector the home’s electrical wiring was being inspected this week. Examination of the fire logbook indicates checks on emergency lighting and fire fighting equipment are not taking place within the required timescales. Portable appliance testing took place in March 07. The home has good clear information regarding the control of substances hazardous to health including information about chemicals used in cleaning materials used in the home. The accident book is well maintained. Issues regarding the lack of information held in residents’ pre admission assessments care plans and risk assessments are raised earlier in this report. Earlier in the report the inspector discussed with the manager the need to ensure all members of the staff team have a good understanding of their roles and responsibilities with regard to the protection of vulnerable adults. Earlier in the report examination of staff files indicated a risk assessment had not been carried out where specific issues of concern had been highlighted during the recruitment process. Issues regarding poor care planning and risk assessments are raised earlier in the report as are issues relating to the lack of detailed information recorded in pre admission assessments. The manager acknowledged the issues raised during the site visit and told the manager she would work to resolve them as a matter of urgency. Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X X 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X X 1 2 Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Full assessments must be undertaken for prospective residents’ to determine whether the home can meet their holistic needs. This is to ensure prospective residents’ care need requirements and lifestyle aspirations are compatible with the home’s ability to meet these needs. Timescale for action 16/04/07 2. OP4 14 Pre admission assessments must 16/04/07 fully document all identified needs including specialist care needs to ensure the home can demonstrate to the person requesting a service and their supporters that they have the knowledge and expertise to meet these needs appropriately and safely. Care plans must provide detailed 16/08/07 information regarding the holistic needs of residents. This is to ensure medical, personal care, emotional, mental wellbeing and social needs are met and enable resident to live the lifestyles of their choice. DS0000059534.V332062.R01.S.doc Version 5.2 Page 26 3. OP7 15 Pensby Hall Residential Home 4. OP8 13 Residents’ health care needs must be assessed, understood, monitored and acted upon to ensure their health and welfare is protected and promoted. 16/04/07 5. OP9 13 Residents’ medication must be 16/04/07 recorded, stored and administered safely by designated members of the staff team. This is to ensure residents’ medication regimes are followed and they receive the health care benefits from their prescribed medication. Information regarding preferred routines of the day and how residents’ wish to be supported with their personal care needs must be incorporated into individual plans of care. This is to ensure residents’ individual preferences and privacy and dignity are central to the services the home provides. Residents’ lifestyle preferences, social, cultural, religious and recreational interests must be sought and recorded. This is to ensure activities provided by the home are based on the wishes and choices of residents. Residents’ care files must provide information about the significant relationships in their lives. This is to ensure the staff team can support residents to maintain positive relationships that promote their emotional wellbeing. The staff team must receive training to ensure they have a good understanding of protection DS0000059534.V332062.R01.S.doc 6. OP10 12 16/08/07 7. OP12 16 30/06/07 8. OP13 16 30/06/07 9. OP18 13 30/06/07 Pensby Hall Residential Home Version 5.2 Page 27 of vulnerable adults procedures and protocols including their roles and responsibilities. This is to ensure the staff team supporting residents’ are able to recognise abusive situations and act appropriately to safeguard them. 10. OP19 23 The hall patio doors must provide level access to the patio area. This is to promote residents safety and to maintain their independence. The tiles in the ground floor bathroom must be free of excess grout. This is to provide a maintained and pleasant area for residents for residents to access. The bath chair in the ground floor bathroom has rusted this requires to be repaired or replaced. This is to ensure residents safety and comfort while using this equipment. When information comes to light through the selection and recruitment processes that may have a negative impact on residents’. Documentary evidence should be available in the home demonstrating a risk assessment has been carried to ensure residents safety at all times. The staff team must be provided with training and information to assist them to support residents’ in the most appropriate and safe way. This is to ensure when specialised care needs are identified in pre admission assessments and subsequent care plans the staff team feel DS0000059534.V332062.R01.S.doc 30/06/07 11. OP21 23 10/06/07 12. OP22 23 10/06/07 13. OP29 19 16/04/07 14. OP30 18 30/06/07 Pensby Hall Residential Home Version 5.2 Page 28 confident and competent in the care and support they provide. 15. OP37 23 All fire safety checks including ensuring fire-fighting equipment such as fire extinguishers are in good working order. Also fire safety equipment such as emergency lighting are functional must be carried out within the required timescales. This is to ensure a safe living and working environment is maintained for both residents’ and the staff team. 16/04/07 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. Refer to Standard OP7 Good Practice Recommendations Daily records should reflect the assessed care needs of residents and provide a concise narrative of the daily lives of residents. Sufficient hours must be provided to ensure all areas of the home are kept clean and tidy and free from offensive smells. So that a pleasant environment is maintained for residents’ living in the home. All residents’ should have unobstructed views of televisions situated in communal lounges provided for their enjoyment and pleasure. 2. OP26 3. OP20 Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Pensby Hall Residential Home DS0000059534.V332062.R01.S.doc Version 5.2 Page 30 - 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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