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Inspection on 23/11/09 for Pentrich Residential Home

Also see our care home review for Pentrich Residential Home for more information

This inspection was carried out on 23rd November 2009.

CQC found this care home to be providing an Adequate service.

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

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

What the care home does well

Medication record keeping has improved since the last inspection. No one has run out of their medicines since the last inspection.

What the care home could do better:

The medication policy and procedures are yet to be fully updated.

Random inspection report Care homes for adults (18-65 years) Name: Address: Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ one star adequate service 29/05/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Steve Baker Date: 2 3 1 1 2 0 0 9 Information about the care home Name of care home: Address: Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ 01262674010 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Olu Femiola care home 13 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Conditions of registration: 13 The maximum number of service users who can be accommodated is: 13 The registered person may provide the following category of service only: Care Home only - Code PC, To service users of the following gender: Either, Whose primary care needs on admission to the home are within the following category: Mental Disorder, excluding Learning Disability or Dementia - Code MD, maximum number of places 13 Date of last inspection Brief description of the care home Pentrich is registered to provide accommodation and personal care for a maximum of thirteen adults who have a mental health problem. Nursing care is not provided. Should such care be required on a short-term basis then it will be provided by the community health services. Pentrich is a linked double fronted property situated in a residential area of Bridlington Care Homes for Adults (18-65 years) Page 2 of 12 2 9 0 5 2 0 0 9 Brief description of the care home and is conveniently located for all of the main community facilities including the public transport network. A parking area is available at the front of the property. There is also restricted on-road parking. The property has three floors. The accommodation consists of three shared bedrooms and five single rooms, two of which have en-suite facilities. Bathing/toilet facilities are available on each floor of the property. A dining room and two lounges, one designated for the use of people who smoke, are located on the ground floor. The property does not have a passenger lift so is only suitable for people who are able to use the stairs. On 29 May 2009 the manager said that the weekly fees are £283.69. People pay extra for chiropody, hairdressing, transport and toiletries. Information about the home is available in the Statement of Purpose if people want to see it. The most recent inspection report is available on request. Care Homes for Adults (18-65 years) Page 3 of 12 What we found: The reason for this inspection was to check the progress made against the three medication requirements issued after the last key inspection in September 2009. A pharmacist inspector examined the medication storage arrangements, the medication ordering records and the current medication administration record sheets (MARs). The outcome is as follows. The first medication requirement stated all medicines must be stored correctly at temperatures recommended by the manufacturer. We saw records of twice daily checks made of both room and fridge temperatures which showed that medicines were being kept at the correct temperatures. All medication storage units were locked securely when not in use. Advice was given to the manager reinforcing the need to ensure that medication keys are always held by the person in charge to prevent unauthorised access to medicines kept in the home. This requirement was felt to be met at the time of this inspection visit. The second medication requirement stated that medication must be given as prescribed and an accurate record must be made at the time that it is given. We examined the MARs for the monthly cycles beginning 22nd October 2009 and 19th November 2009. No significant administration gaps were were found. This suggests people are now receiving their prescribed medicines correctly as directed by the doctor. We also saw improvements in the way other medication records were kept. The manager has put in place a medication log book describing each persons medicines together with any dosage changes. These records are not yet complete but appear to be helping staff to communicate with each other about any medication changes each month. Hand written entries on MARs have been reduced in number and those we saw were complete and accurate. Printed entries contain clear instructions for use and very few discontinued items remain printed on the MARs. This requirement was felt to be met at the time of this inspection visit. The third medication requirement stated that arrangements must be in place to ensure that sufficient quantities of medicines are available in the home so that all medication can be administered as prescribed. We found no evidence on the MARs or ordering records of people not receiving their medication beacuse none was available in the home. We found records demonstrating that the GP or hospital prescriber is contacted to check whether further supplies of certain medicines are needed. All medicines are now ordered in good time and the manager told us there have been no instances of people running out of their medicines since the last inspection. This requirement was felt to be met at the time of this inspection visit. The homes medication systems and record keeping have improved considerably since the last key inspection. The manager is making good progress with updating the medication policy and procedures which, when completed, will hopefully lead to further improvements in medication safety in the home. What the care home does well: What they could do better: Care Homes for Adults (18-65 years) Page 4 of 12 The medication policy and procedures are yet to be fully updated. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 5 of 12 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 Peoples assessed needs must be fully identified in plans of care with clear guidance for staff in how to support people. This will ensure that staff know how to support people and avoid care being missed. 30/11/2009 2 6 12 Staff must follow guidance and instructions written down in care plans. This will ensure that peoples needs are being met in line with their assessed needs. 30/11/2009 3 9 13 Risk assessments must be completed fully for areas of risk in daily living activities. This must have detailed actions required by staff to help minimise the risks. This will ensure that staff are fully informed of any risks, know what they must do to support people to minimise the risks, and will help to safeguard residents and staff from harm. 30/11/2009 4 19 12 The dieticians advice and guidance must be sought regarding the limited diet one particular resident 30/11/2009 Care Homes for Adults (18-65 years) Page 6 of 12 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action chooses to take. This will give staff dietary ideas and ensure professional involvement in managing any perceived risk to the residents health and wellbeing. 5 19 12 A health plan for each 30/11/2009 resident must be produced that clearly identifies any physical or mental health needs and how these are going to be met, for example with dates for appointments and follow up checks. This will ensure health care needs are not missed. 6 23 13 The manager and staff team must familiarise themselves with, and use, the multiagency safeguarding of adults policies and procedures. This will ensure that the local authority, which is the lead agency for any investigations of abuse, is made aware swiftly of any issues and can decide whether they need to be investigated. Appropriate use of the procedure will help to safeguard residents and promote their wellbeing. 7 24 23 There must be a redecoration 30/11/2009 and refurbishment plan produced with clear timescales for short and long term work. Page 7 of 12 13/11/2009 Care Homes for Adults (18-65 years) Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action This will enable work to be planned in line with budgets and give clear information about targets and whether these are met. 8 27 23 The floor in the downstairs toilet must be repaired. This will prevent it from becoming a health hazard to people that use it. 9 30 16 There must be a system of deep cleaning the kitchen included in the domestic rota. This will ensure areas of the kitchen are cleaned thoroughly. 10 34 19 New staff members must have full checks in place prior to the start of employment. This will help to ensure that only suitable people are employed to work with vulnerable adults and will help promote their safety and wellbeing. 11 35 18 Staff working in the home must be supervised by their line manager. This will ensure that their work is monitored and management is confident that residents needs are being met as per their care Care Homes for Adults (18-65 years) Page 8 of 12 30/11/2009 30/11/2009 13/11/2009 13/11/2009 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action plans. 12 35 18 Staff must have up to date 30/11/2009 mandatory training and receive service specific training in line with the identified physical, mental health and in one case learning disability needs of the residents living in the home. The training must be identified and planned by the timescale required. This will ensure that staff have the right skills and knowledge about the needs of the people they support, will help them to identify quickly when peoples mental health needs start to deteriorate and will help them to be confident in their role. 13 41 17 Documentation required for the running of the home such as recruitment, medication, assessments, care plans, risk management, and staff training and supervision must in place and be up to date. This is to ensure that we can be confident the home is being managed appropriately. 14 42 37 Any incident affecting the welbeing of residents must be reported to the Care Quality Commission. 13/11/2009 30/11/2009 Care Homes for Adults (18-65 years) Page 9 of 12 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action This will enable us to monitor incidents and check that the home is manageing them well. Care Homes for Adults (18-65 years) Page 10 of 12 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 11 of 12 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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