Inspection on 02/12/05 for Peregrine House

This inspection was carried out on 2nd December 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 but made no statutory requirements on the home.

Other inspections for this house

Peregrine House 29/08/07

Peregrine House 19/10/06

Peregrine House 01/08/05

Peregrine House 04/10/04

Peregrine House 08/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Peregrine House 350 Hermitage Road South Tottenham London N15 5RE Lead Inspector David Hastings Unannounced Inspection 09:30 2 December 2005 nd X10029.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 Peregrine House DS0000010734.V253161.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 Older People and 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. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peregrine House Address 350 Hermitage Road South Tottenham London N15 5RE 020 8809 5484 020 8802 1471 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) Servite Houses Ms Yvonne Evadney Smythe Care Home 35 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (35), Old age, of places not falling within any other category (35), Physical disability (16), Physical disability over 65 years of age (35) Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Limited to 35 people of either gender who fall into the category of old age (OP) and who may also have a mental disorder (MD(E)) and who may also have a physical disability (PD(E)). Up to 16 of the 35 places may accommodate people of either gender who are aged between 40 and 65 years of age and have a physical disability (PD) 1st August 2005 Date of last inspection Brief Description of the Service: Peregrine House is a large care home for up to thirty-five service users, the majority of whom are older people but there is a significant group of younger service users with physical disabilities. The home is run by Servite Homes. The home is located in a residential road in South Tottenham. It is sited close to local shops, public transport and local amenities. The home is organised over two floors, with the ground floor functioning as a specialist unit for up to sixteen younger people with physical disabilities. All bedrooms are for single occupancy and have en-suite facilities. There is a lift and a number of assisted bathrooms. There are patio areas with raised tubs which are accessible to service users. The stated aims of the home are: ‘Peregrine House offers care and support to enable residents to remain as independent and active as possible. Each person is treated as an individual with his or her own likes and dislikes.’ The home provides twenty-four hour care and support and access to a range of residential specialist services geared towards meeting individual service users needs. Peregrine House DS0000010734.V253161.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 on 2 December and lasted five and a half hours. The inspector spoke with nine of the residents during the inspection and the feedback was very positive regarding the management and staff at the home. Four staff were interviewed in private. A tour of the premises took place and care records were inspected. The inspector was assisted by the registered manager of the home, who was open and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: One requirement, issued at the last inspection, relating to the review of fire procedures has not been complied with and is restated as part of the recommendations from a recent fire officer’s visit. Three requirements have been issued at this inspection relating to minor medication issues. Some sauce bottles and jams need to be stored in a refrigerator. Although the home is generally well maintained, the carpet in room 11 needs to be replaced. A requirement has been made at this inspection for all staff to attend training in mental health issues in order to underpin their care practices. The inspector is confident that the manager will comply with these seven requirements within the timescales given. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 6 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. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) Prospective service users can be confident that their needs will be assessed prior to their admission to the home to ensure those needs can be effectively met. Their needs continue to be reviewed if they are admitted to ensure that their changing needs will also be able to be met. EVIDENCE: Four service user files were inspected including files for the two service users most recently admitted to the home. Each had satisfactory assessment information with evidence to confirm that this information had been received by the time the person was first admitted to the home. There was also evidence that the individual’s needs were reviewed on a regular basis and changing needs recorded. The home operates a key worker system and staff Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 9 spoken to confirmed that they were involved in regular reviews for the service users they were key worker for. A number of service users spoken to were able to confirm that they attended their reviews. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Service users needs are well set out in their care plans to ensure their current assessed needs are being addressed. Service users health needs are well monitored and service users are supported in addressing these with relevant health professionals. Service users receive the medication prescribed to them at the appropriate times. EVIDENCE: Four service users care plans were inspected and each was current and comprehensive. There was evidence that the care plans had been regularly Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 11 reviewed, monthly for older people and at least six monthly for younger adults. There were also current risk assessments with evidence that these had been reviewed on a regular basis as with the care plans. Risk assessments seen included moving and handling assessments and risk assessments for those service users that smoke. The manager informed the inspector that new care plan formats are being introduced and a sample of these care plans were seen and were detailed and well designed. There was evidence that service users health needs are satisfactorily addressed, this was recorded on the service user files inspected. This included that service users were registered with a GP and relevant appointments had been attended by individuals with healthcare professions such as chiropodists, opticians and planned hospital outpatient appointments. Records in relation to the receipt, administration and disposal of medication were examined. A requirement issued at the last inspection that medication for service users is kept in the cupboard in the unit where the service user is accommodated has now been complied with. Medication records were examined from two of the four units. A requirement has been issued that the temperature of the main medication storage room is recorded. In general the medication records were satisfactory however in one unit there were two minor issues regarding the recording of medication obtained during the month and a lack of records indicating when medication has been brought forward from one month to the next. Two requirements relating to these matters have been issued in the relevant section of this report. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 The home provides a range of social and other activities to meet service users needs and wishes. Service users receive a wholesome appealing balanced diet and can choose from a range of menu options. EVIDENCE: A number of service users attend external day services and a weekly programme of activities run by the home was seen displayed on the notice board by the entrance foyer of the home. Service users were being supported by staff in playing indoor board games and reading newspapers. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 13 The manager informed the inspector that nine service users and five staff recently went to a Butlins holiday centre in the summer and two other service users went on holiday to Spain and Turkey. As a result of a service users’ meeting staff take service users out to local shops and entertainments. Service users that the inspector spoke with said they were satisfied with the level of activities available to them. An outside contractor, which is linked to the provider organisation, provides the main meals at the home. The main kitchen was inspected and found to be clean and tidy. A satisfactory record of fridge and freezer temperatures was seen. Food was stored appropriately in the main kitchen, was within its use by date and matched the planned meals on the menu. There are kitchenettes in each of the four service user units where breakfast and snacks can be prepared by service users and by staff for service users. Food in the fridges of these kitchenettes was being labelled appropriately. This was a requirement from the last inspection that has now been complied with. It was noted that tomato ketchup bottles were being stored in the cupboard and not in the fridge as required. A requirement relating to this has been issued in this report. The chef confirmed that she met with the registered manager on a regular basis to discuss any current issues. She also stated that the company prepares menus, which included an alternative for each main meal, for approval by the provider organisation and that service users are consulted about meals at service user meetings. The lunch options looked appetising on the day of the inspection and most service users spoken to said that they enjoyed the meals at the home. A requirement that the home provide suitable alternative menus for service users from ethnic minority communities has now been complied with. It was clear that the manager and the kitchen staff were working hard to provide suitable menus for all the service users at the home. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 18 All complaints are dealt with in a professional manner and in line with the home’s complaints procedure. Service users are protected from abuse by clear procedures and by a appropriately trained staff team. EVIDENCE: There have been five complaints since the last inspection. Records indicated that these have been dealt with in an open and professional manner and outcomes have been recorded in line with the home’s complaints procedure. One service user commented, “I feel things happen when I complain”. The registered manager informed the inspector that Adult Protection awareness is undertaken by staff as part of the induction programme. Staff interviewed were aware of the forms that abuse can take and the importance of reporting any suspicions of abusive practice to the manager. The manager is aware of her responsibilities with regard to the home’s Adult Protection procedure and is a member of the local authority’s Adult Abuse committee. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Service users live in a home that is well decorated, well maintained and that meets their needs. The home was clean and tidy throughout creating a pleasant environment for service users, staff and visitors. EVIDENCE: The home is purpose built with service users living within one of four semi selfcontained units, two on the ground floor and two on the first floor with a lift to assist access to the first floor. Two requirements made at the last inspection, relating to minor repair issues have both been complied with. The home is Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 16 decorated and maintained to a good standard. However the carpet in bedroom 11 needs replacing. A requirement relating to this has been made in this report. Service users’ rooms that the inspector visited had an individual feel and service users stated that they were satisfied with their accommodation. The home was clean, tidy and free from offensive odours during the unannounced inspection. The home has a satisfactory laundry and new washing machines have been fitted that were seen to meet the requirements of this standard. Laundry was being undertaken during the tour of the premises and the process was explained to the inspector including that each service user’s laundry was washed individually. Suitable arrangements were in place to deal with soiled laundry and to dispose of other soiled material. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The home has an effective and stable staff team, in sufficient numbers, to support service users and to assist in meeting their assessed needs. Service users are properly protected by the homes recruitment policies. There are good training opportunities for staff at the home. EVIDENCE: The staffing for the home consists of six staff on the early and late shifts with one staff member being allocated to each of the four units and two staff floating between the units. Three waking night staff cover the four units between them of a night. The staff rota was seen and matched the staff that were on duty. One service user commented that the staff were, “very nice”. A requirement was issued at the last inspection that all CRB’s are retained by the provider organisation until they have been seen by the CSCI. Although no new staff have been employed since the last inspection, the registered manager told the inspector that new procedures have been implemented to address this issue. The requirement has been complied with. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 18 Training records examined indicated that there are good training opportunities for staff. This was also confirmed by the staff interviewed on the day of the inspection. The home supports people with mental health problems and it was noted that no specific training is available to staff regarding this issue. A requirement has been issued in the relevant section of this report that staff are provided with mental health training. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The registered manager is professional and carries out her duties and responsibilities effectively. Service users have a say in how the home is run. Service users’ finances are safe guarded by clear accounting procedures. Fire safety policies and procedures at the home have improved. However more work is needed in order to comply with the relevant safety legislation. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 20 EVIDENCE: The registered manager has been in post for a number of years and staff and service users were very positive regarding her professionalism and effectiveness as a manager. It was clear from discussion that the manager takes her roles and responsibilities seriously. The home uses an outside organisation to carry out a quality audit/ customer satisfaction survey every two years. The last survey was carried out in April 2005. Minutes of service user and relatives meetings were examined. These minutes provided evidence that service users are being consulted about the running of the home and issues such as complaints, menus and transport were discussed. The manager informed the inspector that ten service users manage their finances independently. The remaining service users have their money dealt with either by their family or the provider organisation. Some small amounts of money are held by the home on behalf of service users. Three randomly selected service user accounts were examined. These were all being accurately recorded and clear audit trails were available. The registered manager informed the inspector that the home had recently being inspected by an outside auditor in October of this year. At the last inspection the fire detection system was found to be faulty and an immediate requirement was issued that the system be repaired and interim measures taken. This immediate requirement has been complied with and the home now has a new fire detection system. Risk assessments have been completed for all service users that request their bedroom door to remain open during the night. This was a requirement from the last inspection. The registered manager informed the inspector that a contractor has repaired all magnetic door devices. This was also a requirement from the last inspection that has now been complied with. The local fire officer inspected the home on 5th October 2005 and as a result six fire related issues have been highlighted for action. A requirement has been issued in this report that the registered provider must comply with the recommendations of the fire officer’s report by 6th January 2006. These recommendations included the revision of the emergency plan for the home. This was a requirement from the last CSCI inspection and is included in the above requirement. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 21 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that the temperature of the main medication storage room is monitored and recorded. The registered manager must ensure that any medication brought forward from the previous month is recorded on the MAR chart. The registered manager must ensure that any medication received into the home is recorded. Records must detail the date the medication was received and the amount of medication received. The registered manager must ensure that any ketchup bottles or jams that require refrigeration are kept in the fridge. The registered manager must ensure that the carpet in room 11 is replaced. The registered manager must ensure that all staff are provided with mental health training. The registered manager must ensure that the requirements from the fire officer’s report are DS0000010734.V253161.R01.S.doc Timescale for action 01/02/06 2 OP9 13(2) 01/02/06 3 OP9 13(2) 01/02/06 4 OP15 13(4) c 01/01/06 5 6 7 OP19 OP30 OP38 23(2) b 18(1) c 23(4) c 01/04/06 01/08/06 06/01/06 Peregrine House Version 5.0 Page 23 fully complied with. This includes a requirement, restated from the last CSCI inspection, that the home reviews the fire emergency plan. (Timescale of 31/08/05 not met) This requirement has been amended and restated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. Peregrine House DS0000010734.V253161.R01.S.doc Version 5.0 Page 25 - 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. 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