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Inspection on 26/09/06 for Perry Locks Nursing Home

Also see our care home review for Perry Locks Nursing Home for more information

This inspection was carried out on 26th September 2006.

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 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

Senior staff carry out comprehensive pre-admission assessments to ensure that the home is able to meet all identified needs and that any specific equipment is in place on the day of admission of the resident. The staff of Perry Locks support residents in meeting their health, welfare and personal needs to promote their well being. There is a friendly atmosphere and accommodation is well maintained, comfortable and hygienic for the comfort of residents. Residents are encouraged and supported in maintaining good links with relatives and friends to enhance the quality of their lives. Residents and staff provided positive feedback to both inspectors during the course of the fieldwork visit. A quarterly magazine is developed and distributed to residents and staff. The home responds positively to any shortfalls that are raised during and following fieldwork visits.

What has improved since the last inspection?

The dependency levels of residents who live in Brooklyn house are high. The home has responded positively by increasing the number of carers on duty at night from three to four. This ensures that the needs of the current client group are being met. Perrywell house has been refurbished. New bedside cabinets have been purchased for another house. One house has been supplied with replacement chairs and commodes. In Brooklyn house a bath has been removed and replaced with a wheel-in shower unit. The home has introduced an initiative, which enhances the quality assurance arrangements. This entails staff volunteering and taking on tasks that enhance the standard of the services supplied. Tasks include boot cleaning and sewing buttons on shirts etc. The registered manager advised that this has resulted in positive effects on staff as well as improving services for residents.

What the care home could do better:

The practice of staff propping open external fire doors must cease to protect residents and staff from risk of injury. Regular and robust audits are required of the medication arrangements in each house to ensure staff carries out safe practices and risks to residents are eliminated. Staff failed to demonstrate sufficient knowledge about how to respond when adult abuse is suspected. The home is advised to review the training supplied to staff.

CARE HOMES FOR OLDER PEOPLE Perry Locks Nursing Home 398 Aldridge Road Perry Barr Birmingham West Midlands B44 8BG Lead Inspector Kath Strong Key Unannounced Inspection 26th September 2006 09:00 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 Perry Locks Nursing Home DS0000024879.V312098.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. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Perry Locks Nursing Home Address 398 Aldridge Road Perry Barr Birmingham West Midlands B44 8BG 0121 356 0598 0121 331 1261 slyms@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) Mrs Sarah Elizabeth Slym Care Home 120 Category(ies) of Dementia (120), Dementia - over 65 years of registration, with number age (120), Mental disorder, excluding learning of places disability or dementia (120), Old age, not falling within any other category (120), Physical disability (120), Physical disability over 65 years of age (120) Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Males & females over 50 years Care Home for service user categories OP, DE(E), DE, PD(E) PD, MD and people over 50 with dementia or physical disabilities requiring continuing care. That two named service users (names held on CSCI file) under the age of 50 may be accommodated in the home. 2nd February 2006 Date of last inspection Brief Description of the Service: Perry Locks is a modern purpose built Nursing Home and is part of the BUPA organisation. The home comprises of four separate houses, each with thirty beds. Three houses are registered for nursing care: Lawrence, Brooklyn and Calthorpe and Perrywell house for dementia care. All four units take residents requiring respite care. All houses have access to small landscaped gardens (Perrywell is safely enclosed). Each house has a lounge/dining room and a further quiet room for residents to frequent. There is ample off road parking facilities at the front of the home. In addition to the Registered Manager, there is also a Clinical Team Manager and a Senior Nurse for each house. All bedrooms are for single occupancy. There are no en-suite facilities; a wash hand basin unit is included in each bedroom. There is a good supply of specialist equipment and moving and handling devises to assist staff in carrying out safe transfer of residents. The current weekly accommodation fee range is £423.14 to £1,200.00. The home is situated beside a canal in a residential area, four miles from Birmingham City Centre. It is sited close to a local bus route and local shops are only a short distance away. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced and undertaken by two inspectors over a period of one long day. The registered manager and the clinical team manager provided assistance. Verbal feedback was given to the clinical team manager at the conclusion of the visit. There were 120 residents living at the home at the time therefore, there were no vacancies. Information was gathered from speaking with residents, relatives and staff. Examination of care, health and safety and medication were carried out. Relevant records were reviewed including the standards of a sample of care plans. The registered manager had completed a pre-inspection questionnaire and CSCI received comment cards from a number of residents and relatives. During the fieldwork visit a pharmacy inspector from the Primary Care Trust carried out an audit of the arrangements for medications in one of the houses and gave feedback to the inspectors. The feedback has been included in this report. No Immediate requirements were made. What the service does well: Senior staff carry out comprehensive pre-admission assessments to ensure that the home is able to meet all identified needs and that any specific equipment is in place on the day of admission of the resident. The staff of Perry Locks support residents in meeting their health, welfare and personal needs to promote their well being. There is a friendly atmosphere and accommodation is well maintained, comfortable and hygienic for the comfort of residents. Residents are encouraged and supported in maintaining good links with relatives and friends to enhance the quality of their lives. Residents and staff provided positive feedback to both inspectors during the course of the fieldwork visit. A quarterly magazine is developed and distributed to residents and staff. The home responds positively to any shortfalls that are raised during and following fieldwork visits. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 6 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. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 7 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 Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents, relatives and external professionals are not supplied with adequate written details about the services for them to make an informed decision about the home. Comprehensive pre-admission assessments are carried out for the home to confirm that it is able to meet all of the individuals needs. EVIDENCE: The statement of purpose and service user guide were examined. The home was advised that it is not good practice to expect the reader to have to locate several BUPA policies and procedures before they are fully informed about the services provided. The statement of purpose should be amended to include the two residents who are currently below the age of 50 years of age as per the conditions of registration. The home is advised to produce the service user guide in large print and audio cassette to assist people with sensory impairment. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 9 The contract of terms and conditions of residency was noted to be excellent in that it is accompanied by full written explanations of each section to ensure clarification for residents or their representatives. The inspectors were impressed with the standard of the contracts. The care plans seen included pre-admission assessments. The tool used and the standard of records in them were found to be comprehensive. The home demonstrates that it is able to meet resident’s needs at the point of admission. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not demonstrate that all healthcare needs are being met. The procedures for the administration of medications fail to protect residents from harm. Observations indicated that staff practices ensure that resident’s privacy and dignity are maintained. EVIDENCE: Care plans included an index for ease of access to relevant sections. The files are detailed, informative and indicate that individuality of residents needs are incorporated. Separate short term care plans are developed for such conditions as chest or urinary tract infections. They include comprehensive records of the services provided by external healthcare professionals. Risk assessments are completed and reviewed regularly. Daily recordings were being completed for day and nighttime. There was evidence that staff were carrying out the instructions in care plans such as regular changes of position to reduce the risk of pressure ulcers occurring. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 11 The home needs to ensure attention to detail as some shortfalls were identified: • Moving and handling risk assessments were well completed but staff instructions were not sufficiently detailed. The equipment to be used for changes of position had not been recorded or the sling size for those who require hoists • A care plan recorded that a resident was losing weight but failed to provide information regarding the action to be taken • Care plans had not always been signed by the author • A social assessment sheet had been developed July 1996 but had not been updated to reflect the present condition of the resident • A short term care plan for a leg ulcer did not include a good description of the wound to enable efficient monitoring to be carried out • The care plan of a recently admitted resident indicated that it had been developed twelve days following admission. The home must ensure that care plans are developed in a timely fashion • A care plan regarding difficult to manage behaviour did not include the type of behaviour displayed. There was ample evidence to confirm the involvement of external professionals and that staff were carrying out the suggested instructions. The home is currently participating in ‘The Gold Standards Framework Programme In Care Homes’ scheme. This ensures that all needs are being met for those persons with a limited life span. Staff should be commended for this initiative to provide a quality lifestyle for ill residents. Comments received by residents included, “They are as good as gold here, my nails haven’t been done, I’m happy here, all the staff are lovely, I’m happy”. The inspectors met with a Primary Care Trust pharmacist who had completed an audit of staff practices in Perrywell house. The feedback given was that MAR (medication administration record) charts were not always being completed and that any gaps found should be explored to reduce the risk of recurrence. The information included that staff are failing to record the number of tablets administetered for PRN (as required) medications. An inspector carried out an audit of the medication in another house. Hand written instructions were not being verified as being correct by the signature of a second trained nurse. The MAR chart for a resident did not include the dates for a two week period and staff had continued recordings in the outer margin of the page instead of commencing a new chart. This indicates that staff are failing to ensure the health and well being of residents because the administration of prescribed medications are not accurate. Staff were observed using the preferred term of address and did not enter bedrooms without being invited to. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 12 The interactions and assistance provided by trained and care staff were noted to be appropriate and delivered in a sensitive way. This demonstrates that staff respect and preserve the dignity of residents. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. There was inadequate evidence that the recreation programme is sufficient to stimulate residents. Residents are encouraged to maintain links with the community and contact with their families to promote their individuality and independence. A wholesome and nutritious diet is provided with choices offered and specialist diets being catered for. EVIDENCE: The home has an internal activities programme. The information provided indicates that an activity is supplied every morning and afternoons of weekdays and in which house residents need to attend to participate. Information provided was that the timings of the recreations are not included in the programme to permit resident’s ample time to finish their meals. Discussions held with residents suggested that they are unsure about the timings of them and when to attend another house to participate. On the day of the visit there was little evidence of residents moving between houses. Comment received included, “There aren’t enough activities, sometimes I go to other houses to play bingo, staff don’t’ offer to take me out much”. A comment card received prior to the fieldwork states ‘I don’t always get the activities I would like’. On the day of the fieldwork a donkey was taken round Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 14 the home, feedback received was that residents appreciate and get pleasure from these visits. Each house records the residents who have participated but the comments section was not completed enough to determine the level of enjoyment of individuals. This system is not effective for staff to be able to clarify residents and their preferences, as records are not being maintained within the resident’s respective house. The home needs to provide evidence that the programme suits resident’s preferences and to ensure that trends and monitoring is effective. Regular outings are provided to such places as the botanical gardens and advice was given that a number of residents are registered for the ‘Ring and Ride’ bus service. The home has a policy of open visiting and residents commented that their relatives could visit at any time. Staff encourage and arrange for residents to attend day centres as appropriate. One resident said, “In the summer I will go for a walk”. Relatives were observed visiting residents in one of the houses. One relative takes her dogs into the home regularly, which residents were noted to enjoy. A relative was observed providing a drink between her relative and another resident who indicated that she would also like some. There was a relaxed and friendly atmosphere between residents, visitors and staff. This helps to make residents feel at ease. The home operates a system of a main menu and a separate list of alternatives if they do not like what is being offered. Each bedroom is supplied with a list of the alternatives and the breakfast menu. Lunch was observed being served in two houses. Staff served well presented meals and provided discreet and constructive assistance to residents who required help. Relatives were also observed to be providing assistance to ensure residents enjoyments at mealtimes. Soft and pureed diets were served appropriately and specialist plates were used for some residents to encourage them in feeding themselves and in maintaining their independence. The evening meal was noted to include pots of tea on each table. Comments received from residents included, “Its not too bad and I have choices, food is very good”. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure does not provide residents with clear instructions on where to send a complaint. The arrangements for protection from abuse are not sufficient to protect residents from harm. EVIDENCE: A copy of the complaints procedure is available in each bedroom but this does not supply the contact details of the local CSCI office. The actual written procedure is good, includes clear instructions and has a section that can be used to record and submit a complaint. The home also has a good system for the recording the investigations and outcomes. The home also carries out monthly audits. There were no formal complaints received by the home since the last inspection but CSCI have received one. The complaint was made by a hospital and the outcome was that the home was not failing in meeting the needs of the resident. The written policy in respect of adult protection requires amendment. Section 3.4.5 instructs the home manager to undertake an investigation, this needs to be deleted. On previous occasions the home has demonstrated that in practice appropriate action is taken; this must be reflected in the written policy. Staff training is regularly supplied in-house. Some staff were not able to fully demonstrate that they would respond appropriately when an abuse is suspected. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 16 Although they would report and record the incident, they would ask the abuser why, which is not a correct course of action. The home is advised to review the training supplied and staff understanding of their responsibilities. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, and 26 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Perry Locks provides a clean, warm and comfortable environment, in which residents can feel secure and relaxed. EVIDENCE: A tour of the premises was carried out. Each house is built in an identical fashion and provide the same communal and bedroom accommodation. The fixtures and fittings included a good and varied range of ornaments to ensure a pleasant and interesting environment for residents to enjoy. An abundance of soft furnishings and ornaments were evident in Perrywell house. Furniture is of a high standard and well maintained. Each house included a kitchen to enable staff to serve refreshments and snacks. An ample range of assisted bathing consisting of baths and showers and communal toilets are strategically located through the premises. This enables residents to make choices about the type of bathing they wish to have. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 18 Bedrooms are pleasant, airy and comfortable. They were noted to be personalised to the extent preferred by the occupant. Suited door locks permits residents to have a door key to ensure their wishes for privacy are maintained. Random checks of water temperatures were being recorded of all hot water outlets accessible to residents to minimise the risk of scalds. The home was clean and tidy throughout. The kitchen areas were especially hygienic. Communal rooms where a water supply exists were supplied with cassette soap dispensers and alcohol hand rub to ensure prevention of cross infection. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Adequate staffing levels are maintained to meet the needs of the current client group. The home operates a robust recruitment programme, which protects residents from harm. Staff inductions and training ensures that staff have the knowledge and skills to carry out their roles effectively. EVIDENCE: The recently increased staffing levels achieved in Brooklyn house are in excess of the registration requirements as well as the twilight shift every night in Perrywell house. A senior trained nurse runs each house. Other trained staff and carers support them. Care staff are complemented by a full compliment of ancillary staff, which permits them to carry out their designated roles. Some staff employed are of ethnic minorities, there was no evidence of communicated problems or cultural differences. A sample of staff files revealed that the home operates a comprehensive and safe means of staff recruitment with all necessary checks being carried out before they commence employment. There is a good induction programme for care staff, which mirrors the contents of Skills For Care. At least 50 of staff have successfully completed NVQ level 2 training and some have achieved level 3. Examination of the training details indicated that all staff have received mandatory training and have attended other courses that are relevant to the individual needs of residents. Where gaps exist staff are currently undertaking long distance training. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 20 The home employs trainers who provide Moving and Handling training to staff every six months on a rolling basis. Those staff who work in Perrywell house have all undertaken training in dementia care. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 21 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 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 has a clear vision for future progression of the home and standards of care. The quality assurance system ensures a consistent approach and ongoing means of improving the services. Resident’s personal monies are safeguarded. Health and safety procedures do fully ensure that residents are fully protected from the risk of accidents. EVIDENCE: The registered manager possesses a wealth of experience and skills to carry out her role effectively. A clinical team manager supports her. Each house has a senior trained member of staff and there are a number of senior carers. Discussions held with residents and staff indicated that the senior staff are supportive, approachable and willing to listen to suggestions, which may result in improvements of the services. A senior manager regularly visits the home and carries out an inspection, which is followed up with a report. An annual survey is carried out on the Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 22 home and questionnaires are distributed to residents. The responses are collated and a report written, which highlights any shortfalls and how they need to be addressed. Resident’s personal monies were reviewed; it was noted that money received did not include two signatures. The home was advised to ensure that two signatures are obtained for all transactions. The clinical team manager advised that it would be actioned immediately. Accidents were being recorded and audited to identify trends and take appropriate action to minimise them. The home is carrying out the necessary checks and servicing of equipment. Regular testing of the fire alarms and emergency lighting was being undertaken and recorded. Regular fire drills are carried out and names of staff who have participated are recorded. All aspects of health and safety were being met with one exception. Staff must cease the practice of propping open external fire doors to ensure that residents are protected from risk of injuries. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 23 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 2 4 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 X 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 491)(2) Requirement The registered person must ensure the statement of purpose includes all relevant information and be further developed to include the current conditions of registration concerning residents who are below the registration age group. The registered person shall ensure that: Care plans are comprehensive, up to date and signed by the author as detailed in the body of this report. The registered person must ensure that medications are appropriately recorded, any gaps explored and hand written instructions are signed by two trained staff. The registered person must ensure that the local contact details of CSCI are included in the written complaints procedure. Timescale for action 30/11/06 2. OP7 15(1)(2) 31/10/06 3. OP9 13(2) 31/10/06 4. OP16 22(2) 15/11/06 Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 25 5. OP18 13(6) 6. OP38 13(6) The registered person must 30/11/06 amend the written policy regarding adult protection. The home must review the training package supplied to staff and explore staff knowledge about how to respond to allegations of abuse. The registered person must 31/10/06 ensure the staff practice of propping open external fire doors ceases. 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. Refer to Standard OP7 OP26 Good Practice Recommendations It is recommended that staff receive instruction on how to measure residents for slings, to use with the hoist. It is recommended that alternative arrangements for male staff changing are sought and that personal belongings and clothing are not stored in residents toilets, due to the risk of cross infection. Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Perry Locks Nursing Home DS0000024879.V312098.R01.S.doc Version 5.2 Page 27 - 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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