Inspection on 05/09/06 for Perrygrove

This inspection was carried out on 5th 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 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

Perrygrove 08/05/08

Perrygrove 25/06/07

Perrygrove 02/09/05

Perrygrove 11/04/05

Perrygrove 26/04/04

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 HOMES FOR OLDER PEOPLE Perrygrove Rectory Fields Crescent Charlton London SE7 7EN Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 05th September 2006 09:25 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 Perrygrove DS0000006855.V298195.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. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Perrygrove Address Rectory Fields Crescent Charlton London SE7 7EN 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) 020 8856 3995 020 8319 1663 Kent Community Housing Trust Post vacant Care Home 43 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (36) of places Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: Perrygrove is a Care Home for up to 43 older people. Accommodation and personal care is provided to 36 older people and identified unit provides accommodation and person care to 7 older people with dementia. Kent Community Housing Trust runs the service. The property is situated in a quiet road in Charlton close to local shops and bus routes and the town centres of Lewisham, Greenwich and Woolwich are within easy access. Accommodation is provided over three floors. The home has one shared room and the rest are for single occupancy. Fifteen rooms have en-suite toilet and wash hand basin and there is adequate communal space on the ground floor. To the rear of the property is an enclosed small garden, which is accessible to residents and to the front there is some parking space. The current fees ranged from £414.71 - £484.19. Residents pay privately for items such as hairdressing, private chiropody, toiletries, newspapers and outings. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 5th September 2006 over 9 hours. The manager and staff assisted with the inspection. Fortyone residents were in the home and there was one vacancy. The service was last inspected on the 2nd September 2005. The inspection included a review of information held on the service file, a tour of the premises, inspection of records, talking to residents, staff and the manager and reviewing compliance with previous requirements and recommendations. Comment cards received from relatives and service users prior to the inspection were viewed. This feedback was mostly positive and indicated an overall satisfaction with the care provided. One concern raised by a relative was brought to the manager’s attention. Since the last inspection the service had altered the accommodation and had a variation to registration to provide a seven-bed unit for residents with dementia. This unit opened on 4th September 2006. What the service does well: What has improved since the last inspection? Steps had been taken to address issues residents had regarding the quality of meals provided. Care plans seen included social histories for residents. The service had been changed to provide care for seven residents with dementia. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 6 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. Perrygrove DS0000006855.V298195.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 Perrygrove DS0000006855.V298195.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): 3 and 4. Standard 6 did not apply to the service. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. A care manager or staff from the home completed pre- admission assessments for residents. Residents did not receive written confirmation that the home could meet their needs. EVIDENCE: An admission policy and procedure was provided. Care manager assessments were seen on the resident files viewed. Staff from the home also completed a pre-admission assessment. There was no evidence on the files seen to show that residents received written confirmation that the home could meet their needs based on assessment. This issue was raised at the last inspection. Requirement 1. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 9 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 – 10. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. The quality of the care plans viewed was poor. The new care plan format should help to improve care planning and to show how identified needs will be met. Medicines were satisfactorily managed with some minor improvements required. Systems were in place to ensure resident healthcare needs were met. Resident and relative feedback was positive in relation to the way resident dignity was respected. EVIDENCE: A new care plan format had been introduced and staff were in the process of changing to this new format. The old care plans did not include a care plan format to show how identified needs were to be met. The new care plans have this included. The new care plans included space for care managers and relatives to sign but there was no space to evidence resident involvement with preparing their care plans. Three care plans were viewed. One of these was for a resident who had been in the home for three months. No care plans or risk assessments had been prepared to show how this resident’s pre-admission assessed needs would be met. This matter was brought to the attention of the manager and the Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 10 Commission received written confirmation that care plans had been prepared for the resident the day after the inspection. One care plan was on the old format and did not show how assessed needs were to be met. One ethnic minority resident who spoke little or no English did not have a care plan in place in relation to communication. One resident had a catheter in place and again there was no care plan in relation to catheter care. One care plan viewed was for a resident in the new dementia unit. The care plan indicated the resident was provided with a pressure relief mattress and cushion but the resident was not using either of these items on the day of the inspection. Daily evaluation records did not show how often residents had a bath and provided little information to support the implementation of the care plans. The issue about recording baths was raised at the last inspection. A number of care files viewed did not contain any evidence that the resident’s weight was being monitored. Requirement 2 and recommendation 1. All residents were registered with a GP. A district nurse visited the home regularly to provide advice and nursing care. Residents were supported to access other healthcare such as dental and optical care. Specialist services were accessed through GP referral. Staff could refer residents to a psychiatrist and the community psychiatric nurse (CPN). The CPN was seen in the home and said that staff used this service appropriately for the benefit of the residents. Residents paid privately for chiropody care, as this was difficult to access from the NHS. Staff had access to policies and procedures in relation to medicines. The team leader on duty confidently explained the procedures in place for ordering, storing, administering and disposal of medicines. Medicines were supplied in blister packs with pre-printed medicine administration charts. Medicines were stored in the allocated surgery and a medicine fridge was provided. Medication records were generally well maintained. Medicine administration records were viewed and were up to date. Issues noted were that two signatures were not included when staff entered prescription details on the charts and there was no evidence to show that topical medicines prescribed had been administered. Due to lack of storage space in the medicine trolley and cupboards a number of blister packs were stored on the bottom of an open trolley in the surgery. The surgery room was kept locked and the team leader on duty held the key. It is recommended in this report that additional cupboard be provided to ensure safe storage for all medicines. Staff had access to a list of homely remedies agreed by the GP. It was not possible to complete an audit trail for the homely remedy medicines, as there were no records for receipt of these. Requirement 3 and recommendation 2. A number of residents spoken with and completed comment cards received from four residents said that staff listened to them and that they were satisfied with the way staff treated them. Comments received from seven relatives supported these comments. One relative said that on occasions their resident Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 11 ‘looked scruffy’ when they visited and this upset them. This comment was fed back to the home manager without identifying the relative. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 12 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 – 15. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Residents were satisfied with the activities provided. Residents said they enjoyed contact with family and friends and relatives indicated they were welcome when visiting the home. More effort must be made to directly involve residents with care planning. A new food supplier was being introduced and management will monitor changes. Staffing levels on the dementia unit at mealtimes must be adequate to meet the needs of the residents. EVIDENCE: Care plans seen include nice social histories and a number of residents said they had enough activities provided. An activity organiser was employed for four days a week and records seen showed that regular activities such as crafts, cooking, quizzes, painting and bingo were arranged. Entertainment was also ‘bought in’ and some residents had trips outside the home. The company ‘activity bus’ visited the home once a month and residents were said to enjoy spending time on this. The activity organiser was in the process of preparing care plans for individual residents with efforts being made to provide activities suited to them and to spend one to one time with the less able residents. The activity organiser had been in post for about two years and had received training such as dementia awareness, moving & handling and fire safety; however no training specific to the role, as an activity organiser had been Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 13 provided. Several residents enjoyed sitting in the newly landscaped garden. The garden provided a pleasant area for residents. It was easily accessed by residents including wheelchair users, had lovely shrubs, aromatic plants and adequate seating. The introduction of the dementia unit had meant the smoking room had been lost. Currently residents smoked in the hairdressing room or in the garden. This was not seen as appropriate and the manager said she was looking into this and hoped to provide a more suitable smoking room. In the dementia unit residents were seen sitting in the lounge, some were asleep and some were watching television. However both the television and stereo were on at the same time, which must be very confusing for people with dementia. Requirement 4 and recommendation 3. The home had an open visiting policy, which supported residents to maintain contact with family and friends. A number of residents said they enjoyed outings with and visits from their family. Completed comment cards received from relatives did not indicate there were any problems when visiting the home. Residents who spoke to the inspector said staff enabled them to make choices about things such as meals, what to wear and taking part in activities. Records seen showed that residents could refuse a bath if they wished. However there was little evidence in care records to show that residents were involved in preparing their care plans and as mentioned the new care plan format may not provide evidence of resident involvement in their care planning. Requirement 2. The kitchen was not inspected on this occasion. Comments about meals received from residents during the inspection and in the completed comment cards varied. Four completed comment cards showed that two residents usually liked the meals, one did not comment and one said they always liked the meals. Comments made during the inspection included ‘the food is satisfactory’, ‘the food is good but ‘samey’, the food is not bad and we get a choice’ and ‘the food is mediocre, we get carrots every day and the cabbage is undercooked’. The manager said that residents had expressed dissatisfaction with the food and she held a meeting with them to discuss this. Plans were in place to trial a new food supplier called ‘3663’. This company will provide the food, the menus, which will be assessed by a nutritionist, and new recipes for the cook to try out once a week. The manager will monitor resident satisfaction with the new system. Residents were seen having lunch and a number said they enjoyed the meal. Staff were seen offering support where needed. In the dementia unit, which had seven residents, there was only one carer to assist at lunchtime. Meals were served and left in front of the residents but as at least four of the residents needed help to eat their meal this was seen as poor practice. The inspector brought this issue to the attention of staff and a second carer was sent to help. Requirement 5. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Adequate procedures were in place to manage complaints and adult protection. However the registered person must ensure staff receive training to keep them up to date. EVIDENCE: A complaints policy and procedure was provided. Residents spoken with knew how to make a complaint and who to make this to. Residents knew the home manager and deputy by name. A copy of the service user guide was seen in some of the bedrooms viewed. Comment cards received from seven relatives showed that only three were aware of the home’s complaints procedure. A system was in place to record complaints made about the service and to show how these were managed. The manager recorded all complaints made about the service, regardless of how minor they seemed. Since the last inspection fifteen complaints were recorded. Records showed these complaints had been managed appropriately. Also since the last inspection ten compliments were received about the service. An adult protection policy and procedure was provided. Staff spoken with displayed a good understanding of adult protection and how to manage an allegation or suspicion of abuse. Since the last inspection two allegations of abuse were reported and investigated. One was substantiated and the employee involved no longer worked at the home and the second one was not substantiated. In the last year no adult protection training had been provided for staff. Four members of staff had completed NVQ training, which included elements of adult protection. Requirement 4. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 15 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, 20, 21, 24 and 26. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The environment was generally well maintained and suited to meeting the needs of the residents. Residents said they were satisfied with the communal and personal space provided. Some maintenance issues were noted and those referred to below must be addressed. EVIDENCE: The home was bright, clean, generally free of offensive odours and well ventilated. The maintenance technician completed weekly safety checks on areas such as lights, call bells, wheelchairs and emergency lighting. Staff recorded repairs and health & safety issues identified and the maintenance technician attended to these. During a tour of the environment it was noted that the cover for a radiator outside bedroom 32 had been removed. This was left by the radiator and could pose a risk to residents and others. In view of the possible risk this issue was brought to the attention of the manager. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 16 Since the last inspection the rear garden had been very nicely landscaped. This now provided a bright, pleasant and relaxing area accessible to all residents. Residents were very pleased with the new garden and said they enjoyed just sitting there. A section of the garden was fenced off to provide a safe outdoor space for the residents in the dementia unit. Two lounges, a seating area in the front corridor and a dining room were provided in the main part of the home. The small lounge near the staff office had an unpleasant odour. Staff said this came from the carpet and said a new carpet was being fitted the following week. A number of the armchairs in this room needed to be cleaned or replaced, as did one of the occasional tables. A lounge diner was provided in the dementia unit, which was clean and tidy. Adequate bathing, assisted bathing and toilet facilities were provided and those seen were clean. Hot water temperatures checked were within safe limits and records seen showed these were checked monthly. Assisted baths were last serviced on 22/8/06. Bedrooms viewed were generally clean, tidy and personalised to varying degrees. Residents spoken to said they were satisfied with the environment and said their bedrooms were kept clean. Bedroom 22 was quite cluttered and the resident had a small fridge, which had unlabelled foods. It was unclear who took responsibility for keeping this fridge clean and maintained. The outside of the door on bedroom 26 was badly scratched and needed repainting. Bedroom 15 had lots of nails in the walls, which may have been used by a previous resident to hang pictures. A number of doorframes throughout the home were badly scratched and chipped. It was disappointing to note that prior to opening the dementia unit time had not been taken to redecorate the bedrooms. Bedroom 7 had numerous hooks and nails left in the walls and in bedroom 6 the wall by the bed needed repair. Requirement 6 and recommendation 4. Hand washing facilities were provided where waste was handled. It was good to see supplies of cleansing hand gel located round the home. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 17 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 – 30. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Staffing levels were difficult to assess from the rotas provided. The staffing levels on the dementia unit must be monitored to ensure these are adequate to meet the needs of the residents. Over 50 of care staff had achieved NVQ2 qualification or above. Recruitment procedures needed some improvements and staff had access to training relevant to their roles. EVIDENCE: The staff team comprised of a manager, two assistant managers, team leaders, care assistants, domestic and ancillary staff who worked together to meet the needs of the residents. Staffing rotas seen were confusing and did not accurately reflect the staff on duty each day or which staff were allocated to the dementia unit. As mentioned the dementia unit had only been opened on the week of the inspection and the staffing levels on this unit must be monitored and altered based on resident dependency. The current practice was to have one carer in this unit in the morning and afternoon with a ‘floating’ carer assisting when needed from the residential side of the home. At night the home was staffed as one unit with a team leader and two carers, which was the staffing level provided prior to the introduction of the dementia unit. Again the staffing levels at night must be monitored and adjusted as needed to meet the needs of all the residents including the residents in the dementia unit. The manager planned to allocate named staff to the dementia unit and to ensure the rotas reflected the staff on duty there at all time. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 18 Residents spoken with were complimentary about the staff team and many knew their key workers. Comments made included ‘staff are helpful and friendly’, ‘staff are very pleasant’ and one comment made was ‘some staff are o.k’. All of the seven comment cards received from relatives showed they were satisfied with the contact staff made with them on behalf of their resident. Requirement 5 and 7 and recommendation 5. Eighteen of the twenty-six carers employed had achieved NVQ2 or above. This equated to 69 . Recruitment policies and procedures were provided. Five staff files were viewed. These contained some but not all of the information required by regulation. One file did not have a CRB check, two files did not have a health statement, four files did not have a recent photo and one file had unexplained gaps in the employment history. Requirement 8. The manager maintained a staff training matrix. This showed that since the last inspection staff had access to training on the following topics NVQ, dementia care, food hygiene, first aid, moving & handling and managing challenging behaviour. Staff spoken with said they had access to appropriate training and adequate support and supervision to fulfil their roles. Requirement 4. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. A new manager was in post and was not yet registered with the Commission. From the evidence provided attention was given to monitoring the service. Safe systems were in place to manage resident personal allowances. Some issues were noted in relation to safety. EVIDENCE: A new manager was in post since the last inspection and has not yet registered with the Commission. The registered person must ensure a registered manager is in post to manage the service as required by the Care Standards Act 2000. A number of residents had the ability to voice their opinion on the service. Resident meetings were held and minutes seen for those held in June and September 2006. One of these was to discuss issues with meals provided and Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 20 the other to look at general issues such as changes to the smoking room. The manager planned to hold a resident / relative forum in October 2006. Residents spoken with said staff listened to them and acted on what they said. An external provider completed the last quality assurance assessment in September 2005 under ISOQQA. Action plans to improve deficits in the service were prepared based on the quality assurance findings. These were not seen. The manager completed in-house audits such as resident money but did not record the findings. Visits were made to the home as required by regulation 26 but reports not always sent to the Commission. Requirement 9. Some residents continued to manage their own finances. For others family assisted with this. Management supported some residents with managing personal allowances. This money was held in a Perrygrove resident account with individual bank accounts held for the residents. Receipts were kept for money received and spent. Personal finance records were available to residents/relatives on request. Safety records viewed included lift service, hoist service, electricity and hot water temperature checks. All of these were up to date. The landlord’s gas safety certificate was out of date and the manager agreed to address this. Fire safety records were viewed and showed the system and emergency lighting was last serviced on 8/5/06, weekly alarm tests were undertaken and the last fire drill was held on 8/5/06. There was no evidence to show that staff had access to fire safety training in the last year. Accident records were kept and regulation 37 notices sent to the Commission when relevant. Accident reporting could be better as a number of the accident forms seen did not provide adequate details about the event. Requirements 4 and 10 and recommendations 6 and 7. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 3 X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No. 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 OP4 Regulation 14 Requirement The registered person must ensure residents receive written confirmation that based on assessment the home is suitable to meet their needs in respect of health and welfare The registered person must ensure: • Care plans are prepared for all residents to show how identified needs will be met. • Daily evaluation records must reflect the implementation of care plans. • A system must be in place to monitor resident’s weight. • Efforts must be made to involve residents in preparing their care plans. The registered person must ensure that: • All prescribed medicines including topical medicines are administered and the information recorded on medicine administration charts. DS0000006855.V298195.R01.S.doc Timescale for action 24/10/06 2. OP7 15 24/10/06 3. OP9 13 24/10/06 Perrygrove Version 5.2 Page 23 4. OP12 18 5. OP15 18 6 OP19 23 7. OP27 17 Records for homely remedy medicines must be maintained so that an audit trail can be completed. • Two members of staff must sign prescription entries they hand write on medicine administration charts. The registered person must ensure all staff receive training relevant to the work they perform including the activity organiser. Staff must receive regular update training on fire safety and adult protection. The registered person must ensure adequate staffing levels are provided on the dementia unit at mealtimes to assist residents. The registered person must ensure the property is well maintained, decorated and that furniture provided is of a satisfactory standard. • The maintenance issues identified under the environment standards must be addressed. • Furniture must be kept clean or replaced when needed. • Prior to admitting a resident the bedroom must be prepared to provide a pleasant and welcoming private space. • A system must be in place to ensure fridges kept in resident bedrooms are kept clean and food stored correctly. The registered person must ensure that staff rotas include the full name of employees, their DS0000006855.V298195.R01.S.doc • 24/10/06 24/10/06 24/10/06 24/10/06 Perrygrove Version 5.2 Page 24 designation and accurately show all staff on duty at all times. 8. OP29 19 The registered person must ensure that all information required by regulation is obtained for staff and available for inspection. The registered person must ensure that regulation 26 reports are sent to the Commission regularly. The registered person must ensure an up to date landlords gas safety certificate is provided. The Commission must be informed in writing that this has been obtained. 24/10/06 9. OP33 26 24/10/06 10. OP38 23 24/10/06 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 OP9 Good Practice Recommendations The registered person should ensure that the care plan format provides evidence to show that where possible residents were involved in preparing these. The registered person is strongly advised to provide enough lockable storage cupboards in the surgery to ensure safe storage for all the blister packed medicines held in the home. The registered person should ensure that residents have access to a suitable and comfortable smoking area. The registered person should ensure an annual maintenance programme is provided for the home to include decoration, furniture and fittings. The registered person should ensure that staffing levels on the new dementia unit are monitored and changes made as needed to ensure resident needs are met in respect of health, safety and well-being. The registered person should ensure that fire drills are held at times to include all staff including night staff. Fire DS0000006855.V298195.R01.S.doc Version 5.2 Page 25 3. 4. 5. OP12 OP19 OP27 6. OP38 Perrygrove 6. OP38 drill records should include the name of the staff that attended, the time the drill took place and a comment on how staff responded. The registered person should ensure staff complete accident records accurately and provide adequate details of the event. Perrygrove DS0000006855.V298195.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Perrygrove DS0000006855.V298195.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. 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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