Inspection on 29/08/07 for The Peele

This inspection was carried out on 29th August 2007.

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

The Peele 13/08/08

The Peele 09/05/07

The Peele 30/01/07

The Peele 01/06/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Peele Walney Road Benchill Wythenshawe Manchester M22 9TP Lead Inspector John Oliver Unannounced Inspection 29th August 2007 10:00 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 The Peele DS0000066003.V347992.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. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Peele Address Walney Road Benchill Wythenshawe Manchester M22 9TP 0161 490 8057 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) Inspirit Care Limited Under Application Care Home 108 Category(ies) of Old age, not falling within any other category registration, with number (108), Physical disability (12) of places The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate a maximum of 108 service users. Up to 108 service users may require care by reason of old age. A maximum of twelve (12) beds on a specified unit can be used for Intermediate Nursing Care for service users who are 50 years and over. Of these twelve (12) beds, two may be used to accommodate people who are over 18 years of age. 9th May 2007 Date of last inspection Brief Description of the Service: The Peele is a purpose built care home providing personal care for a maximum of one hundred and eight older people. The home was registered on 8th February 2006. Although this is a large home, the emphasis is on providing group living. The home is divided into three wings on three levels. Each level accommodates three units, making a total of nine units, each of which provides accommodation for between 11 and 13 residents. Each unit has an individual shared living and activity space. All bedrooms lead off from the communal area. Units on the ground floor benefit from direct access into small cottage gardens, whilst the first and second floors lead out onto balcony areas. The ground floor has a large foyer area, which includes a reception area, and a lounge/sitting area with comfortable seating. The kitchens for the whole building are accommodated on the ground floor. The first and second floors provide additional facilities. This includes a library, which overlooks the front gardens and provides large windows, which project light into the building. Furnishing and fittings are of a high standard, and this room provides a pleasant multifunctional area for residents and their families to use. There is also a large social room, which is used for staff training and there are plans to fit it out as a cinema. The home is situated in the Wythenshawe area of Manchester, within easy reach of shops and community amenities. There are secure gardens around the building, providing pleasant outdoor facilities and safe walkways for residents to enjoy in the warmer months. Beyond the garden areas there is parking for a large number of cars. The fees set for ninety-six of the beds in the home are between £378.84 to £450.00; the Primary Care Trust funds the remaining twelve of the beds. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 5 Additional charges are made for hairdressing, newspapers, visitors’ meals and refreshments, and for telephone installations. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the last inspection visit to The Peele in May 2007. A visit took place on 29 August 2007 over a period of 6.5 hours and the home was not told about the visit beforehand. During this visit the inspectors had a look around the home and looked at paperwork that must be kept by the home to show that it is being run properly. Another way that was used to find out more about the home was by talking with some of the people and staff who were in the home on the day of the visit. Some of the people living in the home were unable to express their views directly, so time was spent watching how staff talked to and supported them. The main focus of this inspection was to understand how the home was meeting the needs of the people living in the home and how well the staff were themselves supported by the management of the home to make sure that they had the skills, training and support to meet the needs of those people and if the management of the home had addressed those issues identified in the last inspection report. As there was a need to check a lot of information during the visit, a second inspector and a Pharmacist inspector also took part in the visit. The Pharmacist inspector checked whether the requirements made regarding medication practice and administration following the last inspection visit had been met or not. What the service does well: The home continues to be maintained to a good standard and provides people living in the home with comfortable surroundings. The intermediate care unit provides people with an opportunity to further build up their strength, usually after a stay in hospital, before returning to their own homes. Any person staying on this unit is provided with the support of other health care professionals such as Occupational Therapists and Physiotherapists to further aid their recovery before returning home. Regular ongoing assessments are also carried out to make sure no one leaves the unit to return home until they are well enough to do so. Meals served in the home during this visit were well presented, and people were offered choice. The opportunity to sample a main meal was taken during The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 7 this visit and the meal was found to be well balanced nutritionally, was nicely presented and tasted very good. Residents spoken to said, “Meals are lovely”, “I’m having liver and onions today, you could have had pork” and, “I’m diabetic, but staff know that”. What has improved since the last inspection? What they could do better: Although the way in which care plans are written has improved, the care plan format is difficult to follow and is not particularly ‘person centred’. Discussion with the quality manager confirmed that a review of the format used was currently taking place and that it was hoped a more ‘person centred’ format would be developed. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 8 Medicines must be administered at the right time in relation to food intake. Receiving medicines at the wrong time can affect the health and well being of residents. Arrangements for residents who look after their own medicines must be improved to ensure they receive any support they might need. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 9 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 The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are only admitted into the home following a full assessment of their needs with information being supplied to help them make an informed choice about the care being offered by the service. EVIDENCE: A copy of the latest information provided to prospective residents was made available during this visit. This information is in the form of a document called ‘Living At The Peele’ and a Statement of Purpose. The Statement of Purpose had been updated to show the recent changes that had taken place within the management team of the home. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 11 From a sample of residents’ files that were seen there was evidence of Care Managements and Nursing assessments and Care Plans that had been carried out by the purchasing authority before the person came to live at the home. In addition to this, the manager confirmed that they or a senior member of the staff team would visit any potential new resident to find out more information and confirm that they could meet the prospective resident’s assessed needs. There was evidence on files to show that a ‘Summary of Needs’ assessment had been carried out and completed prior to admission into the home. The home has the facility on one particular unit to offer an intermediate care service to people requiring support during their transition from a stay in hospital and returning home. No charges are made for this service and it is supported by the Primary Care Trust (PCT). The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans had improved, as had the standard of medicines management within the home. However, further improvements are still needed to ensure the safety of the residents who live there. EVIDENCE: Each resident in the home had an individual care plan on file. Of those plans examined during this visit it was clear that more effort had been made to ensure that relevant and important details had been included that would support staff in the way they help to meet the needs of the individual resident. However, many of the supporting documents used in the care plan format such as the ‘Life Plan’ document (past history information) had not been completed and therefore were not being used to support the information contained within The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 13 the care plan. No clear evidence was available to demonstrate that care plans were being reviewed on a regular basis, which could place residents at risk from changing care needs not being met. Discussion with the manager confirmed that the organisation are currently reviewing the present care plan format and are developing a much more person centred approach in developing a new format. This will be good for the residents, as it will help and support them to be more involved in how they want their care to be delivered. One resident spoken to during this visit said, “Staff are good, they help me to get washed and dressed and things like that”. Information contained within other parts of the care plan confirmed that regular visits took place by other health care professionals such as GP’s and district nurses. In one file seen it was noted that good recordings had been made within the daily notes to confirm the outcome from a GP’s visit. This is good for the residents as it helps to keep all staff informed of the individuals current health needs. One resident spoken to during this visit said, “I have bad eyesight, but I regularly visit the Optician”. Risk assessments had been completed for various identified risks. Evidence was seen that generic risk assessments had been completed regarding the balcony areas on each floor of the home. Individual risk assessments had then been completed for each resident who could be potentially at risk from using these balcony areas. This is good practice as staff can then support the individual to maintain choice and independence within a safer environment. Written procedures and policies were in place that support the safe handling of medicines, these were available in all units and in general these were being correctly followed. Residents that were looking after their own medicines were not fully supported to do so. Written risk assessments and supporting care plans were not always up to date, as they had not been properly reviewed. One record showed that a resident was on an inhaler but the resident said that this had been discontinued some time ago. Having up to date records and care plans is important to ensure residents receive any support they might need. Records of medicines given to residents showed significant improvement from previous inspections. Detailed checks on records and current stock found that medicines were now usually given as prescribed. Some examples of medicines not “adding up” correctly were found but it was not possible to confirm whether this was due to inaccurate record keeping or medicines being given incorrectly. Handwritten records were occasionally incomplete or incorrect which had contributed to some of the mistakes and discrepancies. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 14 Care staff and residents said that most medicines were administered during or just after mealtimes and this was confirmed by looking at the records. Records showed and staff confirmed that several medicines that should be given before food were given afterwards; this could affect the way they work and can increase the chances of side effects. Not all medicines prescribed as “when required” or, as a “variable dose” had clear written instructions for care staff to follow to ensure they are given correctly. This is particularly important for residents that are suffering with pain or who are agitated and have difficulty communicating. Managers said and carers confirmed that all relevant care staff had received medicines handling training. An assessment of competence had been made to ensure staff follow the correct procedures when giving and recording medicines. Managers have carried out audits and these were being developed further, this is important to ensure medicines are given correctly and to help ensure staff remain competent. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives, were encouraged to maintain contact with the community and are provided with a wholesome and well balanced diet. EVIDENCE: Since the last inspection visit in May 2007 there had been a significant improvement in the way in which activities are offered and arranged for residents living in the home. Discussion with one of the activities organisers demonstrated that residents had been asked what particular activities they enjoyed doing and then appropriate activities had been arranged. Information was displayed on notice boards on each unit and also included some photographs of recent activity events such as a ‘coffee morning’ and a trip to see Concord at the airport. Residents spoken to say, “We do have things going on such as making things and the like” and “I don’t join in much – I like my own company”. A recent The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 16 summer fair held at the home raised £600 for the benefit of the residents and a grant of £3.500 has been secured from ‘Britain in Bloom’ to further develop the outdoor living space for residents. A lot of visitors were seen to come and go throughout the day and the visitor’s book demonstrated that visitors frequented the home on a very regular basis. Staff spoken to confirmed that they had recently had training in supporting people suffering with dementia. Watching staff interacting with a number of residents demonstrated that this training appears to have been effective and that staff were seen to assist those residents with patience and understanding. There was evidence of a choice of menu and the cook confirmed that residents are asked on a daily basis what choice of meal they would like. The kitchen area was well equipped and plenty of food stocks were seen to be available including fresh fruit and vegetables. The opportunity to take a main meal with the residents was taken in order to sample the quality of the food being served. The choice of meal was pork or liver with mashed potatoes, vegetables and gravy. This meal was found to be well balanced nutritionally, was nicely presented and tasted very good. Residents spoken to said, “Meals are lovely”, “I’m having liver and onions today, you could have had pork” and, “I’m diabetic, but staff know that”. One visitor had travelled from Wales to visit their relative and was encouraged to take a meal by the staff. This visitor confirmed that she came to the home on a regular basis and was always offered a meal and drinks. She confirmed that the meals were always of a good standard and that she had no concerns or worries about the standard of care her relative received. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any issues of concern and to protect residents from neglect and abuse. EVIDENCE: The home has a detailed complaints procedure in place, which was readily available. Since the last inspection visit in May 2007 the home had received seven complaints. Six had been investigated and concluded by the manager with written evidence kept on file. One complaint was ongoing and on the day of this inspection visit the area manager was visiting the home to carry out further investigations into the complaint raised. Discussion with the manager confirmed that no allegations had been made or referred under the Protection of Vulnerable Adults (POVA) procedure since the last inspection visit to the home in May 2007. It was confirmed that all staff had received POVA training and this would be ongoing for any new staff. Staff spoken to during this visit were very clear about the process to follow should an allegation be made. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment is generally clean, well maintained and comfortable for residents. EVIDENCE: Cleanliness and hygiene throughout the building were generally good and no unpleasant odours were detected in any parts of the home during this visit. Communal areas and bedrooms had been made more ‘homely’ by the provision of personal effects such as pictures, plants and ornaments and it is recommended that key workers continue to encourage residents to personalise their rooms in order to maintain their individuality and personal character. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 19 Communal areas area nicely furnished with a variety of different style seating and efforts have been made to arrange furniture in order that residents can speak to each other rather than all face the television. This is good for residents, as it will encourage them to get to know each other and perhaps develop friendships/relationships. Residents are able to access a small balcony area via patio doors and the manager confirmed that risk assessments had been placed on file for those residents who may need support when using this area. A copy of a risk assessment was seen. Each unit has a small kitchen where residents and their visitors can prepare light snacks and drinks should they wish to do so. The cook confirmed that these kitchen areas are replenished with food stocks each morning and evening to make sure that residents always have access to some light refreshments should they want it. This will help to encourage some residents to maintain their independence. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are employed in the home with staff training and development helping to ensure that staff are competent to carry out their jobs. Staff’s improved knowledge and skills regarding caring for people with dementia has had a positive effect on meeting resident’s individual needs. EVIDENCE: Discussion with the manager confirmed that two new staff had been employed in the home since the last inspection visit carried out in May 2007. The personnel files for these two staff members were examined and were found to contain all the required and relevant documentation. One file was still awaiting the return and confirmation of a satisfactory Criminal Record Bureau (CRB) check. The manager confirmed that this person had not yet commenced working in the home and would not do so until a satisfactory CRB was received by the home. Staff rotas were checked and confirmed that this person had not yet commenced working in the home. Staff had recently received some training from a tutor from Bradford University in supporting people with dementia. Discussion with staff indicated that they The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 21 now felt more supported by the new manager and management team and that they were better able to understand how to meet the needs of those residents with dementia. Watching staff interacting with those residents who suffer with dementia gave a good indication that what had been learnt during training was being put into use when supporting these residents. Staff were seen to assist people calmly, with patience and using gentle encouragement and were seen to talk to residents in a quiet and respectful manner. Examination of staff rotas and talking with a number of residents confirmed that there was usually enough staff on duty to meet their needs and comments included, “Staff here are very good”, “They help to me to get ready” and, “Some are better than others”. As there is a high level of dependency on at least two units in the home, staff known as ‘floaters’ are used to support staff on these units at peak times of the day. Floaters are allocated to work between the units rather than on one specific unit. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents living in the home now benefit from having the support of a manager and management team that are able to maintain and provide a good quality service and have developed procedures to promote their interests and well being. EVIDENCE: Since the last inspection visit in May 2007 there have been good improvements in the way in which the home is managed. The management team have The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 23 worked hard to address a number of issues that had been raised in the last inspection visit and, at the time of this visit, this work was continuing. The last quality audit of the service had been carried out in May 2006 and information contained within this audit also included the findings from a survey carried out in March 2006. This survey was detailed and comprehensive. Where management dealt with the personal allowances for individual residents a record of balances was kept with receipts in place. Examination of one record demonstrated that two staff witnessed and signed all transactions carried out on behalf of individual residents. There was evidence that the management team had arranged and planned regular one to one supervision for all staff working in the home and this was also confirmed by those staff spoken to during this inspection visit. It was confirmed by one member of the management team that regular team meetings were taking place to ensure up to date information about the management of the home was being filtered through to all staff and that information regarding available and up to date training can be shared. This is good for the staff team and should encourage them to participate in reviewing their individual training needs. During this inspection visit both the area manager and quality manager visited the home. It was confirmed by the management team that this was a regular occurrence and these visits were used to support the development and management of the home. It was confirmed within the written information provided by the manager prior to the last inspection visit taking place that all routine maintenance and servicing of equipment used in the home is carried out. A random selection of reports taken at that time confirmed this. The fire alarm system is tested on a regular basis and staff and residents spoken to confirmed this. The last fire drill recorded was carried out on 22/08/07 and the staff taking part signed the record. The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement All care plans must be reviewed (and be updated where required) on a regular basis. (Previous timescale of 05/03/07 and 27/07/07 not met and still applies) 2. OP9 13 (2) For residents that look after their own medicines a written risk assessment must be carried out that is regularly reviewed. This is important to ensure residents receive the correct amount of support from care staff. Medicines must be given to residents at the right time in relation to food intake, receiving medicines at the wrong time can affect their health and well being. 01/10/07 Timescale for action 29/08/07 3. OP9 13 (2) 01/10/07 The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations Medicines prescribed as when required or, as a variable dose should have clear written criteria for care staff to follow to ensure they are administered correctly. Patient information leaflets should be used for all medicines kept in the home to ensure medicines are administered correctly. All handwritten medicines records should be an exact copy of the pharmacists dispensing label, which should be double-checked and countersigned, this should help prevent mistakes. It is recommended that Key Workers continue to encourage residents to personalise their bedrooms in order to reflect their individuality and character. This should help some residents to feel more settled and at home. 2 OP19 The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Peele DS0000066003.V347992.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!