Inspection on 30/01/07 for The Peele

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 29/08/07

The Peele 09/05/07

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 Helen Dempster Unannounced Inspection 30th January 2007 10:30 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.V329499.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.V329499.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 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.V329499.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. 1st June 2006 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 £373.54 to £374.00; the Primary Care Trust funds the remaining twelve of the beds. The Peele DS0000066003.V329499.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.V329499.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by gathering lots of information about how well the home was meeting the National Minimum Standards. The inspection included carrying out an unannounced site visit to the home on 30th January 2007 from 10:30 am to 6pm as part of the inspection process. During this visit, lots of information about the way that the home was run was gathered and time was taken in talking with the residents, the manager and the staff team about the day-to-day care and what living at the home was like for the residents Other information was also used to produce this report. This included reports about events affecting residents that the home had informed the Commission about and details of the findings of earlier random inspections, which were conducted on 20th December 2006 and 2nd January 2007. The main focus of the inspection was to understand how the home was meeting the needs of the residents and how well the staff were themselves supported by the home to make sure that they had the skills, training and support to meet the needs of the residents. This inspection did not include an assessment of all the key National Minimum Standards. What the service does well: What has improved since the last inspection? What they could do better: The home was not always using information from the care management and nursing assessments to inform their own assessments. This meant that the home’s assessments were not always accurate and the home might accept a resident whose needs they could not fully meet. The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 7 The home was not always using important information from assessments to prepare care plans for residents, which informed the staff how they needed to support and care for residents in the way that individual residents would wish to be cared for. The home was not preparing care plans and risk assessments, which were based on an individual’s specific needs and risks, e.g. not mentioning that a person was registered blind on a care plan about the risk of falls. This could put residents at risk. The home was keeping detailed day-to-day progress notes about residents. However, when a resident’s needs changed after an accident, when they were unwell, or in pain, the home was not always taking action to agree a strategy and change care plans to inform staff how they should care for and support these residents. A complaint about the care of a resident was made to the Commission and was investigated during this inspection. It was of concern that the home had not commenced an investigation in to the serious issues, when they had received the complaint from a family member almost 3 weeks before the inspection. The way that staff were deployed in the home was causing some problems. In particular, one member of staff was working alone in a unit with up to 12 residents while the second member of staff was giving out medication elsewhere. This could put residents at risk. The home was found to be handing medication poorly and residents were at potential, but significant, risk. 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.V329499.R01.S.doc Version 5.2 Page 8 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.V329499.R01.S.doc Version 5.2 Page 9 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 and 3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Failure to note and act on information in the care management and nursing assessments may result in the home accepting a resident whose needs cannot be fully met and could result in the home failing to meet specific needs and to minimise risk for residents. EVIDENCE: At the previous random inspection of the home, conducted on 20th December 2006, it was recommended that the home review arrangements to ensure that information is readily available to people who use the service. This had been addressed by making a range of information available in the reception area. The files of 3 residents who staff said had been admitted to the home most recently were seen. All 3 residents had detailed care management assessments and, in some cases, a nursing assessment. All 3 residents also The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 10 had a “summary of needs” which was completed by senior staff from the home during a pre-admission assessment visit. Care management and nursing assessments were held in a separate confidential file and were not readily assessable to staff. Important information, which had implications for the health and safety of these residents, had not been consistently included in the home’s summary of needs and was not therefore included in care plans and risk assessments. One example was that of a person whose nursing assessment, dated 28/07/06, stated that this person had “self neglect and significant weight loss” and “required much encouragement to take diet and fluid”. Despite this, the home’s summary of needs completed before admission to the home, dated 12/09/06, stated “eats and drinks independently”, “normal diet”. Another person’s nursing assessment noted “adverse reaction to eggs and fowl”. This information was not on the assessment of needs, care plan, risk assessment or nutritional assessment. This person’s nursing assessment also noted that the person was at “risk of falls” and was “registered blind”. This important information was not reflected in the falls risk assessment. This was also the case for a resident, whose file was seen at the previous inspection on 20th December 2006. This person’s risk of falls was based on the person’s hypertension and consequent dizziness, yet this was not reflected in care plans or risk assessments. (See health and personal care for further details). At that time, information from the care manager’s assessment was not consistently reflected in the home’s summary of needs, care plan or risk assessment. Overall, there was very little evidence to demonstrate that care management assessments were noted before admission and very little information from detailed care management assessments was included in assessments, care plans and risk assessments. There was a resulting risk that the home may accept a person whose needs it cannot fully meet. In addition, not including important information in the home’s assessments, care plans and risk assessments could put people at risk. A requirement was made about this. The registered person said that the organisation took these issues seriously and later confirmed, in writing, arrangements to review the needs assessments of all residents at the home. The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 11 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 poor. This judgement has been made using available evidence including a visit to this service. Inaccurate assessments care plans, risk assessments and day to day records, which did not reflect individual need, and inadequate monitoring and review of residents’ needs were putting some residents at risk. Medication practice was also unsafe. EVIDENCE: At a previous inspection, conducted on 1st June 2006, a requirement was made concerning the need for the home to ensure that care plans clearly identified all care needs, with details of the interventions required to meet the needs. A random inspection was conducted on 20th December 2006, to find out what the home had done to meet this and other requirements made in June 2006. At this time, some care plans talked about risks e.g. the risk of falls. However, The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 12 specific details of the risk and control measures in place to reduce the risk were not recorded. Care plans concerning the risk of falls appeared to be a standard format and made reference to wheelchairs, footwear and obstacles, even when residents were seen to be fully mobile without any obvious problems and were not wheelchair users. This meant that care plans did not reflect residents’ needs in a meaningful way and a requirement was made about this. During this inspection, conducted on 30th January 2007, these concerns had not been addressed. Further concerns about the failure to include important information from the care management and nursing assessments, which may have implications for residents’ health and safety, in the home’s own assessments care plans and risk assessments were discussed. (See choice of home for details). On 30th January, it was noted that a standard falls risk assessment was in place for all 3 residents for whom the file was seen, which was almost identical in content and did not reflect that individual’s specific conditions and risk factors, which would increase the risk of falls. In addition to the examples above, the falls risk assessment for one resident, which talked about offering a wheelchair was discussed with a member of the management team. This person said that this resident was ”mobile independently” and “doesn’t use a wheelchair”. Other concerns were also discussed during this inspection. These are as follows: • Residents, whose care management assessments identified risk factors associated with nutrition and weight maintenance, had nutritional assessments, which calculated risk through a numerical formula. However, these assessments did not include important information about the residents’ individual needs, preferred food, dietary and weight maintenance history, or known adverse reactions to food. This meant that staff would not be able to meet individual needs in a meaningful way and this could put residents at risk. The home completes care plans for only a limited number of issues. For one of the 3 residents whose file was seen, care plans addressed personal hygiene, falls, night checks and one other personal issue. The fact that there were no assessments of oral health and foot-care and that there were areas of need for some residents, identified on the care management/nursing assessments, for which there was no care plan was discussed. • The requirement made at the previous inspection concerning risk assessments, which was not met, was repeated and requirements were made about the other issues above. The complaint of a resident’s relative about the care provided by the home and the way that medication was administered was investigated during this inspection. The home’s complaints record and the file for this person were The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 13 seen. Day to day records of the progress of this person was found to be of a poor standard. In particular, there was little evidence of senior staff taking action to monitor the person’s wellbeing and respond to the constant references to this person’s pain and records were not always accurate. The issues of concern with regard to this complaint will be addressed separately with the provider and the complainant. The pharmacist inspector looked at medication practice during the inspection because the complaint regarding medication, outlined above, indicated that the poor practices found during the inspection on 2nd January 2007 were ongoing and that residents may be at risk. The pharmacist inspector’s visit was also planned to make sure that the previous requirements, regarding medication, had been complied with. During this inspection the home was still found to be handing medication poorly and residents were still at potential, but significant, risk. The administration of medication was poorly recorded and it was difficult to tell whether or not medication had been administered. There were a number of gaps on the MAR sheets (Medication Administration Records Sheets). On some occasions the medicine had been given and not signed for, on other occasions medicine had not been administered at all. The issues relating to poor management of medication has been communicated to the provider in a separate letter dated 2nd January 2007. The registered person said that the organisation took these issues seriously and later confirmed, in writing, arrangements to review care plans and risk assessments and medication arrangements for all residents at the home. The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 14 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): These standards were assessed during the last key inspection on 1st June 2006 and the outcomes were found to be good. These standards were not assessed during this inspection. EVIDENCE: The Peele DS0000066003.V329499.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff training in the protection of vulnerable adults had the potential to protect residents. However, complaints are not handled in the best interests of residents and in a way which safeguards them. EVIDENCE: The home has a complaints procedure, which was readily available. As stated earlier, during this inspection the complaint of the relative of one of the residents, which was made to the Commission, was investigated. It was noted that this relative had also complained direct to the home by telephone on 7/01/07 when the complainant spoke to a care officer. The entry by this member of staff noted that the complainant had rang to speak to the manager on other occasions and was told that the manager was not available. It was recommended that the home review the arrangements for recording and responding to complaints. It was noted that the complaint was registered on the complaints record, by the manager, on 9/01/07, when limited details about the complaint were recorded, although the manager was able to recall and discuss specific details The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 16 of the complaint from the telephone discussion. It was of concern that a full investigation of the complaint, which raised serious concerns about the health and wellbeing of the resident, had not been undertaken, even though 23 days had elapsed since the complaint was initially made on 7/01/07. A requirement was made about the need to fully investigate all complaints in a timely manner. The delay in investigation of this complaint was discussed with the responsible individual for the organisation at the time of inspection. This senior manager expressed concern about the issue and said that a thorough internal investigation would be conducted without delay. The home has a protection of vulnerable adults (POVA) policy, which is readily available. Following the random inspection, conducted on 20th December 2006, the manager stated, in writing, that a percentage of the staff had received up to date training in POVA and the remaining staff had training arranged in February 2007. The Peele DS0000066003.V329499.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. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the last key inspection on 1st June 2006 and the outcomes were found to be good. These standards were not assessed during this inspection. EVIDENCE: The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Aspects of staff deployment and communication had the potential to put residents at risk. EVIDENCE: Recruitment practice and staff training was not assessed at this inspection, as staff files were not available for inspection. However, at the previous key inspection in June 2006, all staff files contained appropriate documentation including application forms, interview notes, references, evidence of job consultations, training plans and CRB checks. At an earlier random inspection of the home, conducted in December 2006, some concerns about staff deployment were discussed and a requirement was made. These issues were followed up during this inspection. This included interviewing 2 care officers and a carer. The care officers on the ground floor and first floor were each responsible for the medication rounds for the 3 separate units on that floor. There were 5 staff, plus the care officer, on each The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 19 floor. Therefore, as was the case at the previous inspection, the care officer was the second member of staff caring for residents on one of the units and this meant that when they left the unit to administer medication at the other units, one member of staff was left alone caring for up to 12 residents. There was an inconsistent approach among care officers about taking telephone calls when administering medication. This meant that some staff ignored internal calls, which according to staff could be emergency calls for help from a unit. This could result in delay in dealing with an emergency and has the potential to put residents at risk. There was a general consensus among staff that the home needs to have 2 carers on each unit at all times, plus the care officer on each floor. The requirement made at the inspection in December about staff deployment was repeated and it was recommended that the need for continuity of care for residents be considered before moving staff into units to cover when the care officer is on another unit. The above issues were discussed with the manager initially, and then with the registered person for the organisation. The registered person said that the organisation took these issues seriously and would review staff deployment in the light of the issues raised. The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and staff did not benefit from clear lines of accountability in the home in the absence of the manager. EVIDENCE: During a random inspection, conducted on 20th December 2006, it was noted that the care officers’ job description stated that it was their responsibility to be the “designated” person in the absence of the home’s managers. However, it was the team leader of the Intermediate Care Unit, based in the home, who took the lead role in the inspection before one of the support managers The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 21 returned to the home. This person was unclear about procedures, e.g. adult protection procedures. Therefore, the provider must ensure that whoever takes a lead role in the home must be familiar with all the policies and procedures in the interests of residents’ safety. It was recommended at that time that staff were clear about who would take a leadership role at the home in the absence of the management team. Standard 38, which relates to the health, safety and welfare of residents and staff was assessed by asking the manager of the home to provide evidence, in writing, of the health and safety checks completed by the home. A senior manager provided a statement to the effect that the home was completing all required health and safety checks with some examples of the records of these checks. This senior manager described a time consuming audit trail. It was recommended that the home review the way they record and audit health and safety checks. The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 22 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 1 X X x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 X X X X X X X x STAFFING Standard No Score 27 2 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14(1) Requirement The home must ensure that detailed information from the care management and nursing assessment is reflected in the home’s assessment, care plans and risk assessments. This is necessary to ensure that the home can demonstrate that it is able to meet individual needs and so that known risks are minimised where possible. (a) Care plans must be in place to address all aspects of identified need, including that identified on a preadmission care management assessment. Care plans must clearly identify how the actual care and intervention support must be delivered by staff in an effort to meet residents’ identified needs. All residents’ care plans Version 5.2 Page 24 Timescale for action 05/03/07 2. OP7 15 05/03/07 15 (b) 15. (2) The Peele (c) DS0000066003.V329499.R01.S.doc (b) must be reviewed when residents’ needs change taking account of their views. (d) When a resident is ill or has suffered an injury and the changes in their needs place them at increased risk, care plans which guide staff on how to support them to recover must be in place immediately to cover agreed and medically advised strategies concerning e.g. pain relief, nutrition and falls prevention. Residents’ day-to-day progress records must be consistently monitored to ensure that they are accurate and to ensure that a resident’s needs are being met and that their safety and wellbeing is consistently monitored. 05/03/07 14 (2) (a) and (b) and 13. (4) (b) and (c) 14 (2) (a) and (b) and 13. (4) (b) and (c) (e) 3. OP8 13. (4) (b) and (c) Risk assessments must be in place to assess all risks applicable to an individual resident: (a) These must be subject to consistent review to take account of any changes and residents’ progress following an accident must be observed and the outcomes recorded. (Previous timescale of 20/01/07 not met). (b) This must include nutritional assessments, The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 25 and risk assessments concerning the risk of falls, which reflect each individual resident’s specific needs. 13 (1) (b) Specialist medical advice and attention must be sought for residents promptly: (a) When any concerns about their health and wellbeing are identified. When there are any concerns about meeting their medical needs e.g. providing appropriate pain control. 05/03/07 (b) 4 OP9 13(2) The registered person must ensure that a risk assessment is made on the storage of controlled drugs/ fridge lines and the provision for their transport across the floors. (Previous timescales of 01/06/06 and 29/01/07 not met). 5 OP9 13(2) 30/01/07 The registered person must ensure that medication is stored securely at all times. Medication must only be stored in residents’ rooms if the risk assessment indicates that they are able to safely self-administer medication. (Previous timescales of 01/06/06 not met). This requirement was not assessed on this visit and must be met by the previous time scale of 29/01/07. The registered person must ensure that accurate records and an audit trail are kept for all prescribed medication. DS0000066003.V329499.R01.S.doc 6 OP9 13(2) 05/03/07 The Peele Version 5.2 Page 26 (Previous timescales of 01/06/06 and 02/01/07 not met). 7 OP9 13(2) The registered person must ensure that medication is administered as prescribed by the doctor. (Previous timescales of 01/06/06 and 02/01/07 not met). The registered person must ensure that all medication is accounted for at all times. The registered person must ensure that residents’ medication is in date before administering it. The registered person must ensure that medication is securely stored at all times. The registered person must ensure that all staff that administer medicines are assessed as competent to do so safely. This requirement was not assessed on this visit and must be met by the previous time scale of 29/01/07 05/03/07 8 9 10 11 OP9 OP9 OP9 OP9 13(2) 13(2) 13(2) 13(2) 05/03/07 05/03/07 05/03/07 30/01/07 12 OP16 22(3) and 22(4) 13 OP27 24 The home must ensure that all complaints, made under the complaints procedure are fully investigated. This includes ensuring that the investigation is conducted in a timely manner, so that key evidence is not lost. The manager must review the deployment of staff in the home to ensure that all parts of the home are staffed appropriately and in a manner that meets the needs of the residents. 05/03/07 05/03/07 The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 27 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 OP3 Good Practice Recommendations It is strongly recommended that staff are given further guidance and training in completing assessments and that assessments are audited and reviewed to ensure that people’s needs are being met. It is strongly recommended that the time of all entries in the day-to-day progress record of residents be recorded to provide a clear audit trail of events. It is recommended that the home produce a policy concerning taking telephone calls when completing medication rounds in the interests of residents’ safety. It is recommended that the home review and update the medication policies regarding disposal of waste medicines. It is recommended that medication is stored within manufacturers recommended temperatures and that staff are aware of what action to take in the event of medication being stored incorrectly. It is recommended that the home review the arrangements for recording and responding to complaints. It is recommended that care officers and other staff, including ancillary staff, are briefed so that they are clear about who would take a leadership role at the home in the absence of the management team. It is recommended that the home review the way they record and audit health and safety checks. 2. 3. OP7 OP9 4. OP9 5. 6. OP16 OP31 7. OP38 The Peele DS0000066003.V329499.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection CSCI, Local office 11th Floor West Point 501 Chester Road Old Trafford 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.V329499.R01.S.doc Version 5.2 Page 29 - 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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