Care Home: Pemberton Fold

What has improved since the last inspection? This was the first inspection since the service has been registered with the providers Inspirit Care Limited. What the care home could do better: No requirements were made during this visit.Pemberton FoldDS0000072949.V375012.R01.S.docVersion 5.2Page 8 Key inspection report CARE HOMES FOR OLDER PEOPLE Pemberton Fold Pemberton Street Little Hulton Manchester M38 9LR Lead Inspector Geraldine Blow 11 th Unannounced Inspection 21st May 2009 09:30 Version 5.2 Page 1 DS0000072949.V375012.R01.S.do c This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pemberton Fold Address Pemberton Street Little Hulton Manchester M38 9LR 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) 0161 702 5100 0161 702 5159 Inspirit Care Limited Ms Michelle Claire Phillips Care Home 60 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (60) of places Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories Old age, not falling within any other category - Code OP Dementia - Code DE - (maximum 20) The maximum number of service users who can be accommodated is: 60 Date of last inspection First inspection Brief Description of the Service: Pemberton Fold used to operate under the name of Manchester care. It was part of a larger organisation that provided care and support services across the North West region. In November 2008, this organisation merged with ‘Community Integrated Care’, a national care provider, and became ‘Inspirit Care limited’, a ‘not for profit’ voluntary organisation and a registered charity. It is a purpose built care home providing accommodation for up to 60 people. Accommodation is provided on 4 separate units over two floors. The home is a large, spacious and modern care home. All bedrooms have en-suite facilities, with a level floor access shower and aids and adaptations, WC and hand basin. All bedrooms have profiling beds. There is a large reception area with seating and tea and coffee making facilities. Each unit has a lounge and dinning area. There are well maintained, enclosed garden and patio areas are people to access. The inspection report is available in the main reception area for people to read. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 5 The charges for fees range from £383.47 to £525 per week. There are additional charges for magazines, papers and hairdressing. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3. This means the people who use this service experience excellent quality outcomes. This report is the first inspection report since Inspirit Care Limited was registered with the Care Quality Commission (CQC) in November 2008. This report is based on information gathered by the CQC during the unannounced visit on the 11 and 21 May 2009 and supporting information received in Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. The visit took place on Monday 11 May 2009. This report is an overview of what the inspector found during the visit. References to we or us in this report represent the CQC. Staff and some people living at the home were sent comments cards so that we could get their views on how the home is run. We received four completed comment cards from staff and six comment cards from those sent to people living at the home. Some of the comments are included in the body of the report. As part of the visit we spent time examining relevant documents and files. We also spent time talking with several people living at the home, some members of staff and a visitor to the home. We also walked round the home and looked at the communal areas and some bedrooms. Feedback was given to the manager during the course of the visit. What the service does well: The home is a well maintained, purpose built care setting with spacious communal and private areas. There are safe, enclosed well maintained garden and patios areas for people to use. Everybody spoken to and information received in the completed comment cards indicated that the home was always clean and fresh. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 7 Staff and a relative spoken to said that where possible people are encouraged to make their own choices around their day-to-day lives. People were seen to be freely moving around the home. Visitors spoken to said that they able to visit whenever they liked and staff make them feel welcome. Staff spoken to also confirmed this. All of the returned comment cards indicated that people receive the care and support needed. One visitor spoken to said that her relative received excellent care and she was very happy for him to be at Pemberton Fold. She said that the staff knew him very well and she had also been involved in the planning of his care. Information received in the majority of comment cards indicated that there were always activities arranged within the home. However one member of staff did say she would like to see more activities. People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home before making a decision to move in. People spoken to were all complementary about the food provided and the received comment cards indicated that people liked the food. All of the returned staff comment card indicated that they received training relevant to their jobs and this was confirmed by staff spoken to during the visit. Staff also said that they felt supported by the management team. What has improved since the last inspection? What they could do better: No requirements were made during this visit. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Pemberton Fold DS0000072949.V375012.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 Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before admission to ensure their care needs can be met. EVIDENCE: Admissions to the three residential units are only made after a pre admission assessment of the persons needs has been undertaken, to ensure that those needs can be met by. In addition to the homes own assessment they also receive information from the care managers assessment of the placing authority. Evidence was seen of these assessments on the three care files looked at during this visit. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 11 However it was noted that the homes own pre assessment document did not include an assessment of people’s specific religious or cultural needs. To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. The Dementia Care unit is an assessment and respite care unit so the home’s own pre admission assessment is not always undertaken prior to the person’s admission. However she confirmed that admissions are planned as referrals are made through Social Services and they always get the care managers assessment and further information from the person’s family or from the ward if they are in hospital. People who are thinking about moving into the home and or their relatives are encouraged to visit, have a look round, meet staff and other people living at the home. Information received in the completed comment cards confirmed that they had received enough information before making a decision to move in. The Statement of Purpose is available in the main reception for people to look at. The manager confirmed that the marketing department was currently updating the Service User Guide to include the details of the newly registered provider. The Service User Guide is available in each bedroom Pemberton Fold does not provide an intermediate care service. Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, social and personal care needs of people were being met by staff that respected their privacy and dignity. EVIDENCE: The manager confirmed that it was the intention of the new providers to implement new care plan documentation. Three support plans were looked at during this visit to see how information is received and maintained to evidence how people’s needs are being met. The manager stated that the unit team leaders undertake ‘A support plan review’ on a regular basis to ensure that peoples needs are being met. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 13 One of the support plans looked at was for a person on Dementia care assessment unit. This evidenced that the care required by that person is assessed and reviewed on a regular basis. Approximately three or four weeks after admission there is a multi disciplinary team meeting that families are invited to, to review the assessed care needs of the individual. The support plans contained details of peoples personal choices, preferences and care needs. There was documented evidence that the individual support plans had been reviewed regularly, which ensures that people’s needs are being appropriately met. There was no formal assessment for oral hygiene needs. To ensure that peoples needs are appropriately met it is recommended that an oral assessment is undertaken on admission and then incorporated into the support plan. Risk assessments relating to nutrition, falls and risk of pressure sores were completed where appropriate to ensure that all assessed needs are being met. The returned comment cards indicated that people receive the care and support needed. One comment received was that the care was ‘very good and I am pleased with the way staff treat me’. All six comment cards indicated that staff listen and act on what you say Procedures relating to safe storage, administration and recording of medication were assessed and found to be in order. A visual check of the blister packs and a random count of boxed medication was found to be correct. Recording of doses administered were accurate and the correct coding had been used. To ensure the safe administration of medication staff who are responsible for administering medication had received appropriate training. Staff, people living at the home and relatives spoken to confirmed that people are treated with respect and dignity. One relative said that as far as she could see privacy and dignity was always respected. Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are provided and people are able to maintain contact with family and friends. People have a choice of varied, well-balanced meals. EVIDENCE: From observations on the day of this visit and from talking to people the daily living arrangements are relaxed and people are able to make choices around their day to day living. The home employs the services of two activity coordinators. However one of the organisers has very recently left the home, although the manager said that the post has been filled but the person has not yet started. The AQAA demonstrated that there is a varied flexible programme of activities to suit the choices and preferences of people. These included one to one activities and group activities. This was confirmed by people spoken to. Some of the activities include monthly live entertainment, weekly religious services, quizzes Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 15 and the activity organiser is trained to deliver ‘healthy hips and hearts ‘. This is a tailor made exercise session for older people. The lounge areas offer people a pleasant and easily accessible area for people to come together. People can sit and watch television or participate in planned activities. There are also a range of activities held in a large activity area. There is an active core of staff and relatives involved in fund raising ventures. The proceeds are used to fund all social and leisure activities. This included trips out and lunches to local venues. The care files have a ‘my past experience’ assessment. This includes details of people’s hobbies and interests as well as spiritual and religious needs, which ensures that individual needs are met. The home also has good links with the local community. People living at Pemberton Fold are encouraged to maintain contact with family and friends. To support this the AQAA identified that visitors are welcome at any time and they are welcome to use the facilities to make refreshments. This was confirmed by people spoken to. People spoken to confirmed that there is a choice of meals and drinks and snacks are available on request. The meals are prepared in the main kitchen and transferred to each unit’s satellite kitchen for serving in accordance with individual preferences and requests. The dining areas on each unit offer people a pleasant area to take their meals. From speaking to people living at the home, staff and a visitor it appeared that people are encouraged to exercise choice and control over their lives. The support plans documented peoples personal preferences around their day to day lives and people were free to access their rooms or the communal areas without restriction. The manager has recently completed Deprivation of Liberty Safeguard training (DoLS), which came into force on 1 April 2009 and forms part of the Mental Capacity Act. It is her intention to arrange training for staff and a DoL’s assessor it due to come in the home the week following this visit. A booklet is available in the main reception for people to access. Staff on the Dementia Care Assessment unit have attended Mental Capacity Act Training to ensure that the rights of the people on that unit are fully protected. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Pemberton Fold are able to raise concerns and are confident that they will be listened to. This means that people are protected from harm and abuse. EVIDENCE: There is a complaints procedure, which is included in the Service User Guide and every person has been given a copy. All returned comment cards indicated that people knew how to make a complaint and knew who to speak to if they are not happy. All the returned comment cards from staff indicated that they knew what to do if somebody wanted to raise a concern or complaint. One relative spoken to said she knew how to make a complaint but had never wanted to, she said she was more than happy with everything at the home. The manager kept a record of all complaints as well as compliments received by the home. Evidence was seen that complaints had been appropriately recorded and investigated. The manager confirmed that her line manager is informed all complaints received. This ensures that complaints or concerns are analysed so that any patterns of poor practice can be identified at an early stage and fully addressed. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 17 No complaints have been received by us in relation to this service. There was a copy of the updated local Safeguarding Guidance and the manager was able to clearly describe the correct actions to be taken in the event of an allegation of abuse being made. To ensure people living at the home are protected from harm or abuse the manager confirmed that all new members of staff cover safeguarding training as part of their induction. In addition the manager said she was waiting for dates for staff to attend refresher training. No allegations of abuse have been made. Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clean and pleasant environment is provided for the people who live at Pemberton Fold. EVIDENCE: As part of this visit a tour of the building was undertaken which included all the communal areas and several bedrooms. The home was clean, tidy, well decorated and furnished to a high standard. There were no offensive odours and people spoken to all confirmed that the cleanliness of the home was always of a high standard. The received comment cards also indicated that the home was always clean and fresh. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 19 There is a large reception area with comfortable seating areas, tea and coffee making facilities and a reminiscence area. Each unit has a satellite kitchen, a lounge and dining area and all bedrooms have en suite facilities, which include floor access showers. In addition there are toilets and assisted baths on each unit should people prefer to have a bath. Bedrooms were bright, airy and furnishings were of high standard. The AQAA indicated that people are encouraged to bring in personal possessions with them and evidence was seen of this in the bedrooms looked at. Each room has a TV and telephone point. There is a large communal activities area where people enjoy crafts, social events and other activities. There is also a hairdressing salon. There is a secure garden court comprising of raised flower beds and a central water feature. Some of the people living at the home have also developed a small vegetable garden. There is a well maintained garden which can be accessed from patio doors on the ground floor. The garden is enclosed so that people are not put at any unnecessary risk. There are also 2 gazebos and attractive garden furniture so that people will be able to enjoy the garden in the warmer weather. There were policies and procedures relating to infection control and the manager confirmed that they due to have an infection control audit undertaken by the Primary Care Trust (PCT) infection control team. To reduce the risk of cross infectious there are wall mounted gloves and other Personal Protective Equipment (PPE) is easily accessible to staff. Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care needs are met by the numbers and skill mix of staff. EVIDENCE: From observations during the visit and from information supplied in the returned comment cards there was enough staff to meet the needs of the people living there. The comment cards indicated that there was enough staff to meet people’s needs. Thirty eight care staff are employed at Pemberton Fold. Thirty seven care staff have successfully completed training in the National Vocational Qualification (NVQ) Level 2 or above and three staff member are currently undertaking NVQ Level 3. A sample of staff files were looked at to see whether the required documentation was in place and if the necessary safety checks had been Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 21 made. Three files were looked at for staff that had been recruited since the last inspection visit. All the files seen contained the required documentation. The files contained some photocopied documents but not all of them had been signed to evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. Evidence was seen that a set interview assessment form is completed during the interview to assess knowledge and experience of the candidate. This is seen as good practice. All new members of staff must attend induction training. One of completed staff comment cards indicated that induction covered everything very well, two indicated that it mostly did and two said it partly did. There was a training matrix for staff that the manager was in the process of auditing to make sure that staff have received training appropriate to their job. The manager confirmed that there were some shortfalls, in particular refresher training. However she said she had informed the providers of these and was waiting for them to provide her with training dates. Staff spoken to and comments received in the returned comment cards indicated that they are supported and encouraged to attend training relevant to their job. Pemberton Fold DS0000072949.V375012.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in the best interests of the people living there. EVIDENCE: The manager has the necessary experience and knowledge to manage the home in the best interest of the people living there. She is registered with us and has completed the Registered Mangers Award and has a Diploma in Management and Leadership. Staff spoken to during this visit were positive Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 23 regarding the manager and her commitment to provide a high quality care for the people living at Pemberton fold. The service continues to deliver a sustained quality of care and support for the people who live there. This was also found during this inspection visit. The findings are that the outcomes for people living at Pemberton Fold are positive and meet the objectives of the service. The opinions of the people living at the home, relatives/visitors and staff are regularly sought through meetings. In addition comment cards are sent out to relatives to gain their opinion of the service being delivered and evidence was seen that the returned comment cards are analysed. There is also a ‘comment box’ in reception so that people can leave any comments or suggestions they may have. The new providers are in the process of implementing their own policies and procedures to ensure they reflect current legislation and good practice advice, which staff will have access to. Systems are in place for people’s finances to be managed. The system was secure and records provided evidence of running totals for individual people and included receipts for any purchases made on peoples behalf. However to ensure people are fully protected it is recommended that the policies and procedures regarding people’s finances are reviewed and updated to accurately reflect the procedures and processes used in the home and that agreements are made for staff to make purchases on people’s behalf. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Evidence was seen that fire safety checks were regularly undertaken to ensure that people are not put at any unnecessary risk. Pemberton Fold DS0000072949.V375012.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 4 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 x x 3 Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. To ensure that peoples needs are appropriately met it is recommended that an oral assessment is undertaken on admission and then incorporated into the support plan. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. It is recommended that the policies and procedures relating to finances are reviewed and updated to clearly set out the systems to be followed. It is also recommended that written agreements be developed between people and the home setting out permission for DS0000072949.V375012.R01.S.doc Version 5.2 Page 26 2. OP7 3. OP29 4. OP35 Pemberton Fold the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. Pemberton Fold DS0000072949.V375012.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Pemberton Fold DS0000072949.V375012.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!