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Care Home: Pendleton Court Care Centre

  • 22 Chaplin Close Salford Manchester M6 8FW
  • Tel: 01617439798
  • Fax: 01617378080
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Pendleton Court Care Centre is a care home registered to provide accommodation for up to 37 older people requiring nursing care and 21 places for older people requiring personal care only. The home is owned by Southern Cross Healthcare Limited. The home is a converted mansion house situated in an elevated position at the rear of a residential estate. Accommodation is on two floors in single en-suite bedrooms. A passenger lift provides access to each floor. The home is within walking distance of a local park and shops. The home is close to the local bus routes into Manchester city centre and Salford/Eccles and is close to the motorway network. The current scale of charges at the home are £355-52 to £425 per week. Costs in addition to the fee are hairdressing, chiropody(private) and newspapers.

  • Latitude: 53.493000030518
    Longitude: -2.2999999523163
  • Manager: Manager post vacant
  • Price p/w: ~
  • UK
  • Total Capacity: 58
  • Type: Care home with nursing
  • Provider: Southern Cross Home Properties Limited
  • Ownership: Private
  • Care Home ID: 12212
Residents Needs:
Dementia, Physical disability, Old age, not falling within any other category

Latest Inspection

This is the latest available inspection report for this service, carried out on 29th April 2008. CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

For extracts, read the latest CQC inspection for Pendleton Court Care Centre.

What the care home does well Before moving to Pendleton Court, prospective people who may live there, or relatives on their behalf, may visit to look around. One relative said, "The staff were kind when I came to look around I felt this was going to be the right place for Mum. It has a good name around here too". The atmosphere in the home was friendly and warm and staff spoken to enjoyed working at Pendleton Court. The internal and external appearance of the home provides a clean, homely and comfortable environment for people to live in. Some people said they though their bedrooms were homely and that the home was always kept clean. One resident especially liked the fresh flowers on display. The home continues with its programme of redecoration and upgrading. Assessments are undertaken of people before the offer of a place is made at the home. Information gathered at this stage was used to start the person`s care plan. The home has flexible visiting arrangements to enable the residents to have regular contact with their families and friends. The relationships the residents and the staff have appeared good and the residents privacy needs were well respected. Staff must be reminded of the need to call residents by their preferred term of address. The manager supported and encouraged staff to undertake National Vocational Qualifications and to attend training courses where appropriate. What has improved since the last inspection? Since the last inspection a pre admission draft care plan has been developed to help in the admission process. Since the last inspection there were some improvements to the monthly evaluations, in the care plans, which took some account of changes to make sure information for staff was up to date. There have been improvements made to the garden area and there has been an additional activities organiser employed and an increase in the activities provided. CARE HOMES FOR OLDER PEOPLE Pendleton Court Care Centre 22 Chaplin Close Salford Manchester M6 8FW Lead Inspector Elizabeth Holt Unannounced Inspection 09:30 29th and 30th April 2008 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 Pendleton Court Care Centre DS0000006726.V363059.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. Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendleton Court Care Centre Address 22 Chaplin Close Salford Manchester M6 8FW 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 743 9798 0161 737 8080 www.southerncrosshealthcare.co.uk Southern Cross Home Properties Limited Care Home 58 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (58), Physical disability (1) of places Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of either gender, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical disability - Code PD (maximum number of places: 1) Dementia - Code DE (Maximum number of places: 9) The maximum number of people who can be accommodated is: 58 Date of last inspection 15th May 2007 Brief Description of the Service: Pendleton Court Care Centre is a care home registered to provide accommodation for up to 37 older people requiring nursing care and 21 places for older people requiring personal care only. The home is owned by Southern Cross Healthcare Limited. The home is a converted mansion house situated in an elevated position at the rear of a residential estate. Accommodation is on two floors in single en-suite bedrooms. A passenger lift provides access to each floor. The home is within walking distance of a local park and shops. The home is close to the local bus routes into Manchester city centre and Salford/Eccles and is close to the motorway network. The current scale of charges at the home are £355-52 to £425 per week. Costs in addition to the fee are hairdressing, chiropody(private) and newspapers. Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social care Inspection in relation to this home prior to the site visit. Prior to the inspection the provider completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment and a dataset that is filled in once a year. It is one of the main ways that the CSCI obtains information from providers about how they are meeting outcomes for people using their service. The AQAA also provides the CSCI with statistical information about the individual service and trends and patterns in social care. Service user, staff and relatives surveys were provided for distribution before the inspection and 4 were returned from service users/relatives and 0 from members of the staff team. Comments from these surveys have been included in this report where possible. The visits were unannounced and took place over the course of 9.5 hours on Tuesday 29th and Wednesday 30t April 2008. During the course of the visit time was spent sitting and chatting with people who use the service, some of the staff including the registered manager and visitors to the home. Records were looked at in relation to the running of the home and health and safety and a partial tour of the premises was made. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those living at the home There is currently one safeguarding allegation being investigated under Salford Council’s adult safeguarding procedures. The outcome of this investigation is not known at the time of this report. What the service does well: Before moving to Pendleton Court, prospective people who may live there, or relatives on their behalf, may visit to look around. One relative said, “The staff were kind when I came to look around I felt this was going to be the right place for Mum. It has a good name around here too”. The atmosphere in the Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 6 home was friendly and warm and staff spoken to enjoyed working at Pendleton Court. The internal and external appearance of the home provides a clean, homely and comfortable environment for people to live in. Some people said they though their bedrooms were homely and that the home was always kept clean. One resident especially liked the fresh flowers on display. The home continues with its programme of redecoration and upgrading. Assessments are undertaken of people before the offer of a place is made at the home. Information gathered at this stage was used to start the person’s care plan. The home has flexible visiting arrangements to enable the residents to have regular contact with their families and friends. The relationships the residents and the staff have appeared good and the residents privacy needs were well respected. Staff must be reminded of the need to call residents by their preferred term of address. The manager supported and encouraged staff to undertake National Vocational Qualifications and to attend training courses where appropriate. What has improved since the last inspection? What they could do better: The staff need to be aware of whose responsibility it is to keep the records up to date and accurate. The care plans need to be checked to see they detail the ongoing needs of the residents and show staff clearly how they can provide the support needed for the residents accommodated. Some of the information was not used and the records were not always fully completed. The information gathered at the admission stage should be used to develop the care plan. Shortfalls in the Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 7 recordings in the care plans and risk assessments have the potential for residents’ to be at risk of their needs not being met. Procedures for making sure medicines are received in a timely manner and to make sure waste medicines are returned before they build up need improving to protect residents. 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. Pendleton Court Care Centre DS0000006726.V363059.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 Pendleton Court Care Centre DS0000006726.V363059.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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the home and have an assessment of their needs before admission. EVIDENCE: A Statement of Purpose and a Service User’s Guide which describes the home, the services and facilities provided is available within the home and is provided to prospective residents and their relatives. Residents have an assessment of their needs carried out, by the manager, or a senior nurse, before admission. The assessment includes a visit to the person in their own home, or in hospital, by talking with the individual or with family members. One resident’s relative whose mother was new to the home said, “The manager visited Mum in hospital and told her all about the care home. She Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 10 was very proactive in getting Mum out of hospital where her social and mobility conditions were deteriorating.” Assessments are also obtained from health and social services agencies. Three pre admission assessments were looked at which included copies of the assessments undertaken by the local authority. Some of the information was not always transferred over to the home’s pre admission assessment and care plan. For one of the assessments, the pre admission draft care plan was not signed and dated to show who and when it was carried out. The manager confirmed that admissions to the home only take place if she is confident that the assessed needs of the individual can be met. Those considering moving to the home are invited and encouraged to visit so that they can have a look around, and meet staff and other residents before making a final decision. Standard 6 is not applicable to this home. Pendleton Court Care Centre DS0000006726.V363059.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 good. This judgement has been made using available evidence including a visit to this service. Systems are in place to monitor and record the healthcare needs of residents but these must be consistent to make sure their needs are met in full. EVIDENCE: The care plans for four residents were looked at. The care plans included information about a wide range of the residents health and personal care needs and these were reviewed and updated regularly. Care plans looked at were quite specific to the resident’s individual needs. There were some shortfalls noted as staff had not always filled in the records fully. Risk assessments were not always fully completed. For a resident who had been in the home for three weeks the moving and handling risk assessment had not been fully completed, the residents weight was not recorded in the care plan however the nutritional risk assessment showed her to be “at risk”. The continence assessments were not completed for this person. There were Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 12 no general risk assessments in place and in relation to falls there was no risk assessment but a care plan for falls was in place. It was of concern for one resident that the care plan showed the staff had been unable to weigh the resident since December 2007. Staff commented this resident ate well and they observed her eating pattern and her nutritional risk assessment was adequate. The manager said hoist scales had been ordered but these were still not available. Following observations of the staff attempting to encourage a resident to sit at the dining table and eat their lunch it was clear this was not the most appropriate support this resident needed. The care plan for the resident needing updating to reflect their current needs and how the staff can best provide support for this resident. A copy of the updated care plan was forwarded to the CSCI in relation to how this resident should be supported for example, how the resident must be offered finger foods as necessary and that she may prefer to eat at times at the office desk. The outcome showed how the staff must support the resident to eat a well balanced diet. For another resident the care plan stated they were in need of constant supervision and that hourly observations were in place. There was no ongoing monitoring or recording of these observations and it appeared the care plan had not been updated to show the current support the resident required. In some of the care plans the records in the daily statements had lines left between the entries. This was discussed with the staff on duty and they were advised that leaving gaps between the recordings of the daily statements leaves this open for the risk of other staff adding information between the records. A sample of medication administration records and the blistered medicines held by the service were looked at to make sure that residents were receiving their medication safely. Medication administration records included copies of photographs of each resident and a record of staff specimen signatures was held. Records were in place to record when medicines were received into the home. Staff signed the charts following the administration of medicines and there was evidence of the codes used appropriately. A recording in the daily statement showed that there was a time delay in the home receiving a Controlled drug for pain relief for a resident and there was an inappropriate comment from a registered nurse recorded in relation to this in the daily statement. The manager used the homes formal supervision record following this being brought to her attention. Systems were in place for the returns to pharmacy however the bin was overfull and there were a large quantity of bins waiting to be returned. A discussion with one of the registered nurses and the manager showed that staff have not received specialist training in Care of the Dying but they were Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 13 keen to develop their skills in this area of nursing. One resident said, “The staff are good at keeping me comfortable and I feel safe here.” During the two days of this visit we spoke to residents and relatives and they were generally treated with respect and dignity. One staff member was overheard saying, “all right sweetie” to one of the residents and staff must remain aware of maintaining the dignity of the residents at all times. A number of the staff over the two days were seen to be very gentle and kind with the residents and encouraged them to take drinks and food showing they were understanding of how they needed supporting. Pendleton Court Care Centre DS0000006726.V363059.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): 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. Residents are satisfied that the service meets their expectations and preferences in respect of daily routines and meals. EVIDENCE: Two activities organisers were employed at the home at the time of this visit. A programme of activities and social occasions was on display in the entrance hall. Activities included arts and crafts, bingo, outings, music therapy and singing. The new activities organiser has been employed to work closely with residents on the dementia care unit. During the site visit he was seen encouraging a small group of residents to participate in some arts and crafts, which they seemed to enjoy. One relative said, “My sister gets a drop of whisky in the evening which she likes” and another relative said, “They are smashing here, out of the ordinary”. Another residents’ representative replied in the survey, “Mum prefers to observe more than join in but she always attends the singing/party events. There are daily activities such as bingo, jigsaws and games.” Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 15 Two residents were seen to assist in the garden and a new garden area was being created to develop this area for the residents to enjoy. The meals at the home are nutritious and varied and the dining tables looked pleasant. Since the last inspection the company had introduced menu planning that addresses the individual nutritional needs and special diets of residents. The chef spoke positively about this system and residents spoke favourably about the food provided. One resident said, “I always enjoy the food I am given, there is plenty of it and its tasty.” The menu of the day was displayed although the residents said they were not aware of what the meal was due to be. Staff spoken to said the residents were asked about their choice or preference each day but they appeared to forget what they had ordered. In one of the upstairs dining rooms, the residents appeared to be left waiting a lengthy period of time for their lunch to arrive and there was no staff member around to supervise these residents whilst they were waiting. Staff must be mindful of the need to observe residents when they are left for periods of time. One of the staff members did comment, “it was unusual to wait this long for the meal to arrive.” One resident who was nursed in bed for periods of time said, “the staff pop in regularly for to chat with me, they are very good. I could call for attention and I am not made to feel a nuisance.” Relatives commented themselves that they were made to feel welcome at the home and one relative said, “I like to feel involved in my father’s care and they make me feel like I am.” Pendleton Court Care Centre DS0000006726.V363059.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. 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. Residents are confident that issues they raise will be dealt with promptly, and they are safeguarded by the staff knowledge of adult protection policies EVIDENCE: The complaints procedure is displayed in the home and included in the service users’ guide. Residents and relatives spoken to had confidence in the manager to address any issues they had the need to raise with her. Advocacy information is displayed, and there are regular relatives’ meetings to ensure that people have an opportunity to express their views. Complaints and their outcomes are recorded and there was clear evidence of the action taken by the manager to provide an outcome following concerns raised since the last inspection in May 2007. Three of the three representatives of relatives who responded to the service user surveys said that they knew how to make a complaint. The manager and staff had received training in the Protection of Vulnerable Adults in March 2008 and staff spoken to were familiar with the procedures regarding the protection of residents and the action to take in the event of an allegation of abuse. Guidance on the local multi-agency procedures is available for reference. At the time of writing this report there is an Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 17 investigation in relation to safeguarding a resident under investigation by other agencies. Pendleton Court Care Centre DS0000006726.V363059.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. Residents’ benefit from living in a well maintained, clean, homely and comfortable environment. EVIDENCE: The home is a converted stone house in a peaceful and attractive residential area, and has well maintained gardens for residents’ use. The furnishings are homely in nature and residents’ bedrooms were seen to be comfortable and personalised. Residents spoken said they liked their bedrooms and one resident said, “Its homely and I like my room, just look I can see the garden from the lovely big window.” The home was clean and homely and odour free on the two days of these visits. A partial tour of the premises was carried out which, showed the bedrooms, bathrooms and communal areas to be adequately decorated. Some Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 19 residents chose to spend the day in their bedrooms and the staff respected their wishes. Procedures are in place for infection control practices and staff were aware of the importance of good hand washing practice. Residents and relatives were complimentary about the fresh flowers provided in the home, one relative’s sister who was sitting on comfortable seating by the entrance hallway said, “It has such a homely feel here, I do like it”. Pendleton Court Care Centre DS0000006726.V363059.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. The arrangements for the employment, training and recruitment of staff ensure the needs of the residents are met. EVIDENCE: On the days of the visits the staffing levels appeared sufficient to meet the care needs of residents. Comments made from a relative in the service user survey highlighted that “Mum is on the nursing floor and so often the staff are tied up with the patients with heavy needs. However, I have never had any problem finding someone to speak to and |Mum says she has no difficulty.” Several staff members have worked at the home for a long time and this provides good continuity of care for residents. The AQAA showed there has been no use of agency or temporary staff in the previous three months and the manager confirmed that permanent staff tend to cover for sickness and absence. In addition to nurses and care staff, the service employs domestic catering and laundry staff, a maintenance person and two activities coordinators. The pre inspection information provided by the manager showed that a staff training programme was in place. Staff had been trained in fire awareness, moving and handling, food hygiene and some staff had been trained in infection control, care planning, medication handling and dementia care. Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 21 There is a commitment to staff training and development. Of the 34 care staff employed at the home 27 have achieved a National Vocational Qualification at level 2 or above and other staff are working towards this qualification. The staff files for three staff were looked at and were all found to contain a completed application form, two files had two written references and the third file had copies of letters to show these had been sent for. There was a note to say “good” verbal references had been made for this applicant. Staff files had evidence of Criminal Records Bureau checks. Copies of written references obtained must be held on the staff members file to ensure appropriate recruitment procedures are carried out for the safety of the residents accommodated. Pendleton Court Care Centre DS0000006726.V363059.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems are in place to safeguard the health, welfare and safety of the residents. The manager must monitor the care practices and record keeping to ensure these practices are kept up to date. EVIDENCE: The manager has been at the home now for a few years and has not yet submitted her fully completed application form to be registered with the Commission. Relatives and residents spoken to confirmed the manager was approachable and friendly and they felt confident she would deal with any concerns they had. There is evidence the manager continually seeks to make improvements in the home for the benefit of the residents and she clearly has a good knowledge of their individual personalities and preferences. Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 23 Although the manager is competent in the care of older people, as she is not a registered nurse, the home have appointed a staff member who has worked at the home for a number of years as the lead clinical nurse. Conversations with staff and residents showed she was familiar with the needs of the residents and keen to develop her knowledge and skills. There was some evidence that the manager had carried out audits of medication practices and care plans. The staff need to be made aware of their responsibilities to address shortfalls identified. A relatives meeting was held in February 2008 and minutes were recorded following this. The manager does obtain the views of residents and visitors, and had developed a quality assurance plan that shows people how their views are being used to improve the service for the residents. Inspection certificates relating to environmental health and fire safety matters were satisfactory. Policies and procedures relating to health and safety and environmental risk assessments were available for the staff to access. Residents’ personal allowances are well managed with accurate records of transactions maintained. The Commission appear to be notified under Regulation 37 of the Care Homes regulations of notifiable incidents/accidents that have taken place in the home. Accidents or incidents occurring in the home were recorded in a logbook that met the requirements of the Data Protection Act 1998. An audit of accidents was in place to monitor any patterns in accident or incidents. Pendleton Court Care Centre DS0000006726.V363059.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 25 No 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. 1. Standard OP7 Regulation 15(2)(b) Requirement Timescale for action 11/07/08 2. OP8 12(1)(a) 3. OP9 13(2) An audit of the care plans must be carried out to ensure these accurately detail the actions required by the staff to ensure that all aspects of the health, personal and social care needs of the residents accommodated are met. The care plans and risk assessments must be reviewed on a regular basis. Appropriate weighing scales 30/06/08 must be provided to make sure the resident’s weight can be accurately monitored. . The ordering system in place for 20/06/08 medication needs to be robust to make sure residents do not run out of required medication. The medicines awaiting disposal must be collected as soon as practicable to avoid the risks of holding excess waste stock. To ensure that residents are 16/09/08 safe, copies of two written references must be sought and held on the staff members file as part of the recruitment process. In order that the service is run in 30/09/08 DS0000006726.V363059.R01.S.doc Version 5.2 4. OP29 19(1) 5. OP31 9 Pendleton Court Care Centre Page 26 the best interests of the residents, the manager must submit an application to be registered with the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP3 OP9 OP10 OP15 Good Practice Recommendations It is recommended the pre admission assessments and initial draft care plans are signed and dated so it is clear when these were carried out. The medicines awaiting disposal should not be Staff should be reminded of the need to use each resident’s preferred term of address so that residents feel that their wishes are being respected at all times. In order to assist the residents with choice at mealtimes menus should be provided in a format residents understand so they are better able to exercise choice at mealtimes. It is recommended the manager develops a training plan in line with the staffs training and development needs. 5. OP18 Pendleton Court Care Centre DS0000006726.V363059.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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 Pendleton Court Care Centre DS0000006726.V363059.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!

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