Care Home: Pendruccombe House

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well The activities in place provided by the home and other agencies such as `Friends of Pendruccombe`, Help the Aged, the local Methodist Minister help to ensure that the lifestyle in the home meets peoples current needs. The staffing levels and commitment to training ensure that peoples, often complex, assessed needs are met. Ongoing redecoration and refurbishment shows that the provider and all of the other staff at the home want the environment to be comfortable and homely. Records seen were well constructed and used appropriately to benefit those living in the home. What has improved since the last inspection? The requirements and recommendations made following the last inspection (September 2006) have been met. Ongoing redecoration and refurbishment, including the conservatory and patio, ensure that the people living in the home live in a well maintained and up to date environment. Door locks are fitted to all individual rooms.Systems put in place for recording what people eat and any specialist diets they may be on have been introduced and are used in conjunction with regular weight measurement to ensure people are receiving a nutritious diet. The recruitment procedure in place ensures that all of the information required such as 2 written references, employment history a CRB check are on file. Environmental and personal risk assessments are in place and have evidence of being reviewed. What the care home could do better: Signs should be put on the toilet and bath/shower room doors for people to indicate if they are engaged or not. CARE HOMES FOR OLDER PEOPLE Pendruccombe House (Nursing) 23 Tavistock Road Launceston Cornwall PL15 9HF Lead Inspector Mandy Norton Unannounced Inspection 10:25 10 September 2008 th 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 Pendruccombe House (Nursing) DS0000009244.V365860.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. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendruccombe House (Nursing) Address 23 Tavistock Road Launceston Cornwall PL15 9HF 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) 01566 776100 01566 775700 pendruccombe@btconnect.com A J & Co (Devon) Ltd Mrs Lynda Anne Winston Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (27), Terminally ill (27) of places Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 27 adults of old age (OP) Service users to incude up to 27 adults with a physical disability (PD) Service users to include up to 27 adults with a terminal illness (TI) some of whom may have nursing needs. Total number of service users not to exceed a maximum of 27 Date of last inspection 19th September 2006 Brief Description of the Service: Pendruccombe House (Nursing) provides accommodation and nursing care for 27 people in need of care due to old age or physical disability over the age of 65. Pendruccombe House is a large purpose built home on the edge of Launceston town. Also owned by the same company and on the same site is Pendruccombe Residential Home. This report relates to the Nursing provision only. The accommodation offered is on two floors, with a lift access to the first floor. People have a choice of two lounges, one of which also has a dining area and a separate dining room. Service users are encouraged to take their meals in the dining areas, but may eat within their private room if that is their choice. There is a large conservatory (recently refurbished) with comfortable seating which leads outside to a patio area, accessible to wheelchair users as well as those more mobile. Activities are arranged within the home as well as outings for people who wish to partake in these trips. For those who do not wish to visit or are unable to get into Launceston, hairdressing, opticians, chiropody and dental services are arranged at Pendruccombe on a domiciliary basis. There is a hairdressing room with specialist equipment, which is operated once a week. There is a small parking area to the front of the home and parking to the rear. The current fee level foe the nursing care provided is £519.77 - £589.56 per week. People are issued with a contract once they have settled in. This breaks down the fee levels and details who is paying what and details the terms and conditions of residency. Pendruccombe House (Nursing) DS0000009244.V365860.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 unannounced inspection took place from 10.25 am until 4 pm on the 10th September 2008. The inspection was conducted with the manager. A tour of the home was carried out and number of the people living in the home were spoken to and observed during the visit. This report also contains information taken from the completed annual quality assurance assessment (a document that is completed annually detailing ongoing improvements and achievements) and discussion with staff on duty on the day of the inspection. There were 24 people living in the home at the time of the inspection. What the service does well: What has improved since the last inspection? The requirements and recommendations made following the last inspection (September 2006) have been met. Ongoing redecoration and refurbishment, including the conservatory and patio, ensure that the people living in the home live in a well maintained and up to date environment. Door locks are fitted to all individual rooms. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 6 Systems put in place for recording what people eat and any specialist diets they may be on have been introduced and are used in conjunction with regular weight measurement to ensure people are receiving a nutritious diet. The recruitment procedure in place ensures that all of the information required such as 2 written references, employment history a CRB check are on file. Environmental and personal risk assessments are in place and have evidence of being reviewed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. This service is not registered to provide intermediate care EVIDENCE: An up to date Statement of Purpose is provided in each room. A copy of the previous report and annual service review was also clearly displayed in the entrance foyer. The home also has a website for people to visit www.pendruccombe.co.uk that provides useful information about what the service offers, including links to CSCI, Age Concern and Registered Nursing Homes Association. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 9 The manager said she visits people in their current setting (where possible) to assess their needs prior to them moving into the home. The information gathered during the assessment forms the basis of the care plan when they move in. A completed pre admission form examined had relevant information about the person and their needs. One person spoken to had moved in recently and had made the decision based on the reputation of the home locally and the information she was given. A contract examined contained information about fees and terms and conditions of residency. Everybody is issued with a contract once the initial settling in period is over. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practice regarding the planning and delivery of care means that people can be sure that their health and personal care needs will be always be fully met. EVIDENCE: Care plans seen had a lot of relevant information about the individual and their health and personal care needs. They were up to date and had been regularly reviewed. The nursing and care staff complete daily records about a person’s welfare and detail what personal care activities have been completed during each shift. There is information kept in a persons room about manual handling and a ‘how to’ guide(written by care staff detailing how people like to do things, when they like to do it etc – this was noted as good practice). The care plans seen had information about visits made by or to health care professionals such as GP’s, dentists and opticians. A tour of the home showed that equipment necessary for the promotion of tissue viability and prevention and treatment of pressure sores was available and the manager said that she felt they had enough equipment to meet Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 11 people’s current needs. All beds are adjustable, many have specialist pressure relieving mattresses on them and between the 2 floors there are 4 hoists with a variety of slings to use. The home uses a blister pack system for administration of medicines they are stored in a locked trolley kept in the treatment room. The drugs fridge has its temperature measured and recorded daily as required. Creams and lotions seen in individual rooms all had prescription labels on them. The Annual Quality Assurance Assessment states that ‘We comply with the NMC guidelines on the administration of medicines. Drugs are stored in compliance with the regulations. We have a pharmacists inspection in line with good practice guidelines’. (Medicines management was not looked at in detail during this inspection). Staff were heard interacting with people living in the home appropriately and providing support and help in a discreet manner. People spoken to said that the staff are very kind and treat them very well, with some going ‘above and beyond the call of duty’. Doors to people’s rooms and bathrooms were shut when personal care was taking place. It was recommended that all toilet and bathroom doors have signs on them to indicate if they are engaged or not. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the home and community mean that people have regular opportunities to participate in stimulating and motivating activities. Meals and mealtimes are not rushed making them an enjoyable, social occasion for people. EVIDENCE: The activities schedule was displayed around the home. On the day of the inspection there was bingo in the afternoon, this was attended by 6 people and they were all kept engaged in the game by the activity co-ordinator, who works 4 hours a week (and more when trips and special activities are taking place) on activities and is the housekeeper and works in the laundry, as she is in the home a lot of the time she knows the current residents well and tries to organise activities she thinks they will enjoy. The manager said that 2 ‘befrienders’ from Help The Aged visit the home and spend time with people who may be bedfast and cannot join in with group activities. The Annual Quality Assurance Assessment states that ‘our holistic therapist has worked extremely well with our service users and many now benefit from aromatherapy and massage’. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 13 During a tour of the home the inspection ‘Friends of Pendruccombe’ visited to refresh the fresh flowers as they do fortnightly. They also help with fundraising activities and decorating the home for special occasions such as Easter and Christmas. This brings the local community into the home as many of the current residents are unable to go out very often. Visitors are welcome at all times and were seen coming and going freely during the inspection, often stopping to talk with staff about their relative and to pass the time of day. Photographs were seen of trips that have taken place recently (not so many as usual the manager said because of the poor weather there has been) as the home has its own mini bus trips can be planned at the last minute if necessary. The lounges have a TV in them and people often also have their own TV and/or radio in their room. Some people have a daily paper or magazine. Part of the care plan includes information about hobbies and interests and the staff try to help people to continue to pursue their interests if possible, for instance people who like to paint can attend the day centre (attached to the home) where there is equipment to do this. There is access to a patio area, that has recently been refurbished, where seating is provided and people can spend time outside if they wish. Many people have their meals in the dining rooms where there are staff available to assist people as required. Other people have meals in their rooms and have support from staff if needed. People are generally asked what they would like to eat the day before the meal (people who are forgetful are asked the same morning), all meals eaten are recorded, along with fruit eaten and drinks taken, in some cases, in order to confirm that people are having a well balanced diet. The manager said the cook will go and discuss any personal preferences with a resident if there are any concerns or questions, that may have come up during discussion or at residents/relatives meetings, in order to meet individual needs. The homes website says that ‘ a well balanced and seasonal menu is provided which changes on a four week rota’ it also displays a sample lunch and tea menu. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Formal complaints and safeguarding policies and procedures are in place and are available to all staff at all times. All staff undertake safeguarding training. This means that people who live at the home are adequately safeguarded. EVIDENCE: The complaints procedure was seen displayed at the front entrance and is in the Service Users Guide a copy of which is in each room. It is comprehensive and gives options of who to contact and timescales for responses to be made. There have been no complaints made to the home or to the Commission in the last 12 months. The manager said that any issues bought up either through daily contact with residents and/or their representatives, or as feedback from the quality assurance surveys are dealt with immediately and any required actions are detailed in the care plans. Staff files examined showed that staff have attended local adult protection (safeguarding) training and the training package recently introduced in the home has sections on safeguarding to work through. Staff members on their induction and studying for a National Vocational Qualification level 2 or 3 also have information about safeguarding. People spoken to said they knew who to approach to make a complaint if necessary. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ongoing refurbishment and redecoration means that people have a homely, comfortable and safe environment in which to live. EVIDENCE: The home presents as welcoming, homely and clean. The ‘Friends of Pendruccombe’ replace fresh flowers in the entrance foyer fortnightly. People’s rooms seen were very personalised with furniture, ornaments and photographs that they had bought in with them. There is a call bell system throughout the house. Communal space consists of a lounge and dining room on each floor and a newly refurbished conservatory. There is a recently created patio area with seating and tables available to use, it is accessible to people with mobility aids. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 16 There are toilets and bath/shower rooms, with adaptations designed to meet the needs of the current residents, throughout the home accessible to everybody. Overhead track hoists have been fitted in the bathrooms which, according to the manager, have proved popular with the residents and the staff. The laundry is suitable and has hand - washing facilities. The policies and procedures around infection control are available to staff at all times and are reviewed annually as part of the quality assurance system. There is a mechanical sluice in the sluice room, which was clean and odour free during the inspection. All of the doors to individual rooms have locks fitted to them and people are asked if they would like a key when they move in (following completion of a satisfactory risk assessment). Each room also has a lockable space for people to keep money and/or valuables in (up to the limit of the homes insurance for any personal item, if above the limit it has to be insured separately: details are in the Statement of Purpose). During a tour of the home it was found to be clean, tidy and hygienic whilst maintaining its homely feel. People spoken to said there rooms are comfortable. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The providers and manager show a responsible attitude and are implementing changes and improvements in order to keep improving quality and outcomes for people living in the home. The staffing levels are satisfactory therefore peoples needs are being met at all times. EVIDENCE: The duty rota examined showed that on duty during the day there is a trained nurse and 6 carers, in the evening there are 4 carers and a trained nurse they are supported by activity, domestic/laundry, catering, administrative and maintenance staff. Overnight there is 1 trained nurse and 2 carers. Care staff spoken to said that the staffing levels are fine for the amount of people they look after (24 on the day of the inspection). People spoken to said that the staff are always very attentive and they do not have to wait long for support or help when they need it. Two staff files were examined and contained all the information required including an application form (which asks for employment history), 2 written references, a CRB check and interview records. The files also included evidence of appraisals and supervision sessions and contracts of employment .The training files seen contained certificates for numerous courses and study days including; health and safety, fire safety, safeguarding and manual handling. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 18 Staff spoken to said that there are training opportunities and no problem in being given time to attend them. Records show that 13 care staff have already achieved a level 2 National Vocational Qualification or above and 7 are currently studying for level 2, 3 or 4. The manager said that the home have recently started to use a training package that allows staff to learn about an area of care (module) then complete a question paper which are sent to the company to be moderated/ marked, certificates are then issued to staff, by the company, if they have passed. The home also uses other outside organisations who provide fire safety training, manual handling training and practical updates such as catheterisation, venepuncture and syringe driver management. New staff complete and induction period which includes principles of care and safe working practices and can take up to 12 weeks to complete. The manager and senior staff are involved in the induction and provide support and advice as required. The duty rota examined showed that on duty during the day there is a trained nurse and 5 carers, in the evening there are 3 carers and a trained nurse they are supported by activity, domestic/laundry, catering, administrative and maintenance staff. Overnight there is 1 trained nurse and 2 carers. Care staff spoken to said that the staffing levels are fine for the amount of people they look after (24 on the day of the inspection). People spoken to said that the staff are always very attentive and they do not have to wait long for support or help when they need it. Two staff files were examined and contained all the information required including an application form (which asks for employment history), 2 written references, a CRB check and interview records. The files also included evidence of appraisals and supervision sessions and contracts of employment .The training files seen contained certificates for numerous courses and study days including; health and safety, fire safety, safeguarding and manual handling. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems/procedures the manager has implemented are designed to meet the needs of the service, and to continually improve the service the home offers to meet the needs of the people that live there. The responsible attitude around health and safety shown by the providers, manager, care and ancillary staff means that people live in a safe and well maintained environment. EVIDENCE: The manager has been in post for 3 years. She had experience of managing care homes prior to taking up the post. She has achieved a Registered Managers Award and level 4 National Vocational Qualification in care and is qualified in tutoring and mentoring. There are clear lines of accountability Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 20 within the home, this was demonstrated with ongoing activity during the inspection. The manager said that one of the providers visits the home at least weekly and are very supportive and good to work with. There is a formal quality assurance/ audit system in place based on seeking the views of the residents and /or their representatives. The Annual Quality Assurance Assessment states that ‘We continue to undertake annual Quality assurance surveys (due August 2008) all service users are asked to complete a questionaire. The results are colated and published with proposals for undertaking issues raised’. The manager also keeps all ‘thank you’ card and letters as an informal form of quality assurance. She said that she sees everybody who lives at the home every day that she is on duty and if any concerns are raised she can deal with them immediately, she said she also sees relatives regularly (confirmed during the inspection when at least 2 asked her a question whilst they were visiting the home) and can discuss any concerns they may have. She said that staff and relatives/residents meetings are held from time to time and people can bring up any issues or concerns they may have and action points are then detailed in the minutes. It was clear during the inspection that although the manager does not generally ’work on the floor’ she knows all of the residents well. Policies and procedures are available to staff at all times and are updated regularly. They were not looked at in detail during this inspection. The administrator described the procedures in place for dealing with people’s money. She said that they try not to be involved in people’s personal allowances if possible. For those they do manage individual records are kept of income, and outgoings and receipts are kept. The money is kept securely and is accessible to people when they want it. Staff files examined had evidence of supervision (one to one) and appraisal sessions being carried out. All records seen were well constructed, up to date and stored securely. Staff files and training records seen showed that statutory training takes place as required. This includes fire safety, food hygiene, moving and handling and first aid. A selection of routine servicing and maintenance documents were seen confirming that people’s health and safety is promoted and protected. The maintenance man is responsible for ensuring that ongoing/routine in house and garden maintenance is carried out (he works full time between the residential and nursing home). A selection of general and individual risk assessments and the fire log- book were examined and found to be up to date. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP10 Good Practice Recommendations It is recommended that signage is put on communal bathroom/shower/toilet doors to indicate whether it is engaged or not. Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Pendruccombe House (Nursing) DS0000009244.V365860.R01.S.doc Version 5.2 Page 24 - 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!