Inspection on 17/11/09 for Penhill Residential Home

This is the latest available inspection report for this service, carried out on 17th November 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Not yet rated. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

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.

Other inspections for this house

Penhill Residential Home 24/03/06

Penhill Residential Home 01/11/05

Penhill Residential Home 08/03/05

Penhill Residential Home 06/08/04

Penhill Residential Home 09/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Penhill Residential Home 81 Station Road Shirehampton Bristol BS11 9TY Lead Inspector Paula Cordell Key Unannounced Inspection 17th November 2009 09:00 DS0000026623.V378392.R01.S.do c Version 5.3 Page 1 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. Penhill Residential Home DS0000026623.V378392.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 Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penhill Residential Home Address 81 Station Road Shirehampton Bristol BS11 9TY 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) 0117 9822685 0117 9822685 jon@penhill.com Mr Stephen Francis Ann Mrs Barbara Ann Mr Stephen Francis Ann Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 17 persons aged 65 years and over requiring personal care. 21st November 2006 Date of last inspection Brief Description of the Service: Penhill is a privately owned and operated care home located in a residential suburb of Bristol. The proprietors are Mr Steven Ann and Mrs Barbara Ann, who is also the registered manager. The home is registered with the Care Quality Commission (CQC) to provide accommodation and personal care for 17 persons aged 65 years and over. The property is a large, detached and extended house. The accommodation is arranged over two levels and is surrounded by well kept-gardens. Accommodation is provided in one shared and 15 single rooms. Communal space includes a lounge, conservatory and extended dining room. A lift and assisted bathing facilities are also provided in the home. The cost per week to reside at Penhill ranges from £450.00 to £475.00. Fees are reviewed annually. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a key inspection process. The purpose of the visit was to monitor the quality of the care to the individuals living at Penhill Residential Home. The last visit to the service was December 2006. There have been no additional visits to the home during this time. However, the Care Quality Commission has completed two Annual Service Reviews where by all information received by us during a twelve month period has been reviewed to ensure the home continues to provide an excellent service to the people living in Penhill. This has included seeking the views of individuals living in the home through surveys being sent annually to the home. The home completed an annual quality assurance assessment which is a document that enables the provider to tell us what improvements have been made since the last visit and where this can be evidenced and what future improvements are planned. This along with notifications and surveys enabled us to plan the visit. The Care Quality Commission has not received any complaints in respect of the care being provided at Penhill Residential Home. Four individuals were case tracked. Their care plans and care files were examined. The inspector had discussions with the individuals and observed them indirectly and the staff team going about their daily routines. Opportunities were taken to speak with a visiting relative, staff and the providers. A tour of the home was undertaken which further enabled discussions to be had with the individuals living in the home and the staff team. Other records were looked at to determine if the home was a safe place to live and work. Structured feedback was given on the outcome of the inspection at the end of the visit to the provider. What the service does well: Individuals can be confident that their assessed care needs are being met in a person centred way. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.2 Page 6 Care plans accurately reflect the peoples’ changing and ongoing needs and how they will be met. Individuals and their families are involved in this process wherever possible. Staff have a good awareness of individuals’ needs and treat the individuals in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. There are safe systems of medication. The people living in the home benefit from a varied activities programme, which are both enjoyable, stimulating and meets individual preferences and expectations. Meals were well presented and menus verify a healthy well balanced diet is provided with a wide variety of choice. Individuals expressed high satisfaction with the food that is provided. The home is comfortable, tastefully decorated and furnished. It provides a safe, peaceful and well-maintained environment for the people living at Penhill. Good staffing levels help to ensure that individual’s needs are met. Staffing levels are increased should the dependency levels of the individuals change. Individuals are protected by the home’s recruitment processes. The home was well organised and managed by an effective, stable management team that promoted the views and interests of the people living in Penhill. Penhill provides a very high standard of care to the people they support, who appear to be happy with the service they receive and are content with their daily lives. What has improved since the last inspection? What they could do better: All of the National Minimum Standards assessed at this inspection were met. No statutory requirements have been made as a result of this inspection. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.2 Page 7 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. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 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 Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Individuals have sufficient information to enable them to make a decision on whether to move to Penhill Residential Home. People’s care needs are assessed prior to moving to the home. EVIDENCE: The home has a statement of purpose and a service user guide. This clearly described the service provided to the people living at Penhill Residential Home and met with the National Minimum Standards. Individuals confirmed that they had copies in their bedrooms and could further access this information in the hallway along with the home’s current Care Quality Commission’s inspection report. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 10 There is a clear admission procedure to guide staff and prospective people wanting to move to the home in the statement of purpose. There was one vacancy at time of writing this report. The manager/provider stated that there is a waiting list for the home. On the day of the visit a relative visited the home with the view to placing a person there. They had visited unannounced and it was evident that the provider was happy to show them around the home and give them information about the service at Penhill. The provider said that it was important for the prospective individual to visit and spend time in the home as part of the assessment process and the length of time would be tailored to the individual but could be for a cup of tea, a meal or to participate in the activities that are being organised on that day. A months trial is offered on both sides to ensure that all parties are happy with the care and support being given ensuring the home can meet the assessed needs of the individual. Three individuals were spoken with during the visit, they said they had visited the home prior to making a decision and had sufficient information. All were happy with the care and the support they were being given. Comments included “you cannot get a nicer place the staff are lovely”, “it is a good home they really do care” a further comment included “I would like to live in my own home but this is the next best place”. Individuals commented on the relaxed and friendly atmosphere and how they were like one big family. Care files included pre-admission assessments which were informative and included all areas as detailed in the National Minimum Standards. It was evident that the individual was involved in the assessment process and where relevant relatives. Where individuals are placed by a social worker then copies of the local authority assessment and care plan is obtained. The information is used to determine whether the placement is suitable. The home’s assessment is then used to formulate a plan of care for the individual. It was evident that the assessments continue to be updated as part of the home’s care planning processes ensuring the plan of care is current and meeting the needs of the individual. Individual’s care files contained contracts and terms and conditions which are signed on admission. Surveys received confirmed that they had copies of the their contract. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Individuals can be confident that their personal and health care needs are being met. Individuals are protected by the home’s safe medication procedures and practices. Staff had a good awareness of the needs of the individuals and were observed treating people respectfully and with dignity. EVIDENCE: Four individuals care was looked at to determine the outcome for people living in the home. This included meeting with the individuals, the staff and the provider and looking at all care related documentation. Each person has a care plan that is generated from the assessment process. Individuals are involved in the planning of their care and any amendments. A relative confirmed that they had been kept informed of any changes in the plan Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 12 of care. The home has a computerised care planning package that assists with the format and highlights any areas of concern. This package has been professionally developed by the son of the provider specifically for the home. Staff said they had received training and support from the providers and their son in the use of the system. The package takes staff through the process of admission, assists with the care planning processes and highlights when reviews are required. Where information is numerical for example weight monitoring and other health related issues a simple graph is produced to emphasis the information. This is excellent. Where individuals needs have changed for example weight gain the system will alert the carer to seek advice and develop a care plan to address the concern or a risk assessment Care plans covered all areas of daily living and information from the home’s assessment process as detailed in the National Minimum Standards. The plans were person centred and included information about the person, how they liked to be supported, their cultural needs and interests. It was evident that a holistic approach to care was in place seeing the individual as a person with the care tailored to the individual encouraging them to be as independent as possible. Each person has an allocated member of staff called a key worker. The key worker completes the monthly reviews with the person and compiles a report on important events, general and physical wellbeing and any other relevant information. All records evidence consistency in assessing, planning and evaluating the individual’s care on a regular basis. The home conducts regular care review meetings with each individual, the key worker and where relevant relatives. Risk assessments were in place relating to accessing the community, self administration of medication, falls, wound care and other health related matters. This demonstrated a good knowledge on preventative health measures and systems to ensure the safety of the staff and the individuals. Individuals spoken with during the visit were extremely positive about the care support given to them both by the staff team and the providers. Comments included “staff always respond”, “the staff are lovely and caring”, “I can not fault this home it is excellent”. Three members of staff were spoken with during the visit and they were able to demonstrate that they had a good knowledge about the individual needs of the people living at Penhill and the expectations of the provider and their roles. Clear records were maintained of visits to health professionals including the GP, dentist, optician and dentist. Staff described a positive working relationship with the district nurse, who was always willing to advice and support them in areas relating to wound care management and diabetes to name a few. One Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 13 individual said that they can always contact their GP if they are worried about health care matters and this is supported by the staff. One relative said “the home is always good at liaising with the GP and families to resolve concerns and have worked well to support their relative”. They said they relative has been extremely happy and settled in the home. The only concern would be if their health care needs deteriorated they would not want to move to another home”. The home has good medication systems in the home with clear guidance on how it should be administered, risk assessments and information relating to the individual’s prescribed medication. The home operates a monitored dosage system for the administration of medication, which is supplied at regular intervals by the local pharmacist. The GP conducts a medication review every six weeks. Good records of medication entering the home, the administration and disposal were being maintained. Staff that have the responsibility to administer medication have received training and their competence is checked annually. This was evidenced in staff training files and in conversations with a member of staff. Staff were observed treating individuals in a respectful and dignified manner. Staff were observed knocking on doors prior to entering ensuring the privacy and dignity of individuals is respected. One visitor said “my relative always looks smart, well groomed and cared for”. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 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): 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. Individuals are encouraged to be active and participate in a wide selection of activities which is both stimulating and enjoyable. Friends and relatives are supported to visit and are made welcome. Individuals are offered a good diet based on choice. EVIDENCE: In consultation with the individuals’, staff develop a monthly timetable of activities and forthcoming events. This is reviewed on a weekly basis during the Saturday Forum a meeting for the individuals living in the home to assist with planning of the activities, menu planning, discuss concerns and talk about ongoing changes in the home. Minutes are kept of the meetings and it is evident that the views of the individuals are sought in respect of improving the service. The home has introduced an innovative idea on how to provide individuals with information about activities that are taking place and much more, whereby it can be accessed through their televisions on a selected channel. This channel Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 15 is also available on the home’s television in the two lounge areas and a screen in the hallway by the visitors book. This was observed up running at the last visit but there were some technical difficulties on the day of the visit. Individuals confirmed that it was normally up and running. The channel provides individuals, relatives and visitors valuable information including, forthcoming events, staff working in the home with photographs, daily menus, daily activities, the weather forecast and the homes complaints, comments and compliments policy and procedure. Regular trips are arranged and individuals like to go to local public houses for lunch, a local garden centre, shows at the local community centre or local walks and places of interest. The individuals also enjoy regular musical entertainers who visit the home and activities provided throughout the week include, bingo, indoor games, quiz time, and reminiscence therapy. On the day of the visit most of the individuals were taking part in a quiz. Special events are arranged throughout the year to celebrate birthdays or special events like bonfire night. Other events arranged this month include a Christmas Party, a Christmas meal at a local pub, Christmas shopping and the local theatre group. From talking with individuals friends and families are made very welcome. Everyone spoken with during the visit said they liked the activities on offer, whilst a couple said they like some but prefer to spend time in their bedroom relaxing. One person said they go for a walk on a daily basis and then return to the home to relax. The home operates an open door policy for visitors to the home. One visiting relative said they are always made welcome and offered a cup of tea on arrival or invited to lunch. The provider said individuals are welcome to invite visitors to join them for a meal and can arrange for private celebrations with families and friends for example a birthday party. Individuals have access to a computer to enable them to keep in contact with friends and family. As stated in the service users guide individuals are supported to attend their local place of worship. Methodist services are held fortnightly and a member of the local Church visits monthly for a communion service. Individuals are free to worship as they wish and any arrangements for services or communal prayers within the home are made in accordance with individual’s wishes and are entirely voluntary. Care planning documentation detailed cultural needs of the individuals and their interests and preferences. An opportunity was taken to spend time with the cook who demonstrated a competent awareness of individual requirements and needs of the people living in the home, including personal preferences. They spend time with the individuals on a daily basis to see if they have enjoyed their meal and if they Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 16 are happy with the menus. Individuals spoken with during lunch all said the food was lovely and the home catered for their likes and dislikes. The menu rota displays two choices for each meal. However the cook said that if neither was to a person’s liking then an alternative would be offered. The menus are reviewed to reflect seasonal trends and availability of produce. Extras are ordered on request for birthdays and special occasions. Fresh fruit and vegetables are delivered daily and fruit is on offer throughout the day. The inspector enjoyed a cooked meal during the visit, which was chicken in a creamy white sauce with mushrooms, boiled potatoes and peas the other choice was chicken curry with rice, followed by ice cream, apple pie and custard or cream. It was very well presented and the atmosphere was relaxed and unhurried. Where support was given, it was done sensitively and discreetly. The kitchen was clean and spacious and stores exhibited a good range of foods. Documentation was provided to show the inspector that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked before serving. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Individuals can be confident that the service is empowering and actively listens to their views about the care delivered. Good safeguards are in place to protect the individuals. EVIDENCE: The home has a complaints procedure. This is included in the statement of purpose and copies are given to the individual and their relatives. Individuals spoken with during this visit described a good level of satisfaction with the care they receive. Individuals said they would speak with staff or the manager and it would be sorted straight away. The home has not had any complaints as evidenced in conversations with the providers and the annual quality assurance. The provider said that this was in the main because individuals are consulted on a weekly basis about the service provided during the weekly forums and are involved in the planning of the menus and activities. Staffing is frequently discussed to ensure that individuals are aware of any changes to the rota or introduced to new staff. It was evident from talking with the provider and individuals that the forum was very empowering for individuals living in the home. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 18 Staff were aware of the policies in place to safeguard the individuals living in the home including whistle blowing and the safeguarding policy in respect of an allegation of abuse. Staff said they had attended training both with the provider and the local council in respect of safeguarding. Certificates were seen confirming this. A number of staff are completing the National Vocational Qualification in care and a component of this is ensuring individuals are protected from abuse and harm. Care plans included information about mental capacity and the amount of environmental control individuals have. This is good practice. Where individuals have relatives or professionals acting on their behalf, this was clearly recorded. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 19 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): 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. Penhill provides a safe, comfortable and homely place to live which meets the needs of the people their support. EVIDENCE: Penhills was built in 1926 and is situated conveniently close to local amenities including shops, a library and churches. It has been extended with a newer wing that accommodates eight bedrooms which links to the original part of the building. An accessible passenger lift has been installed to enable less mobile people to access the first floor. The home is in keeping with the local neighbourhood. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 20 All areas of the home are tastefully decorated, furnished to a high standard and well maintained. Great attention has been taken to make all areas homely with pictures, plants and ornaments. Individuals are supported to personalise their bedrooms with pictures, photographs and ornaments and are able to bring items of furniture should they wish. Individuals can have a key to their bedroom door which is lockable. Individuals were asked their permission prior to entering their personal space. Individuals have access to a large communal lounge, a dining area with a quiet seating area and a conservatory. There are mature gardens surrounding the property. The annual quality assurance assessment said that future improvements are planned for the gardening to make a comfortable decked area and a raised gardening platform making the garden more accessible. The provider stated that this will allow the individuals to enjoy the outside more safely. Another area the home stated that wanted to improve was the development of a storage area into a hair and beauty salon. The home has adequate bathing facilities that have been fitted with equipment to encourage the independence and the safety of the people living there. These are maintained by an external engineer where relevant. There are handrails strategically placed around the building ensuring the safety of the individuals. The home was clean and smelled fresh and pleasant throughout. The home employs a domestic on a daily basis. Individuals spoken with during the visit confirmed the home is always clean and spotless. Monthly audits are completed on the premises ensuring that the home is in a good state of repair. A person is employed to assist with the maintenance and ongoing decoration. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 21 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): 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. Individuals are supported by a flexible and dedicated staff team. There are good support and training mechanisms in place ensuring individuals are supported consistently to a good standard. EVIDENCE: The home is staffed 24 hours by two to three members of care staff during the day and evening and two staff working at night. The provider ensures that the staffing is adequate to meet the needs of the individuals and their assessed needs. Where care needs change then additional staff are employed to assist, as evidenced in conversations with staff. In addition to the care staff the home employs catering, domestic and administrative staff. The providers Mr and Mrs Ann work during the week along with their two sons. One son is involved in the maintenance and the other is involved in administrative tasks and developing the computerised system that is in use. The provider said that there has been a consistent team with a very low turnover of staff. The home does not use agency as this is covered by the staff team flexibly. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 22 Individuals spoken with during the visit complimented the staff on their skills, caring nature and that there was always sufficient staff on duty. Recruitment records were viewed in respect of four members of staff. All records were clear and filed logically. The records were held in accordance with the legislation and included a copy of the application, a criminal record disclosure and two references. The home is still keeping copies of the staff’s birth certificates and other personal information, the legislation has changed in the last two years which now means that this can be destroyed in accordance with the Data Protection Act. There was a good rolling programme of training in place covering both statutory and training relevant to the needs of the people living in Penhill. A matrix is in place detailing when the training requires updating for individual members of staff. Training included infection control, first aid, manual handling, first aid, fire, health and safety, safeguarding and COSSH. Other courses included dementia training, mental health, loss and bereavement and supporting individuals that challenge and depression. Staff spoken with said they have guidance from the district nurses in supporting individuals with wound care management and diabetes. Staff said there is a commitment from the providers to ensure staff have the training, the knowledge and the skills to enable them to perform their roles and care for the individuals. There is a comprehensive induction package in place which includes attendance at some of the training detailed above. Staff are given a mentor to assist with the induction process and offer the individuals living in the home continuity. There is a commitment to ensuring that 50 of the staff team have an National Vocational Award in Care. There are nineteen staff working in Penhill, six have a NVQ and a further six are in the process of completing. Staff described good working conditions with good leadership, support and direction in place. It was evident from talking with the provider that they value their staff team. Regular staff meetings are held to discuss the running of the home and the care of the individuals. This was confirmed in conversations with staff. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 23 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): 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. There is a good management team in place at Penhill which involve and value the staff team and the people they support. Good support mechanisms are in place ensuring a consistent approach with clear directions being given. Individuals can be assured their safety whilst living at Penhill House. EVIDENCE: Mr and Mrs Ann are the registered providers with Mrs Ann being the registered manager. As already mentioned their two sons are actively involved in the running of Penhill Residential Home. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 24 Staff and individuals living in the home described a high degree of satisfaction in the way the home is managed and care delivery. Based on these comments it was evident that the home is run with the interests of the individuals being taken into consideration. The home continues to work hard developing formal quality assurance and has completed an audit this year to assess the satisfaction with regards to the service that the home provides by asking people who live in the home, their relatives, professionals and GP’s to complete surveys. The results and comments from the surveys were very positive. Information from the surveys was being collated to develop an action plan. The results have enabled the home to identify all strengths and any weaknesses. This is good practice. There is an annual appraisal process, which ties in with the supervision arrangements. The management have established a formal recorded supervision procedure for all staff. A plan is devised for discussion relating to the individuals, work issues, staff issues, personal development and training. The recorded outcomes of the supervision evidenced the effectiveness of the sessions. The provider’s sons as previously mentioned are involved in the running of the home one of the sons is responsible for the maintenance of the home and its grounds and in ensuring that Health and Safety in all aspects are kept up to date and regularly maintained. The other son is involved in the administrative tasks and developing the computerised records. Some of the Health and safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment and emergency lighting. The homes records showed all necessary service contracts were up to date including, gas and electrical services and the passenger lift. Some of the health and safety records are held on the computer for example temperatures of the fridge/freezers. Staff are reminded to complete this daily and from the information a graph is produced to give a visual aid of any discrepancies. Again this is good practice in monitoring the health and safety of the home. The fire logbook evidenced compliance to the weekly, monthly and annual checks alongside records of staff training and drills completed, records clearly identified that all members of staff have been present during fire drills as recommended by the Fire Prevention Officer. Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 25 Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 26 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 x 3 Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 27 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. Refer to Standard Good Practice Recommendations Penhill Residential Home DS0000026623.V378392.R01.S.doc Version 5.3 Page 28 Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. 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