Inspection on 22/05/06 for Penang

This inspection was carried out on 22nd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penang 25/04/08

Penang 03/05/07

Penang 20/10/05

Penang 14/04/05

Penang 06/12/04

Penang 20/07/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Penang Charles Road St Leonards on Sea East Sussex TN38 0QX Lead Inspector Unannounced Inspection 22nd May 2006 09:30 Penang DS0000036588.V291435.R01.S.doc Version 5.1 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 Penang DS0000036588.V291435.R01.S.doc Version 5.1 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 Adults 18-65. 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. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Penang Address Charles Road St Leonards on Sea East Sussex TN38 0QX 01424 420484 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) Communitas Limited Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is six (6) Residents must be aged between eighteen (18) and sixty-five (65) years on admission Residents with a learning disability only to be accommodated Date of last inspection Brief Description of the Service: Penang is a care home registered to provide services for 6 adults with learning disabilities. The home is located in a residential area of St Leonards-on-Sea, close to local transport and amenities. The sea front is approximately 2 miles away. The home is large with mainly spacious rooms. The home has three floors although the registered service user accommodation is set over the ground and first floor only. There is a front and rear garden although the rear garden is not currently not accessible or maintained. All bedrooms are single. There are sufficient toilet and bathing facilities, including a walk-in-shower on the ground floor. The Organisations day centre used by some residents for activities, and staff training with no plans for a replacement venue. The home has been without a Registered Manager for over 3 years although at the time of the inspection the current acting manager was preparing an application. The fees charged are at a flat rate of £990.84 per week for each person with socials services not paying any individual variation. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. At the time of the inspection the managing company- Communitas was undergoing a proposed name change to Evesleigh [East Sussex] with the current ownership remaining unchanged from that of July 1st 2005 when Minster Pathways bought share ownership in Communitas. The home has its own mini-bus type vehicle. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 9.30am and 2.30pm on 22 May 06. This inspection focused on the key major areas such as the management, who the home intends to provide care for how care is planned and delivered, activities and lifestyles, the environment and staffing of the home, along with how concerns are dealt with. Discussions with management looked at the future purpose of the home such as the admittance process and staff training plans. The entire home was toured. Meal’s, complaints, Staffing and management, including quality measures for Residents, was looked at. Pre-inspection information and survey cards sent to the home the previous month to be circulated to residents and relatives had not been returned to the Commission prior to the inspection. The inspector spoke with relatives, advocates, and social services following the home visit. Two inspectors carried out the inspection visit due to concerns about the management of the home in recent years and some poor areas especially activities, and compatibility issues linked to a diverse range of people. A monitoring visit by the same two Inspectors on 22 March 06, indicated continued concerns although the introduction of a new permanent manager from April 06 was confirmed The focus of the inspection was looking at three Resident’s two who are over 65 years of age, and two who have lacked activities and attention. Some diversity and equality areas were explored in relation to lifestyles to test what opportunities are provided for Residents. The inspector’s spoke with and observed all 5 Residents and looked at the care records. One outcome area is Good, five Adequate [ok] and two areas Poor, and in need of major improvement. What the service does well: What has improved since the last inspection? Less able residents are now for the first time receiving regular activities and a routine, which is generally now being followed. The home is starting to receive Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 6 more management direction and more attention from the organisation after the home went backwards for a period when the previous area manager and the homes acting manager left the service at the end of 2005. This recent progress which has been evident since the Commission wrote to the service following concerns from a visit March 22, 06, needs to be maintained and improved upon as most areas still need improvement to meet a basic standard. staff training is gradually improving as is the organisation’s understanding of the needs of current Residents. The new manager who has relevant experience is starting to action clear plans, based on improving outcomes for residents and staff who are being better supervised and consulted with. The environment of the home has further improved to reflect Residents needs. Each resident now has a signed contract/agreement. 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. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3, & 5. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Information about the home continues to be confused and lack accuracy, comprehensiveness, and is inaccessible for people using the service. The home continues to attempt to provide care for a wide range of diverse needs with no measure as to how, and if, these diverse needs are being met The home needs to have a clear statement of purpose and admissions criteria, which reflect service provision, so protecting the right of existing service users to live with people who have similar needs and interests. EVIDENCE: The inspector looked at the home’s [service user/ Resident’s] guide, which also contains the statement of purpose, which is on display in the home’s reception area. The most recent inspection report was no longer found to be on display. The guide and statement of purpose was the same version given to the Inspector at a meeting at the Commission’s local office on May4, 2006. The manager stated that he had worked on the guide whilst the area manager had done the statement of purpose. The home were again reminded that both documents should be combined into one to reduce confusion in line with the regulation. The Statement of Purpose was found to be out of date and referred to the previous organisation. The Statement of Purpose is also a generalised Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 9 company document which does not refer to the individuality of the home called Penang, or describes the current service user group it is currently providing care for. The same comments about the statement of purpose are repeated from the last inspection: The Statement of Purpose needs to be tightened and clarified to confirm what needs it can meet and what type of service user it would consider accommodating in line with the homes admissions criteria. The manager was advised to rewrite this document and be specific about what level of learning disability it will attempt to provide a services for. The homes statement of purpose describes the home as being over 3 stories without stating that only the first two stories are registered and that the third floor is now used as a area office where access is through the home’s front entrance. The Statement of Purpose was not accessible for current service users written purely in a typed format. The service user guide was more up to date and used Symbols to convey information although it was agreed that at least 3 of the current 5 service users would not understand it. A confusion arose due to the fact that the previous acting manager sent the Commission an improved service user guide incorporating the Statement of Purpose in August 2005.Although this document lacked clarity about future admissions and the future purpose of the home, it did contain photographs throughout and was an excellent attempt to communicate basic information to all service users, in the absence of a talking tape for the blind service user. This copy was not found in the home and the current manager stated that he had not seen it or had been given it by the area manager. The inspector therefore gave the home the Commission’s copy as a starting point. Two service users are over 65 years of age in a home registered for younger adults. Social services reassessed them in 2004 and deemed that the home could be suitable subject to a range of improvements to the environment and staff training. These recommendations have not yet taken place with only a start made. The home are again advised to confirm in writing that they can meet needs, subject to a review with social services and other relevant specialists such as occupational therapists and visual impairment services. Some initial work was found to have started on communication aids although it was observed that no aids were being used to communicate with service users during the inspection. One had an aid in their room and one had aid in the lounge although the inspector found that the intended service user did not find the aid suitable apart from recognising Christmas shopping. A Personal care task that of supporting someone to eat was observed to be done in silence. Contracts/ service user agreement’s were found to have now been signed and had all necessary information. The independent advocate For the home was found to have gone through the questions with each service user over a series of visits and had also signed these documents. The advocate also confirmed her involvement in discussions following the visit with the inspector. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Care-Plans though containing a good range of information, which is well, organised and kept up to date, goals need to be reviewed to ensure they are based on individual’s diverse aspirations and potential. Some information such as risk assessments need to be completed Resident’s benefit from a good amount of independent advocacy, which operates effectively, and regularly, on their behalf. EVIDENCE: The Inspector’s examined 3 Care plans, which were found to be accessible, clear and frequently reviewed. The plans showed clear evidence of key worker involvement and staff were found to have basic working knowledge of these plans. Guidelines for each service user were good and up to date with realistic short and long-term goals although there was no mechanism on a regular basis of assessing whether these goals were being achieved apart from reference at annual reviews. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 11 All care-plans were found to have some input from specialists and since the last inspection were found to be better and logically organised with all relevant information including assessments enclosed. The manager agreed that further work is needed in relation to developing aspirational goals for service users which have meaning to them and which are not simply based on personal care guidelines. Risk assessments for two particular service users had good guidance information but were not complete in relation to assessing the risk [severity and frequency] in inform staff of the likelihood of the event occurring and what the consequence could be to ensure they are not at undue risk. Daily recording notes are generally complete and informative and linked to care-planning goals and guidance as well as activity schedules such as church on Sundays. All service users were found to be well-presented and wearing clean new clothes with clear time allocated to meeting basic care needs. The manager indicated that he was unclear having just joined the home the extent to which speech and language recommendations were being actioned for affected service users. New referrals have been made along with to liaise with social services and others specialist by carrying out a review of needs for those with communication needs including the two people over 65. All service users were found to have fortnightly visits from their designated external advocate with all service users having written records of the outcome of these visits. More recently the advocate has been supporting service users to understand and sign their contracts as well as discussing how activities are meeting needs. This is especially important as only one service user has any family involvement. This area of the home’s provision was found to be exceptional with the advocate noticing signs of improvement and a busier more active home with staff accommodating and positive with one staff person identified as a good communicator with service users. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12, 13, 15, 16, & 17. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Regular Meaningful and wide ranging Activities are now for the first time taking place for everyone with more attention to diversity. All Service users are beginning to develop good structured routines based on their aspirations. Meal arrangements and leisure opportunities are satisfactory. EVIDENCE: The Inspectors purposely arrived at 9.30am and found that everyone was in the final stages of being supported to go out with clear routines and plans in place based on service user choice. This was a different picture to that on the most recent monitoring visit of March 22, 2006 when staffing levels and decision making was preventing two particular service users from attending their chosen activities. One of these service users has been attending a new day centre 3-4 times a week since the last inspection with this now occurring Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 13 regularly as seen in records. This new centre was found to be meeting his needs as confirmed in discussions with the person and his advocate. The placement had been organised by the previous acting manager. Another person that attends day centres less frequently than the other service users was found to now go swimming twice a week. It was positive to find that the diverse wish for three service users to attend church was now occurring as confirmed by records, on most Sundays. All service users were found to have clear activity programmes which were being followed now that staffing levels are more consistent with staff more closely supervised with the manager now assisting where necessary. The manager was made aware of continuing this recent progress and exploring further evening and week-end opportunities based on service user preferences and ensuring that all staff are led by agreed programmes. It was evident that one service user relates more to staff than peers who are less able and do not have her communication skills. The development of peer relationships was identified as a developmental goal. Visitors confirmed that they are treated with courtesy and respect. Meal arrangements were again found to be good and based on choice within these recorded and additional alternatives offered. The home was found to have good supply of fresh food including fruit and vegetables. One service user has a goal that of developing the skill of being able to feed themselves. During the inspection it was observed that staff were doing the entire task for him, and in silence. It was explained to the manager that stepby-step guidelines should be developed to support this goal. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, & 20. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Resident’s basic health needs are closely monitored and met Medication arrangements are with one exception, soundly managed. EVIDENCE: The medication cabinet was examined along with all records. All aspects of storage and administration was found to meet the standard and best practice. All homely remedies were labelled and accounted for on recording sheets. Staff interviewed were found to be knowledgeable about all aspects of medication including what each drug is for. All staff receive appropriate training before being assessed to be able to dispense medication. On the day of the inspection three gaps on medication recording sheets where noted with no evidence of any confirmation that this medication had been given or any remedial action taken. It was equally concerning that a staff member offered to sign on behalf of someone that had given someone medication on the day of the inspection. It was therefore made a requirement that the sheet is signed once medication has been absorbed. Health needs such as medication reviews, dental check ups where found to be recorded and regularly reviewed. A staff member stated that that they had been told that a service user who has been Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 15 previously and recently confirmed as blind does in fact have a visual impairment, which a cataract operation could reverse. The manager was asked to clarify the diagnosis to the staff team to assist the meeting of his needs. Personal care was observed and recorded to be in keeping with people’s personal preferences. The manager was advised to remind staff to be more discreet when asking service users to go to the toilet as at one point the inspectors and other service users could hear from the lounge someone being asked this question whilst in the outside hallway. Overall staff support to service users was unhurried, warm, and respectful. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, & 23. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The manager of the home responds to concerns and complaints in an open and effective manner. EVIDENCE: There has been just one formal complaint made against staff in relation to the care of service users over the last 3 years. This complaint was communicated directly to social services and concerned how a staff member spoke to a service user. The staff person concerned was working a period of notice at the time of the alleged offence and no longer works in the home. The only other concern expressed to the home related to a staffing concern about the performance of a senior with this addressed by the management of the home with some positive results. The home was described as open and approachable by visitors with a clear complaints procedure in place with some attempt to make this accessible to some of the service users with the use of symbols. Monthly service user meetings have just started in the month of the inspection where the manager hopes that service users will develop skills and confidence in airing any views. All regular staff have received adult protection and prevention of abuse training and again confirmed through discussions how to both identify and report suspected abuse. The home’s policy in this respect is regularly updated. Despite the diversity within the service user group it is positively noted that no service users are at an obvious risk of being harmed by others as seen in the continued absence of such incidents. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,29, & 30. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. A homely environment has gradually been achieved over the last 18 months with all service user bedrooms highly personalised and suited to needs Confirmation is needed that works done to gardens have created safe access and when the gardens will be made attractive area to use. An Occupational Therapist assessment of the building including bedrooms is necessary for those service users who have specialist needs. EVIDENCE: The inspector toured the home and found that all service user’s bedrooms had now been personalised to a high standard with new furniture including comfortable chairs, new wardrobes, and audio/visual equipment, with decoration according to resident’s preferences. Some recent attempts to make some bedrooms more suited to needs has been achieved. Visitors remarked positively on these changes. The home was found to be in the process of putting up pictures of service users along with other homely touches. The new laminated flooring around the ground floor of the home was found to be Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 18 modern and suited to purpose. The dinning room has been further improved with plans to replace the kitchen. The front and rear gardens are large but were again found to be poorly maintained and overgrown, despite being the beginning of Summer. On a positive note some attempt has been mad to create level access with two ramps created to facilitate wheelchair access to the rear garden. The manager was unable to confirm whether the ramps are fit for use and could be safely accessed by the service user who use a Zimmer frame. The inspector was unable to verify due to their unique design and rough and uneven finish whether they were fit for use. The home are therefore required to confirm whether the work is finished and when the gardens will be made attractive so that service users might be inclined to access them A newly admitted service user with mobility needs has not had an occupational therapy assessment to ensure that all adaptations are in place. This also applies to another resident who is blind. The manager confirmed that he believed that these people are on a waiting list. A fire door leading from the kitchen was found to be wedged open with the manager advised to immediately ensure fire safety compliance. The manager is awaiting a auto closing door mechanism. The home was found to be clean, bright, warm, and free from offensive odours. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35, & 36. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that there is sufficient number of staff, who are also experienced on duty to meet assessed needs. Staff training needs to improve to ensure staff are sufficiently aware of how to meet needs with training specific to the home’s needs. Staff will benefit from being regularly and effectively supervised Tight recruitment procedures are followed. EVIDENCE: The recent monitoring visit on March 22, 2006 showed that the shift was one staff down leading to some activities not taking place which was further affected by one staff being too inexperienced to support other planned activities. The day of this inspection showed that enough staff were on duty with skills to meet basic needs and planned activities. The rota showed that at times such as 12/04/06 that there are still instances of inexperienced and insufficient staff with no experienced team leader on shift although in this instance activities still took place as per schedule. The related concern on this day was that the Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 20 flexi had not had Police CRB check returned [still the case] and so needed to work under constant supervision meaning that this shift was one staff down from the standard 3 per shift to meet needs. There is too over reliance on flexi staff and those from other homes to make up numbers. Team leaders were found to have development needs and have required recent guidance to fulfil their job roles, which involves supervising other staff. Tight recruitment procedures are followed with the manager fully aware of what is required. No new staff have been employed since the last inspection with a flexi person undergoing all necessary checks. Less than 50 [10 ] of the full care staff team have at least National Vocational Qualification level 2. However 5 staff were described at being in the final stage of their National Vocational Qualification 2 course so that the target should be reached before the end of the year. A company-training officer has started since the last inspection that organises general training which the home accesses. The questionnaire sent to the home prior to the inspection had not been completed so the home was asked to confirm training plans following the visit. The manager confirmed that no formal communication training had taken place since the last inspection. A Makaton stage 1-9 book has been introduced which staff sign. One of the staff embers on shift was found to be using Makaton with one service user as an effective means of communication and having an conversation. The manager confirmed that enquires for communication training is ongoing. Clarity around the home’s Statement of Purpose should further ensure that training is specific to needs No staff [with one exception] were found to have received supervision this year until March 13 and all staff just one supervision by May06. The new manager has identified this weakness and developed a written schedule to ensure that supervisions now occur at the required rate. Team leaders are also receiving additional training and support to ensure that supervisions are done correctly with the manager planning to sit in on some. All staff employed during the last 2 years have experienced 3 week Induction’ from the previous organisation which covered TOPSS, all mandatory training such as Moving and handling, food hygiene and First aid, and the foundational course level 2 in Care Practice, which leads to an NVQ 2. An in-house structured written induction is undertaken in the home. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, & 42. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has been poor and ineffective since the last inspection although progress is evident over the last month leading to improved outcomes for service users. There are a high number of requirements some which date back several years which will need a focused management approach and permanent management arrangements to address as continuous changes of management has undermined occasional progress. The overall organisation needs to demonstrate how it is measuring and contributing to the quality of service to the Residents. EVIDENCE: An experienced manager has left along with the previous area manager who effectively supervised the home and knew all the service users for many years, Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 22 since the last inspection. Ineffective management arrangements have been in place from the period between January and April resulting in information such as previous services user guides being mislaid and a lack of knowledge about how existing requirements were being met. The present manager has inherited this unhelpful situation but is positively making progress since April in focusing the home and ensuring that service users have active and rewarding lifestyles and that staff are better monitored and supervised. This manager is experienced and is working towards the required qualification. The manager is currently organising an application to be registered and has been given an extended deadline to do this. The home has not had a registered manager in post for over 3 years and urgently needs to ensure that this situation is rectified so that the home can move forward on a clear footing with a clear sense of direction. Section 26 monthly reports of inspections of the home by the organisation are sent to the Commission on a monthly basis within two weeks of the actual visit date. These reports need to be more comprehensive and make reference to the views of Residents and staff in relation to the overall quality of care being provided. Some attempt should be made to measure the quality of care to those who lack verbal skills to express this. Subsequent discussions with the new area manager have indicated clear plans to address this in line with effective quality assurance. Evidence was found to show an recent survey of service users views via a symbol form questionnaire which the advocate was brought in to help service users answer questions. The manager was made aware that information which is collected from service users needs to be followed up and form the annual development plan for the home to show service user involvement in the homes future direction and day to day running. All regular staff were found to have all the basic health and safety training such as first aid and moving and handling. Fire training recently took place for staff. Fire drill occur six monthly with an evacuation carried out. The only shortfall was fire practice in the home with the manager asked to ensure that fire doors are not wedged open. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 1 2 3 3 1 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 2 2 X X 2 X Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 24 Yes 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 YA1 Regulation 5 & 6[a] Requirement That the Registered person must ensure That the home introduces an appropriate Service User guide. That this guide is kept accurate, and contains all necessary information with the statement of purpose contained within the guide, with all information consistent. That the guide contains the most recent inspection report and is specific to the home. That the guide is made accessible to people with learning disabilities and sensory impairment with the use of photographs and other methods such as talking tapes. That service user views are within the guide. That a copy of the guide incorporating the statement of purpose is sent to the Commission within the timescale indicated. [Requirement made at the last 7 inspections. Requirement first made October 2003] Timescale for action 22/08/06 Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 25 2. YA1 4 4[1][c] Schedule 1:8 That the Registered person must ensure that an appropriate Statement of Purpose is produced which reflects the current diverse service user group and that clarifies the intended service user group it aims to provide services to. That this statement is completed in line with a clear admittance policy detailing who will fill current vacancy[s]. 22/08/06 3. YA3 14[1][d] 2 &23[2][a] 4. YA3 121[a] That this admissions policy specific to the home is sent to the Commission by the date shown within the statement of Purpose and Service User guide. [Requirement made at the last 3 inspections. Requirement first made April 14, 2005] That the Registered person 22/08/06 must ensure That the home confirms in writing to the Commission the suitability of the 2 placements [over 65] out of category and how it will meet their needs.] That this review includes social services and all other specialists such as visual impairment and Occupational Therapy. That all current recommendations from the socials services assessment are carried out for both people such as staff training. [Requirement made at the last 5 Inspections. Requirement first made December 2004] That the Registered person 22/09/06 must ensure That service users must have appropriate individualised communication DS0000036588.V291435.R01.S.doc Version 5.1 Page 26 Penang 5 YA6 6 YA9 7 YA20 8. YA24 9 YA24 tools to assist them to get their needs met. That such aids are used in practice. [Requirement made at the last 3 inspections. Requirement first made April 14, 2005]. 15[2] That the Registered person must undertake a review of service user care-plans in respect of goal planning to ensure that they meet the individual’s aspirations and long term plans and results of any consultation. 13[4] That the Registered person must ensure that all risk assessments carried out are complete 13[2] That the Registered person 17[1] must ensure that medication Schedule 3[k] records are completed appropriately and by the person administering the medication, in a timely manner. 1612c232n That the Registered person must ensure That all service users have access to all parts of service user’s communal and private space by the provision of equipment and adaptations to achieving this. That the garden is accessible for all service users. With confirmation sent to the Commission by the date shown [Requirement made at the last 8 inspections. Requirement first made April 2003] 23[2]&[o] That the Registered Person must ensure that the external grounds [gardens] are, and appropriately maintained and are attractive. DS0000036588.V291435.R01.S.doc 22/09/06 22/08/06 29/05/06 22/07/06 22/07/06 Penang Version 5.1 Page 27 10. YA24 23[4] 11 OP29 23[2]& 12 [1][a] 12 YA33 18[1][a] 13 YA35 18[1][c] 14 YA36 18[2] 15. YA37 Sec 10.62 12[2]2 &24 Reg9 That the Registered Person must ensure that the building complies with the requirements of Fire safety by ensuring that fire doors are not wedged open [i.e. the Kitchen] That the Registered Person must ensure that the premises are assessed by an Occupational Therapist or other suitably qualified person, to advise the home on any necessary adaptations with particular reference to intended Service Users with a physical disability. Recommended at the last Inspection That the Registered person must ensure that sufficient numbers of experienced Staff are on duty at all times That the Registered person must ensure That the home ensures that all staff receive suitable training in communication techniques with adults with learning disabilities and help service users develop their own appropriate communication aids. [Requirement made at the last 4 Inspections. Requirement first made December 2004] That the Registered person must ensure that all staff are regularly and effectively supervised and that such arrangements for written supervision occur as per schedule. That the manager of the home must be registered. That a completed application is sent to the Commission by the DS0000036588.V291435.R01.S.doc 23/05/06 22/08/06 23/05/06 22/08/06 22/06/06 22/07/06 Penang Version 5.1 Page 28 16. YA39 24 17 YA39 26 extended deadline date shown. That the Registered person must ensure that a quality assurance and monitoring system based on service user views is established and shown to be effective. [Requirement made at the last 7 inspections. Requirement first made October 2003]. That the results are published in the home’s guide. That recent information collected from service users forms part of an Annual Development Plan for the home. That the Registered Provider must ensure that monthly section 26 reports show sufficient evidence of Service users experiences in order to arrive at a opinion as to the quality of the care. That sufficient numbers of service users and their advocates regardless of disability and diverse needs are included in these reports in relation to their care. That such reports are sent to the commission on a timely basis 22/10/06 22/06/06 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 YA11 Good Practice Recommendations That written guidelines are introduced, which staff refer to, in relation to supporting a particular service user in DS0000036588.V291435.R01.S.doc Version 5.1 Page 29 Penang 2 3 4 YA32 YA37 YA38 relation to independent eating skills. That at least 50 of Care staff are trained to National Vocational Qualification Level 2, by 2008 That the manager completes the necessary management qualification National Vocational Qualification level-4 CARE and Management, as soon as possible [by 2008] That the managing organisation improves the lines of communication with the home and regularly checks and verifies that existing requirements are being met. Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 Penang DS0000036588.V291435.R01.S.doc Version 5.1 Page 31 - 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. 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