Inspection on 25/04/08 for Penang

This inspection was carried out on 25th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penang 03/05/07

Penang 22/05/06

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 35 Charles Road St Leonards on Sea East Sussex TN38 0QX Lead Inspector Caroline Johnson Unannounced Inspection 25th April 2008 09:40 Penang DS0000036588.V361168.R01.S.doc Version 5.2 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.V361168.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 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.V361168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penang Address 35 Charles Road St Leonards on Sea East Sussex TN38 0QX 01424 420484 01424 429102 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) Evesleigh (East Sussex) Ltd Mr Nicholas Harmer Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Penang DS0000036588.V361168.R01.S.doc Version 5.2 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 3rd May 2007 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 bedrooms. 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. All bedrooms are single. There are sufficient toilet and bathing facilities, including a walk-in-shower on the ground floor. The organisation’s area manager uses the top floor of the home, which is unregistered, as an office and meeting room. The fees as of April 2008 are set at a flat rate of £1,063 per week for each person. 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. Minster Pathways managed the service since July 1, 2005 on behalf of the new purchasers of Communitas Ltd. The company then underwent a name change to Evesleigh [East Sussex] in mid 2006. Shares in the company were then transferred in December 2006 to Hermes Equity with a new board of directors including the existing operations director. The overall Regional management team in the organisation is unchanged with some switches of Responsible Individual and Area manager in January 2007. The home has its own MPV type vehicle. Penang DS0000036588.V361168.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 1 star. This means that the people who use this service experience adequate quality outcomes. For the purpose of this report the people living at Penang will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 25/4/08 and it lasted from 9.40am until 3.40pm. The registered manager was at the home for part of the day. Over the course of the inspection there was an opportunity to meet with four of the five residents. In addition time was spent with two staff members in private. All areas of the home were seen during the inspection. A full examination was carried out of two care plans and another care plan was partly examined. In addition records seen included; staff recruitment and training, medication, minutes of staff and residents’ meetings, menus, health and safety, quality assurance and leisure activities. Prior to the inspection user surveys and comment cards were sent to the home to distribute to residents and any visiting professionals. Only one comment card was returned. This was generally positive in all areas. One comment was included in response to what the care service does well. The comment was ‘looking after the complex needs of the patients with learning disabilities’. What the service does well: What has improved since the last inspection? Specialist advice and support has been sought to ensure that the healthcare needs of residents continue to be met and to ensure that the environment continues to meet the needs of those accommodated. The manager has commenced studying for NVQ (National Vocational Qualification) level four and Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 6 the RMA (Registered manager’s Award). A high percentage of the staff team have completed an NVQ at level two or above. The home is introducing a new system for care planning called essential lifestyle planning and work carried out to date in some care plans is of a good standard. 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. Penang DS0000036588.V361168.R01.S.doc Version 5.2 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.V361168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further work is required to ensure that the information provided to prospective residents is available in a format that can be easily understood by them. EVIDENCE: There is a detailed statement of purpose and a service user guide. The guide is in a widget format. As two of the residents use makaton this could potentially cause some confusion. Whilst it is acknowledged that extensive work has gone into preparing the guide in the widget format this is not a format that could be read or understood by any of the residents in the home. The manager advised that he would review the format used and in addition to preparing a guide using makaton he may perhaps prepare a taped version of the guide. The statement of purpose has recently been updated and a copy was received by the Commission, in advance of the inspection. A recommendation was made at the time of the last inspection that some of the aims needed to be Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 9 reviewed to ensure that they were applicable to the client group accommodated. For example the aims include caring for people with epilepsy. None of the residents have epilepsy but they do have communication difficulties and some have a visual impairment. This part of the statement of purpose has not been updated. A requirement was also made at the last inspection that the home demonstrates that they are meeting the assessed needs of residents over 65 and those that have mobility or sensory needs. The manager advised that they invited a member of the local sensory team to visit the home and that the team were satisfied with how the home manages the mobility and sensory needs of the residents. As part of this visit attention was paid to looking at the lighting facilities in the home and the layout of furniture. It was reported that no recommendations were made as a result. Two of the residents are over 65. Changes have been made to the day care arrangements of those residents over 65 in line with their assessed needs and wishes. There have been no new admissions to the home since the last inspection. A second requirement was made in relation to having appropriate individualised communication tools to assist residents in having their needs met. One of the two residents who uses makaton was in the home on the day of inspection and staff were observed communicating with them using makaton. Staff spoken with stated that they are self-taught in terms of signing. In the care plans seen there was information provided about how each resident communicates, but in relation to those residents who use makaton further work is required to clarify the signs used by both residents and to plan how communication can be developed further. A trainer had visited the home a few days prior to the inspection and had started this process. She is currently completing a train the trainer course in makaton and on successful completion she will provide training to all staff. The manager advised that as required at the last inspection a doctor was consulted regarding one resident who has a progressive visual impairment caused by cataracts. The doctor recommended that no further treatment could be provided. The Community Learning Disability Service were also involved in this decision. Penang DS0000036588.V361168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care of residents could be enhanced further if there was a consistent approach used to meet the assessed needs and wishes of the residents. Residents would benefit from being encouraged to make a wider range of choices and decisions about how they want to live their lives. EVIDENCE: Two of the five care plans were examined in detail and a third was partly examined. In each file there is an emergency grab sheet, which would be used in instances such as an unplanned admission to hospital. The grab sheets have been laminated and include detailed information about the resident. However, one key area missing form the sheet is information about how the resident communicates. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 11 The home is moving down the route of introducing essential lifestyle planning and there was a contrast in the variety of information provided in the files seen. One included very detailed information and the other less so. In one file there was information included relating to the ways in which the resident communicates their feelings, what they need to stay healthy and safe and what is important to them. Keyworker meetings had been held monthly in relation to one resident and less frequently in relation to the second. It was noted in one keyworker report that the staff member had identified in three separate reports that staff should be more consistent in completing the resident’s goal plans. When the goal plans were examined it was noted that it was the same two staff that were signing them all the time. Goals were looked at and it was found that the goals were broad and it was not very clear how much the resident could do independently and which areas they require support with. The home also needs to consider how appropriate it is to try to teach new skills to someone who is in their eighties. Risk assessments seen were detailed and had been reviewed recently. In relation to the two residents who use makaton, one resident has a large folder with symbols but there is no indication of how many of the symbols she understands. There is nothing in individual files indicating how many signs each resident knows. One resident uses a zimmer frame in-doors and a wheelchair when out of the home. There is currently no risk assessment in relation to this. Two of the residents have a visual impairment. Although both appear to manage their environment well there is no risk assessment in place to determine if there are any safety implications. There is a residents’ notice board in the corridor near the kitchen area. Here there is a variety of information on display including the minutes of a service users meeting and copies of the weekly menus. None of the residents would be able to read these documents. The minutes are not prepared using a symbol format and there is no picture menu on display. The manager advised that they are intending putting together a picture menu. Residents’ meetings are held bi-monthly. The minutes of the meetings seen were brief and not very informative. Discussion was had about the minutes and it was agreed that planning in advance of the meetings might assist staff in ensuring that a wider variety of topics are discussed and give them time to consider the types of makaton signs they would need to use to enhance conversations with residents. A staff member spoken with was able to demonstrate how her key client is able to make choices on a daily basis. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 12 A requirement made at the time of the last inspection in relation to privacy and dignity was found to have been met. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use 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. Residents have opportunities to participate in interesting and stimulating activities. Experimenting with the format for displaying menus may assist residents in making wider choices about the food they choose to eat. EVIDENCE: All the residents go to day centres throughout the week and the number of days they attend is dependent on their assessed needs and wishes. On the day of inspection one resident was at a day centre. Two of the residents went bowling followed by shopping for the house. One resident went to a music gym and the fifth resident remained in the home. Two of the residents were seen to enjoy knitting. On the afternoon of the inspection the karaoke Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 14 machine was turned on and one of the residents participated in this activity but others were seen to enjoy this activity also. An aromatherapist also ran a session during the afternoon. Three of the residents go to church on a weekly basis. Staff advised that in addition to the church service there is also a social element as they have a cup of tea afterwards in the church hall. Two of the residents go to a club one evening a week. Residents enjoy using local amenities for shopping trips, cafés, theatre, cinema and restaurants. Three of the residents have no next of kin. Staff are supporting a fourth resident with communicating with a family member who has been in touch recently for the first time. One resident has regular contact with her relatives. Four of the residents receive support from the local advocacy service and a meeting is held with them every ten weeks. Residents assist where appropriate in carrying out some cleaning duties around the home such as keeping their bedrooms tidy and helping to lay the table. There is a four-week menu on display that is changed seasonally. There is a choice of main meal offered daily however it was noted that the second choice is not equivalent to a main meal. The manager advised that in practice all the residents have the main meal and the second choice is to generally offered if a resident did not feel up to eating a big meal. A picture menu chart is to be drawn up to enable residents to make more choices about food options. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements in place to ensure that residents’ healthcare needs are addressed are good and the home promotes a healthy lifestyle. EVIDENCE: A requirement was made at the last inspection in relation to one resident’s health needs. The manager advised that in relation to this resident there are often no triggers to behaviour but the home have a number of strategies in place to ensure their comfort and hopefully prevent problems occurring. One such measure is ensuring regular chiropody. One resident has recently seen their gp regarding their health needs and a dietician also visited the home and provided advice and support. Another resident’s medication has been reviewed and the dosage of one long-standing medication has been halved. There was evidence in the care plans that Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 16 arrangements are made for residents to attend a wide range of health care specialists in line with their individual needs. The arrangements for the storage and handling of medication were examined and were in order. Every two years staff completed a medication course and there is an annual refresher. It was reported that all new staff are assessed in-house until they are deemed competent in medication administration. This is an informal assessment so there were no records in place to demonstrate this practice. A member of staff spoken with advised that as a result of her NVQ training the home have now adopted a new practice when administering liquid medication. Staff observed in the course of their duties were seen to treat residents with respect. Residents’ wishes in relation to dying and death have yet to be assessed. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place ensure that any complaints, and any suspicion or allegation of abuse would be dealt with appropriately. A more user-friendly complaint procedure would enhance this further. EVIDENCE: There is a detailed complaint procedure in place. Although the complaint format is available in a widget format, as stated previously, this will need to be adapted to meet the needs of the residents accommodated. The manager advised that no complaints have been received by the home since the last inspection. The home has an updated copy of East Sussex multi agency guidelines on the protection of vulnerable adults. No adult protection alerts have been made by the home since the last inspection. All staff receive training on the protection of vulnerable adults. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 People who use 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. Residents live in a home that is well maintained and decorated to a good standard. EVIDENCE: A full tour of the building was carried out. The majority of the bedrooms are large and airy and have been personalised by the residents. One resident has lots of sensory equipment. It was noted that there were door wedges inside one bedroom door. The manager asked that they be taken away. A new kitchen was installed last November and the manager advised that environmental health officers visited and were happy with the facilities Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 19 available. There is a large lounge area and a separate dining room. Both areas are decorated to a very good standard. Quotes have been obtained to refurbish one of the bathrooms and the home is currently awaiting approval for this work to be carried out. The intention is to replace the current bath with a parker bath. This will obviously be in line with meeting the needs of an ageing client group. There is an assisted shower in the ground floor of the building. On the first floor there is also a small lounge that was being redecorated at the time of inspection. This will be used as a music room. The home has access to a private park across the road from the home. The manager advised that they make more use of this during the summer months. There is also a large garden area both to the front and rear of the property. Since the last inspection a new ramp has been put in, in one part of the garden to make it more accessible. There is a barbeque area in the garden for use during summer months. A requirement was made at the last inspection that the premises be assessed by an Occupational Therapist or other suitably qualified person to advise if any necessary adaptations need to be made. The manager advised that they made contact with an OT who advised that they don’t visit unless there are specific issues identified with an individual. One resident has moved to a ground floor room and the home ensures that they have a commode at night. All residents are able to mobilise freely about the house. Where it has been identified as needed then grab rails have been positioned. It was reported that one resident was given a white cane to assist with mobility to their visual impairment. The resident refused to use the cane. As stated previously a staff member from the sensory team visited the home and looked at the building in relation to the lighting provided and the layout of furniture. No further recommendations were made. All areas of the home seen during the inspection were clean and fresh. All staff receive training on infection control. Laundry facilities include a commercial washing machine with a sanitary cycle and there is a large tumble drier. All cleaning equipment is kept locked in this area. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use 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. Good training opportunities ensure that staff remain equipped to meet the majority of the needs of the residents accommodated. Training in communication would enhance this further. EVIDENCE: A requirement was made at the last inspection that all staff receive suitable training in communication techniques appropriate to the needs of the residents accommodated. There is a makaton folder in place including all makaton signs. It was noted that staff signed it in 2006. Staff spoken with confirmed that they are self-taught in this area and no formal training has been provided. As stated previously a representative from the company is currently undergoing a train the trainer course on makaton. Once this has been achieved training will be provided to all staff. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 21 The staff-training matrix showed that the majority of staff are up to date in relation to mandatory training. Training is booked to cover any areas where there are shortfalls. Five staff have completed NVQ (National Vocational Qualification) level 2 and one staff member level 3. Staff recruitment records were examined and it was noted that the home had been thorough in their procedures. New staff complete an in-house induction and following this they then complete the common induction standards. Records showed that some staff did not receive regular supervision over the past year. The manager acknowledged this and advised that they are now getting back on track with this in that all staff had received a supervision session within March. A staff file was examined and it was noted that there was one supervision record. The matrix was showing that there were two further supervisions but there were no records of these meetings on file. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place for reviewing the quality of care provided could be enhanced further to take account of the aims of the home and what it has been set up to achieve. EVIDENCE: The manager is currently studying for NVQ level four. Staff spoken with stated that they find the manager supportive. They also stated that they are happy with the level of staff training available to them. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 23 Staff meetings are held on an infrequent basis but records showed that the last meeting was held in March 2008. During that meeting a new in-house medication policy was discussed with staff. As part of the home’s quality assurance system the manager advised that satisfaction questionnaires have been distributed to the relatives of the residents and the home are currently awaiting feedback on the outcome. Last year the advocacy service supported residents to complete satisfaction questionnaires. Monthly audits are carried out in respect of the management of medication. It was reported that care plans are also audited regularly but this is an informal process so there are no records to demonstrate this. However, as part of the monthly visits care plans are examined by an external manager to ensure they are up to date. A designated person visits the home on a monthly basis to report to the proprietors on the running of the home. It was noted on the last report that three recommendations from the previous report had been repeated. However these had been completed at the time of this inspection. A requirement was made at the last inspection that the monthly visits show evidence of how quality of care is measured and that reports make specific reference to the performance of the home in meeting outstanding requirements and how the organisation is supporting the service. It was noted in the records for the monthly visit carried out following the home’s receipt of the inspection report that reference was made to how the home would be addressing the requirements. No further reference was made within the subsequent reports on progress in these areas. There was also evidence that the requirements had been discussed at a staff meeting held in June 07. The AQAA (Annual Quality Assurance Assessment) was received by the Commission following the last inspection. Many areas of the AQAA were not properly completed and a requirement was made that a new AQAA be submitted showing greater detail. Following discussion with the manager regarding this, it was thought that there was some misunderstanding about what was actually required and the manager had thought that this requirement had been addressed. However, a new AQAA had not been submitted. A further AQAA will be requested within the next year. At the time of the last inspection a requirement in relation to the statement of purpose had been changed to a recommendation to acknowledge the work carried out to update the document. However it remains of concern that although the document has been updated the aims of the home remain the same. As the majority of the residents have communications difficulties, it is of concern that this is not highlighted in the statement of purpose and also that there is a lack of emphasis on assessment of residents’ abilities and needs in this area. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 24 Two requirements made repeatedly at previous inspections relate to firstly ensuring that there are appropriate communication tools in place to assist residents in meeting their needs. The second relates to staff receiving suitable training in communication techniques. These requirements have been altered on this occasion to acknowledge that a small amount of progress has been made in this area. However, it is disappointing that further progress has not been taken by the organisation to improve in this area. Prior to the inspection user surveys and comment cards were sent to the home to distribute to residents and any visiting professionals. Only one comment card was returned. This was generally positive in all areas. One comment was included in response to what the care service does well. The comment was ‘looking after the complex needs of the patients with learning disabilities’. A range of health and safety checks are carried out on a monthly basis and it was noted that a committee meeting was held on 6/3/08. Records showed that testing in relation to fire safety and monitoring of water temperatures were up to date. Some maintenance issues were highlighted and records showed that appropriate action was being taken to address. Accident records were seen and were sufficiently detailed. Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 25 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 2 2 2 3 X 4 X 5 X 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 2 2 X X 3 2 Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1a) Requirement The registered person must ensure that the aims of the home included in the statement of purpose are reviewed to ensure they are appropriate to the client group catered for. The registered person must ensure that a full assessment is carried out in relation to two residents’ use of makaton and how this can be developed further. Goals in care plans must be specific, measurable and appropriate to the needs and age of the residents. Risk assessments must be drawn up in relation to residents’ mobility problems or any problems associated with their visual impairments to ensure that all safety arrangements that need to be in place have been taken. The registered person must ensure that as far as it is possible to, an assessment be carried out in relation to residents’ wishes in respect of dying and death. DS0000036588.V361168.R01.S.doc Timescale for action 30/06/08 2. YA2 14(1a) 30/06/08 3. YA6 15 15/07/08 4. YA9 13(4a,c) 30/06/08 5. YA21 12(3) 31/08/08 Penang Version 5.2 Page 27 6. YA35 18(1c) The registered person must ensure that all staff receives formal training in the communication techniques used by the residents. 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA1 YA6 YA8 YA39 Good Practice Recommendations The service user guide should be available in a format appropriate to the needs of the residents. The emergency grab sheets should include information about each resident’s ability to communicate. The home should review how residents’ meetings are planned to make them more productive. The home’s quality assurance system should be expanded to include a written record of the audits carried out in relation to care planning and in-house assessment of competency of medication management. Consideration should be given to adapting the Regulation 26 monthly reports to record progress made with achieving requirements of inspection reports. 5. YA39 Penang DS0000036588.V361168.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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