CARE HOME ADULTS 18-65
Penberth House 29 Penberth Road Catford London SE6 1ET Lead Inspector
Kate Matson Unannounced Inspection 14th November 2005 10:00 Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 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 Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 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. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Penberth House Address 29 Penberth Road Catford London SE6 1ET 0208 6974430 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) Ms Jenny White Ms Jenny White Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st January 2005 Brief Description of the Service: Penberth House is a small care home registered for three people. It is an older house that has been extensively modernised and decorated to a high standard. The property is well located in terms of community facilities; it is well served by public transport and local shops, both within a short walking distance of the home. The home offers single bedroom accommodation with adequate communal space including a garden at the rear of the home. Penberth House was initially registered for service users with learning disabilities; however, no service users were admitted and the registered provider/manager successfully applied for a variation of registration to provide care for people with mental health problems. The first service user moved in a month prior to this inspection. The registered provider/manager currently lives at the home and has two other vacancies. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was the first one to be carried out since a service user was admitted to the home four weeks earlier. The inspection included discussion with the service user, a visiting relative, a staff member and the registered provider/manager; a tour of the premises and examination of the service user’s personal file, a staff file and other records. The service user had lived at the home for only four weeks so many systems were still being developed and will be examined closer at the next inspection. What the service does well: What has improved since the last inspection? What they could do better:
Care plans needed to cover all areas of need and identify steps needed to meet the identified goals; however, it is acknowledged that the service user was still settling in and the provider/manager confirmed that care plans were still being developed and confirmed that they would be completed as required. The laundry facilities are sited in the kitchen, which does not meet national minimum standards and the provider/manager had not yet implemented a recommendation from the last inspection to consult with the environmental health department about this issue. However, she stated that she would, now that a service user lives in the home. Although the manager had developed a recruitment policy in accordance with equal opportunities, she had not followed it, as the people she had employed
Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 6 did not have all of the required documents in place because the manager knew them. Although she confirmed that all checks would be carried out in future recruitment she was not aware of the POVA list (list of people considered unsuitable to work with vulnerable adults) and the responsibilities this places on her. This must be addressed to ensure the protection of service users. The home’s training was still under development but the manager had not contacted Skills for Care to ensure that the homes induction and foundation training met with sector skills specifications. The health, safety and welfare of service users are protected though an inspection from the fire brigade is still needed and electrical appliances must be tested annually. 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. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 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 Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 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): 2 The needs of service users are assessed before they are offered a place to ensure that they can be met. EVIDENCE: At a previous inspection, it was noted that the pre admission questionnaire was of a basic tick box nature, and did not allow room for additional comments, or cover cultural, religious or specialist needs that a service user may have or give an indication of how the service user would be involved in the assessment process. The registered provider was required to ensure that the homes pre assessment procedure covers all sections listed in Standard 2, to ensure that the home is able to meet the needs of prospective service users who do not have a full Care Management Assessment / Care Plan. At this inspection the service user who had recently been admitted confirmed that the registered provider had visited him in his previous accommodation and that he had visited the home prior to moving in. On the service users file was an application completed by the referrer and an assessment completed by the home including a risk assessment. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 9 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 and 9 As the service user had only recently moved in, the care plan was still under development. Service users make their own decisions as far as possible. Risks are identified and managed. EVIDENCE: The personal file of the service user was examined. This included some specific goals that had been identified by the referrer and the home to work on. The registered provider/manager confirmed that the care plan was still very much under development and she was trying to involve the service user in its development. She confirmed that she would ensure that when complete, it would evidence the service users involvement, cover all areas of need and outline the steps needed in order to achieve the goals. The service user confirmed that his right to make his own decisions was respected though he was not happy that he had to inform the staff if he was going out, if he would be back late. However he confirmed that the reasons for this had been explained to him before moving in. He manages his own money. The provider/manager had included risk issues as part of the assessment process and had assessed risk in relation to a number of areas. Contingency plans were in place for if a risk should arise.
Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 10 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): 13 and 15 Service users are part of the local community. Service users are supported to have appropriate relationships. EVIDENCE: The service user confirmed that he uses the local community. He has a pass to enable him to use public transport free. He uses local shops, cafes and restaurants. The registered provider described how she is keen to encourage service users to leave the home and staff have been regularly supporting the service user to shops. The inspector spoke with the mother of the service user who has been a regular visitor to the home. She said that it was still early days but that so far she had no problems with the home. She said the home were in regular contact with her. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 11 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): 21 Ageing, illness, and dying are discussed with service users on admission to the home to ensure that they are dealt with as the service user would wish. EVIDENCE: At a previous inspection the registered provider was required to produce policies/procedures relating to dealing with ageing, dying, death and final wishes of a service user. At this inspection it was noted that the service users assessment had included discussion around this and the service users wishes had been noted. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 12 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): Both of these standards were considered met in the last inspection EVIDENCE: Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 13 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, 27, 28 and 30 The home is homely, comfortable and safe. There is adequate communal space including a family bathroom. The home is clean though the provider/manager has yet to consult the environmental health department about the laundry arrangements. EVIDENCE: The home is suitable for its stated purpose and located close to public transport and community facilities. It is in keeping with the local community and does not stand out as a care home. The home is well maintained and decorated and furnished in a comfortable and homely way with good quality furnishings. The accommodation comprises of three single bedrooms of adequate size and a large sitting/dining room, a kitchen, family bathroom, and a garden at the rear of the property. The registered provider had carried out a risk assessment to ensure that the service user could regulate water temperatures for himself as required by a previous inspection. The home was clean and tidy throughout. There is an infection control policy in place. Laundry facilities are located in the kitchen, which means that laundry has to be carried into an area where food is prepared and cooked. At the last inspection it was recommended that the registered provider seek advice from
Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 14 the environmental health department about the laundry arrangements in the home. At this inspection the provider/ manager stated that she had not done this yet but would do so now that a service user had moved in. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 15 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, 34 and 35 Although the staff team is still under development, the current staff team is qualified to national minimum standards. The provider/manager needs to increase her knowledge of issues affecting recruitment practice. The home’s training programme is still being developed. EVIDENCE: The provider/manager stated that she has a team of four staff though so far she has only used two of them. Both of these staff members have NVQ level 3 and the certificate for one of these was seen. The provider/manager stated that she would like all of her staff to have NVQ qualifications and would ensure that at least 50 of them do. At a previous inspection the registered person was required to ensure that the home has a thorough recruitment procedure, based on equal opportunities and ensuring the protection of service users, prior to the recruitment of any staff. At this inspection the procedure was examined and met the requirement. However the staff so far employed were known to the provider/manager and as a result the recruitment procedure had not been followed. There was only one staff file available and this included only one reference and a check with the criminal records bureau (CRB) that had been made in 2003. The provider/manager stated that she would ensure that references and CRB checks are conducted before new staff start work and that all staff files would include all of the documents required by Regulation 19 (Schedule 2). The provider/manager was not aware of the POVA list (list of people considered
Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 16 unsuitable to work with vulnerable adults) and she must obtain information on this to ensure she is aware of the responsibilities this places on her. As staff had only commenced work a month previously the provider/manager was yet to produce a training plan for the home but confirmed that this would be done based on the needs of staff and the service. At the last inspection it was recommended that the registered provider access the necessary documentation from TOPSS (now Skills for Care) to ensure that induction and foundation training complies with National Training Organisation requirements. At this inspection the provider/manager had not done this and although new staff had been given a two-week induction this was not in accordance with Skills for Care standards. Contact details of Skills for Care were given to the provider/manager and this is now a requirement. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 17 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, 40 and 42 The manager is experienced and competent to run the home. The home has appropriate policies and procedures in place. The health, safety and welfare of service users are protected, though an inspection from the fire brigade is still needed and electrical appliances must be tested annually. EVIDENCE: The registered manager has worked for many years in a variety of care settings and has experience of working with service users who have mental health difficulties and service users who have a learning disability. She has a care qualification (Certificate in Social Services) and is currently completing the management qualification; level 4 NVQ in Management. A previous inspection required that the registered person make available for inspection all evidence of her relevant qualifications and training. At this inspection the manager had produced a personal file including details of her qualifications. The registered person was required at a previous inspection to ensure that all the policies and procedures outlined in Appendix 2 of the National Minimum Standards for Adults 18 - 65 (2nd Edition) are produced. At this inspection it was found that all of the topics listed were covered if not in a specific policy
Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 18 then in other documents such as the statement of purpose, service user guide or service user contract. The registered person was previously required to display fire exit signs, install smoke detectors and fire extinguishers in consultation with a fire officer. Fire exit signs, smoke detectors and fire extinguishers have been provided and the provider/manager informed the inspector that she has recently been in touch with the fire officer in order to arrange an inspection. The fire alarm was being tested weekly as required and the provider/manager stated that fire drills would be held at least four times a year. A food hygiene inspection in July 2004 raised no issues. The gas and electrical installation certificates were current though it was noted that portable electrical appliances had not been tested annually as required. This must be done in order to protect the health and safety of the service users. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 1 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Penberth House Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X 1 X DS0000028074.V254344.R01.S.doc Version 5.0 Page 20 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 YA34 Regulation 12(1)(a) & 19(1) (b) 18(1)(a) Requirement The registered provider must obtain information about the POVA list to ensure that she is clear about the responsibilities this places on her. The registered provider must ensure that the homes induction and foundation training is to sector skills specifications. The registered person must display fire exit signs, install smoke detectors and fire extinguishers in consultation with a fire officer (previous timescales of 30/05/04 and 31/05/05 not met though only consultation with fire officer still outstanding) The registered provider must ensure that portable electrical appliances are inspected annually and certificates of safety are available for inspection. Timescale for action 31/01/06 2 YA35 31/03/06 3 YA42 23(4)(a) & (c) 31/01/06 4 YA42 23(2)(c) 31/01/06 Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 21 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 YA30 Good Practice Recommendations It is recommended that the registered provider seek advice from the environmental health department about the laundry arrangements in the home. Penberth House DS0000028074.V254344.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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