Inspection on 15/10/07 for Penberth House

This inspection was carried out on 15th October 2007.

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 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

Penberth House 14/10/08

Penberth House 21/02/07

Penberth House 24/02/06

Penberth House 14/11/05

Penberth House 21/01/05

Penberth House 20/01/04

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

CARE HOME ADULTS 18-65 Penberth House 29 Penberth Road Catford London SE6 1ET Lead Inspector Sean Healy Unannounced Inspection 15th October 2007 09:30 Penberth House DS0000028074.V350898.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 Penberth House DS0000028074.V350898.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. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 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.V350898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2007 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. The registered provider/manager currently lives at the home and at the time of this inspection there were two vacancies. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The recent CSCI report is currently kept at the home in the dining room. The manager agreed to explain it’s content to service users. At 15th October 2007, the homes fees are set at between £750- per week for and £950- per week for accommodation and support. The reason for the difference is due to higher levels of support needed, sometimes up to one to one support. The referring social services authority meets the majority of these costs. There is an additional charge made for food of £25- weekly, payable by each service user. Transport is not provided by the home and any costs are payable by each service user. Residents have to pay for other personal expenses such as hairdressing and personal shopping. The provider’s email address is: j.schoeffer@btinternet.com At the time of the inspection there was one resident living at the home and two resident vacancies Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day on 15th October 2007 and was ended on the 19/10/07 following receipt of further information about health and safety. The inspection was unannounced, and was facilitated by the Registered Manager. I spoke also with the current resident who chose only to speak briefly. The resident’s file was examined to see that care needs are being planned for. One member of staff was interviewed. Five staff files were examined to see recruitment and training and supervision records. The inspection included examination of records and policies and procedures, and a tour of the building. An Annual Quality Assurance Assessment was completed and used to catty out today’s inspection. An Immediate Requirement was made at the last inspection for the home to make sure that staff were properly police checked and had proper references. This was done. An Improvement Plan was required following the last inspection with a deadline for completion of 16/6/06. This was done within the required time and all of the areas in the improvement plan were met at today’s inspection. Eleven of the fifteen requirements made at the previous inspection had now been met. The immediate requirement for the home to ensure all staff had up to date CRB checks carried out had been met following the last inspection. What the service does well: The areas assessed at this inspection showed that the home makes sure that: • • • • • Residents have a tenancy agreement when they move to the home. Residents know that their needs are being assessed and written in their care plans and they are involved in the drawing up of those plans. Residents know how to complain if they need to and can easily get to see the manager The home is clean, well decorated and comfortable throughout. It is in an excellent state of repair and decoration The Registered Manager has a high level of contact with the resident and shows good knowledge of all care needs Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The notes kept by the resident’s keyworker should be kept separate from daily records so that the homes manager can more easily monitor progress. It may also be helpful for the home to use mood charts to help with monitoring and care reviews. The home should look for a specialist dentist who is experienced in helping people who are nervous of having dental treatment. The home must have a written risk assessment agreed with the resident and with social services about how to keep the resident safe when going out alone. The homes self medication policy should be reviewed to include checking the resident’s wishes about whether they want to self medicate, their ability to know the time, and what will happen when they need extra help during difficult periods. The homes has the local social services policy on how to protect residents, and staff have had training, but the home needs to write it’s own policy so that it is easier to understand. The recognised way of inducting new staff needs to be used for all staff and the manager needs to enrol on an NVQ4 course to become fully qualified. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 7 Some policies and procedures need to be still written so that the home can show how it will meet all of its responsibilities to residents and staff. The home has agreed on the type of fire alarm system it is going to install and has booked it in to be installed, but must make sure that it is installed to standards acceptable to the fire officer, so that residents and staff are kept safe. 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. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 8 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.V350898.R01.S.doc Version 5.2 Page 9 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): 1,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make a decision about whether to live at the home. They also know that the home can meet their needs and aspirations, and are given individual written contracts about the service they can expect. EVIDENCE: There was a requirement made at the last inspection for changes to be included in the homes Statement of Purpose to reflect the reason for the difference in fees charged to residents, and to describe some physical changes which had been made within the home. This has now been done. The reason for the difference in fees is accounted for by additional support of up to one to one staffing levels being provided when necessary. Two of the bedrooms have now got ensuite toilet and sink facilities, and this is now explained in the Statement of Purpose. The home now has an adequate Statement of Purpose, which provides all the information needed for residents to be well informed about the services provided and the cost of the service. There is currently only one resident living at the home and Bromley social services are the commissioners for this service. They have provided a full and Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 10 complete core assessment of care needs, and the home has also done it’s own assessment prior to admission. These include areas of risk in relation to the resident’s mental health support needs. The assessment includes personal care, emotional and mental health support needs, health professionals support needed such; as Occupational Therapist, behavioural issues, and management of finances. The assessment shows a good level of input from social services and the health service. The resident was given a contract by the home when admitted, which explains terms and conditions, providers responsibilities, fees and expectations of the resident. This now shows all of the terms and conditions and costs to be incurred, and is signed and dated. Fees are set at £950 per week for accommodation and support for the current resident which is the higher end of the scale of fees for the home. The reason for charging this higher fee is due to higher support needs being provided for and this is explained in the contract. There was a recommendation made at the last inspection for the home to remove a reference to CSCI as a complaints agent, which was incorrect. This has now been done. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents know that their needs and personal goals are reflected in their individual plan, and are supported to make decisions about their lives, but while risks are being assessed there needs to be a risk assessment policy put in place and fully applied to residents risk management. EVIDENCE: Care plan in place, which had recently been reviewed. This care plan is comprehensive and addresses a range of health care and social care needs. The main support being provided is for mental health support needs including emotional support. At the last inspection to resident was in hospital, and it was recommended that the home would ensure that the care plan review took place at the hospital with the involvement of the resident. This happened and the resident moved back to the home at the end of May 2007. Since then there has been a mental health review, which took place in June 2007, and the care plan review, which took place in August 2007. Detailed notes were available, and the care plans showed that activities such as gardening, art, going out to the library, shopping, cleaning and laundry, and visits by the Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 12 family were now been better planned for. Discussions with staff and the manager confirmed that activities are offered a daily basis with most of the fixed activities always happening. The resident said that the staff and the manager are very helpful and were always available to provide help when she needed it. The current weekly plan included visits to the library, and doing laundry, pottery and gardening. Weekly plans also showed that there were visits from the resident’s family and by relevant health professionals. The manager feels that there has been a lot of progress made and that resident has settled back into the home very well. There was a recommendation made to last inspection for the home to record key worker notes and reviews separately from the daily notes taken, to allow more efficient and clear monitoring and reviewing to take place. This has not yet been done, but the manager agreed that she feels that they should do this. (Refer to Repeated Recommendation YA6) It is also recommended that the home consider the use of mood Charts as a means of easily recording emotional and mental health behaviour, which will enable the home to more easily detect when help is needed. (Refer to Recommendation OP6) Health care professionals such as the GP, psychology, occupational therapist and community psychiatric nurse are involved in providing support on a regular basis. The home finds it difficult to help the resident to access dental care support due to refusal on the part of the resident. It is recommended that the home continue to advise the resident, and to seek specialist dental support, which may help the resident to overcome this problem. (Refer to Recommendation YA6) The resident does not currently have any restrictions placed on her freedom, and the home does not operate a policy of restraint of any kind. There is an issue of the resident possibly leaving the home without appropriate support, which has happened recently, which may leave her vulnerable from approach by unsavoury members of the public. The home has informed social services about this problem, which they feel they can only manage by advising the resident, but not by placing any restrictions on her activity, which is her own choice. While the staff and the manager were knowledgeable about how best to support the resident in this matter, there was no formally agreed risk assessment in place. (Refer to risk assessment requirement below) The resident is totally responsible for management of her own finances and benefits. She has asked to be able to keep a larger amount of money in the home safe to be given to her on request. There was a requirement at the last inspection for the home to get written consent from the resident and social services to do this, and they have now agreed this consent, which has been signed and dated the seventh of June 2007. The resident has family who visit regularly and are very supportive. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 13 The home has a good system for identifying risk using a checklist and a rating system, and there are two risk assessments in place regarding the resident’s personal risk. These risk assessments cover perceived risks in the use of the kitchen, and regarding the resident self-medicating. However as discussed above, risk relating to the resident leaving the home without support have not been formally drawn up and agreed with social services or with the resident. Also it was noticed that although the home has a good risk assessment system in place, there is not as yet a formal risk assessment policy for the home. Both of these issues must be addressed, by drawing up a formal risk assessment policy for the home, and by agreeing a risk assessment with the resident and social services regarding the resident leaving the home without support. (Refer to Requirements YA9 and YA 40) Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The resident is able to take part in appropriate activities, and is supported to be part of their local community. They are supported to maintain good relationships with families and friends, and their rights are respected. A healthy diet is provided. EVIDENCE: See also information on activities in the care planning section of this report, Standard 6, for additional information. The care plan for the resident shows there are good opportunities for service users to take part in a range of meaningful activities. These include shopping, reading, knitting, cooking, house work, and meeting with family and friends. The resident had agreed to go swimming as part of regular activities. At the last inspection the manager had written review notes showing the residents choices in activities, such as knitting, and art, and she had said that she Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 15 wanted to attend a knitting course to improve her skills. The course was identified and the resident had a place booked on it. The resident visited local shops and supermarkets to buy knitting materials to follow through on the course. However due to the hospital admission, she did not go ahead with the course plans. Since returning to the home in may 2007 the resident has been supported to follow through on some of these plans, and said that the staff and the manager are very helpful in finding these activities and in going out with her. The care plan for the resident includes maintaining relationships with family and friends. The home is taking reasonable steps to safeguard the resident, when engaging in relationships in the community that may place her risk. Good family links have been maintained with her sister, grandparents, dad and her Nan. The homes visitors’ policy encourages involvement from family, and there is a clear agreement in the contract with the resident to be in the home by 10 p.m. in the evening, or to notify the home in order to ensure that she is safe. The manager stated that the home does encourage and support residents to have full personal relationships. The home provides residents with keys to the front door, and to their own rooms. It is the homes policy and practice for staff to talk with residents, and to be friendly and helpful, and respect their privacy. The home helps residents in shopping and cooking in line with their care plans. The menus maintained at the home show a good range of food being offered. A rolling menu is used, but residents are offered choices each day. Records of what is eaten are kept, and as part of the one residents risk assessment this is important, in order to ensure that she eats well to stay healthy. At the last inspection this record was kept in the daily log with other information about the resident. It was recommended that this record be kept separately, in order to make it easy to monitor. This has now been done and the manager commented that this has been a useful means of discussing healthy eating with the resident. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are asked about how they would like to be supported in personal care, and their physical and emotional needs are included in care planning. The home’s Medication policy supports resident’s wishes or abilities in relation to management of their medication. EVIDENCE: The resident’s personal care support needs have been fully considered in the care planning procedure, and a resident is very independent in the bathroom and in all aspects of personal care, only requiring some prompting. The resident said that staff that are very sensitive and helpful in providing personal care support when needed. The resident’s independence in personal care has increased since returning to the home in September 2007. Religious needs and are supported by the home, but little support is requested by the resident at this time. All health care needs are included in the resident’s care plan and there is good involvement from the GP as and when necessary. Psychiatry is also involved in providing support, and a psychiatric nurse visits the home every two to three Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 17 weeks. An occupational therapist is involved in looking at how activities can be best managed and in motivation for the resident. The resident is reluctant to see the dentist and the home continues to encourage her and advise her. (Refer to recommendation in care planning section of this report) All health care information is well managed and recorded. There was a requirement at the last inspection for the home to include in the homes medication policy a section regarding self-medication. This has now been done. The policy was reviewed in June 2007 and includes selfmedication. However this policy did not clearly include how the residents selfmedication assessment would include her understanding of time, willingness to self-medicate, or how often the resident would be supported partially by staff before support should be withdrawn. Neither did the policy refer to procedures to be adopted during periods of mental health decline. It is recommended that the home review the policy again to include these points. (Refer to Recommendation YA20) The resident has signed a request asking the home to administer her medication on her behalf and this has been recorded in the care plans. Records of storage and administration of medication were well kept with consistent recording happening daily. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do feel that there are views listened to and acted on, but the homes policy on Adult Protection does not fully protect residents from abuse, neglect, or self-harm EVIDENCE: The homes complaints policy was reviewed and in February 2007 and includes timescales for investigating complaints and explains CSCI’s role as a regulator rather than a complaints agency. There has been no record of any complaints being made in the past 12 months. The complaints policy is otherwise adequate. I spoke with staff about their understanding of this policy, and her understanding was good. The homes manager said that copies of the complaints policy are given to residents and their families. The resident said that she was easily able to speak with the manager about any problems if she needed to. There was a requirement made at the last inspection for the home to ensure that there is a copy of the local boroughs adult protection procedure available at the home, and that staff are familiar with it. Although this policy was not available on the day of inspection, the homes manager subsequently confirmed that she had now got a copy and that this is available at the home. As discussions with the homes staff and manager showed that they had a good understanding of the boroughs adult protection procedure, including recording and reporting procedures, and the manager and staff have all had adult protection training since the last inspection, it is accepted that this requirement is now met. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 19 However the homes own adult protection policy has not been reviewed since 2004. This policy must be reviewed to ensure that it is in line with the local authorities policy and procedures. (Refer to Requirement YA23) There have been no reports made to the local authority regarding adult protection since the last inspection. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 20 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): 24,26,27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very comfortable, safe and homely, and toilets and bathrooms are in good order and are private. The home is well maintained and clean. EVIDENCE: The home is provides good facilities for three residents. It is an older property, which has been extensively modernised and decorated to a high standard. It is near to public transport and local shops, and provides single bedroom accommodation for each resident. There are good communal spaces within the home, with a well-maintained garden at the back of the home. The owner has added ensuite facilities to three of the bedrooms and all bedrooms are for single occupancy. The house is open, bright, well decorated and maintained, and has a modern central heating system, and access to the garden from the ground floor. There is a modern kitchen on the ground floor, with a ground floor toilet, and a separate bathroom on the first floor. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 21 The home is very clean throughout, and is well maintained, and the owner pays good attention to maintaining high hygiene standards. There was a recommendation at the last inspection asking the owner to ask the Environmental Health Department for advice about the laundry arrangements in the home, as the washing machine is located in the kitchen area, which is not a desirable location, given that food preparation also happens there. The owner has now done this and the advice she received is that as there are no incontinence materials being washed in this machine and as the laundry is done at separate times than food preparation there are no health and safety considerations at this time. It is advised that the manager continue to keep this issue under review and ensure that staff consistently adhere to the practices described above. Where there is any change in these arrangements such as a need to wash continence materials the home must advice CSCI and ensure that these materials are not washed in the washing machine while it is located in the kitchen area. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 22 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): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider can now demonstrate that the home’s staff and are competent and qualified. Residents are now protected by the homes recruitment procedures, but the Registered Provider cannot show that staff are being properly inducted. The staff are now receiving regular supervision. EVIDENCE: At the last inspection it was not possible to fully assess whether staff had the competencies and qualities required to meet residents care needs as no staff were present at that inspection, and none had been actively employed in the home in the previous two months. Since that time the resident has returned to the home and the home now has 5 female staff recruited to provide support. The rota for the home showed that there is always a member of staff available to provide support for the one resident who lives at the home. During today’s inspection five staff files were examined and I interviewed one staff member. The staff member interviewed had been employed at the home for the past 12 months and currently worked for approx. 20 hours a week. She confirmed that she had an induction for about a week when she started which included going through a range of key policies and procedures, meeting the resident and Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 23 being shown around the home. Discussion with her showed she had a good knowledge of the residents needs as they appeared in her care plan, and was clear on the procedures for reporting complaints and adult protection issues. Comments received from staff about the management of the home were good confirmed that supervision is taking place now between every four to six weeks, and that training is being provided. At the last inspection there was no evidence to show that staff had been properly inducted or that they trained to NVQ requirements. Both of these issues featured as requirements for improvement. These requirements have now been met. Three of the staff are now qualified to NVQ level 2/3, and the home has evidence to show that staff are being inducted in accordance with Skills for Care requirements. Five staff files showed evidence of a formal induction being recorded and the home has introduced and begun to use an induction procedure, which is in line with Skills For Care. The home therefore now has in place an induction and foundation training system that is in accordance with sector skills requirements, but does not yet demonstrate that it has been applied to all staff. The reason for this is that due to the absence of residents at the home staff were not required for work at the home. Now that they are being consistently employed the manager has begun the process of fully implementing the induction system. At the next inspection it is required that that the home is able to demonstrate that this induction process has been applied to all care staff employed by the home. (Refer to Requirements YA 35) Three immediate requirements were made at the last inspection for the home to ensure that: 1. All staff employed at that time be POVA First checked 2. An application be submitted for all staff for Criminal Record Bureau clearance 3. There are two satisfactory written references on file for each staff member. The above three requirements were met within the timescale required. Five staff files showed evidence of a formal interview process having taken place for all staff, and there were enhanced CRB certificates for all staff on their personal file. All staff had a contract of employment showing their terms and conditions of employment. The home has an adequate recruitment policy in place, and the manager conducts all interviews. The policy shows that it is the homes practice to take up references, and to carry out POVA and CRB checks for all staff prior to commencement of employment. At the last inspection there were two requirements made at the last inspection asking that the Registered Provider ensure that all staff have a training plan in place, and to send copies of all staff training records to CSCI, and also to send a copy of the homes training and development plan. These requirements were Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 24 the subject of requirements at a previous inspection also but have now been met. All of the five staff files examined showed training is now being planned. The staff have now got a training and development plan in place, which reflects the assessed care needs of the residents. The home has begun having staff trained to Skills for Care standards. Training includes: mental health, fire safety, health and safety, food hygiene, adult protection, complaints, medication and health and safety. There is now a commitment to having all staff trained to the appropriate NVQ levels. (Refer to requirement under Standard 35 regarding staff induction) There was a requirement made at the last inspection for the home to ensure that all staff receive regular supervision at least every eight weeks. The five staff files showed that staff are now receiving formal supervision at least every four to six weeks. The staff interviewed confirmed this to be the case. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 25 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, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is not yet qualified to NVQ level 4, and resident’s views on how the home is run are not yet included the home selfmonitoring and development practices. The homes health and safety practices do not fully protected staff and residents, although improvements have been made. EVIDENCE: The registered manager is experienced in the area of mental health and care and has a social services qualification. However she does not yet hold and NVQ4 qualification in care in management. The registered manager must enrol on and NVQ level 4 course in care and management by the end of February 2008, and subsequently complete this course. (Refer to Requirement YA37) Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 26 The home holds residents meetings on a monthly basis to allow residents to be given the opportunity to discuss how they are feeling about how the home is run with the management and staff. Currently there is not an annual quality audit or development plan in place for the home. This may be explained by the fact that there is only one resident in the home at the moment, and for long periods of time there have been no residents at the home, and care was provided directly to the hospital. As a result the home cannot at this point demonstrate that it implements a robust quality assurance system, as due to residents absence from the home it has not been possible for them to implement one. This standard should be inspected more thoroughly at the next inspection. Currently many of the policies and procedures required are in place and are being reviewed regularly. However there are nine policies and procedures not yet in place, which the home should ensure are part of the policy and procedure complement. These are: continence promotion, contact with and visits by family and friends, emergencies and crises, gifts to staff, induction and foundation training, moving and handling, physical interventions, risk assessment and working with volunteers. The home must ensure that these policies and procedures are in place and that staff be made aware of them. (Refer to Requirement YA40) The home has good facilities for storage of dangerous liquids and substances. There is a health and safety policy in place, which was last reviewed in February 2007. This policy is adequate in its content and would suffice to protect staff and service users if fully implemented. The public liability insurance is in date and is displayed in the hallway. Health and safety, fire safety, moving and handling, and food hygiene are included in the induction of staff. There was a requirement at the last inspection for the home to have a fire detection system installed, in keeping with the Fire Officers last report recommendations. This has not yet been done, although the owner has now agreed to do this and has scheduled this to be installed in January 2008. This requirement is now met and is replaced by a requirement to notify CSCI when the installation has been completed and to request the fire officer to inspect the work to ensure that it meets fire safety standards. (Refer to Requirement YA42) There was a requirement from the last three inspections, for the Registered Provider to ensure that all portable electrical appliances be inspected annually, and that certificates of safety be available for inspection. This requirement is now met. Following today’s inspection the homes manager/owner forwarded confirmation that equipment had now been PAT tested. The home has electrical wiring and gas safety certificates, which are both in date. There have been no reports made under RIDDOR since last inspection. Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 X 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 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 3 X 2 X 2 2 X 2 X Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13.4 b&c Requirement The registered provider and manager must ensure that a written risk assessment be carried out in relation to the resident leaving the home without support, in consultation with the resident, social services and any relevant professional The registered provider and manager must ensure that the homes own policy on Adult Protection is reviewed to reflect the local authority’s policy The registered provider and manager must ensure that all staff induction records are completed in line with Skills For Care requirements The registered manager for the home must enrol on an NVQ4 course in care and management and subsequently pursue this course to completion The registered provider and manager must ensure that the homes policies include all of the policies specified in this report Standard 40, covering the topics set out in Appendix 2 of the National Minimum Standards for DS0000028074.V350898.R01.S.doc Timescale for action 31/01/08 2 YA23 13.6 31/03/08 3 YA35 18.1 a 31/03/08 4 YA37 9.2 b (i) & 10.3 31/03/08 5 YA40 12 & 13 31/05/08 Penberth House Version 5.2 Page 29 Adults (18-65). 6 YA42 23.4 The registered provider and manager must ensure that the installation of the homes fire alarm system be completed by 31/01/08 and have the fire officer inspect the system to ensure that it meets fire safety standards. The provider must also inform CSCI in writing when the work is completed, or advise if there is to be any delay in meeting this deadline 31/01/08 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 Refer to Standard YA6 Good Practice Recommendations The Registered Provider should record all notes of keywork session separately to the daily log, in the service users’ file. This is a Repeated Recommendation from the last inspection not met The Registered Provider should consider introducing simple mood charts as an aid to monitoring mental health The Registered Provider should seek specialist dental care support from a dental practice experienced in providing a service to people with complex care needs The Registered Provider should review the homes medication policy in relation to self medication to include the areas discussed in this report under Standard 20 2 3 4 YA6 YA6 YA20 Penberth House DS0000028074.V350898.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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