Inspection on 21/02/07 for Penberth House

This inspection was carried out on 21st February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 15/10/07

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 21st February 2007 10:00 Penberth House DS0000028074.V331082.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.V331082.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.V331082.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.V331082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 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 20th December 2006, the homes fees are set at between £800- per week 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 majority of these costs are met by the referring social services authority. 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. Service users have to pay for other personal expenses such as hairdressing and personal shopping. The provider’s email address is: j.schoeffer@btinternet.com Penberth House DS0000028074.V331082.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 21st February 2007. The inspection was unannounced, and was facilitated by the Registered Manager. It was not possible to speak with service users or to include their views in this report, as there is currently only one service user who lives at the home, and she was not available to comment for personal reasons. The service user’s file was examined to see that care needs are being planned for. There were no support staff available for inclusion in the inspection, as none of the staff who have been working at the home, had attended over the previous two and a half months, as the only service user had not lived at the home during that time. Four 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. Five of the fifteen requirements and recommendations made at previous inspections had now been met. It was agreed that the home needs to work to make improvement in meeting requirements. What the service does well: What has improved since the last inspection? The service user is now clear about how much is being charged for staying at the home as it is clearly written in her Tenancy Agreement. The service user’s care plan has been reviewed and the service user has been able to say what she wants to be included. Other important people have also been involved have helped to make sure that the home safely provides help and support. Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 6 There is now a short explanation at the home showing how complaints can be made which is easy to understand. 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. Penberth House DS0000028074.V331082.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 Penberth House DS0000028074.V331082.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): 1,3 and 5 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. Prospective service users have most of the information they need to make a decision about whether to live at the home, but some additions need to be made to the home’s Statement of Purpose. They also know that the home can meet their needs and aspirations, and service users are given individual written contracts about the service they can expect. EVIDENCE: The home has an adequate Statement of Purpose, which provides all the information needed for service users to be well there informed about the services provided and the cost of the service. However there are a number of changes needed to update this document. The current Statement of Purpose says that the homes fees are an £700 per week, but these have increased to between £800 and £950 per week. The difference is accounted for by additional support of up to one to one staffing levels being provided when necessary. Also one of the bedrooms has now got ensuite toilet and sink facilities, and the owner plans to provide these facilities in one other room in the near future. These changes need to be included in the homes Statement of Purpose. (Referred to Requirement YA1) Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 9 There is currently only one service user receiving a service at home, having moved in in August 2006. This person was admitted to hospital in December 2006, and still remains there. There is a full care assessment in place for the service user. The assessment is full and comprehensive, and includes personal care, emotional and mental health support needs, health professional’s 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 cover page of the assessment was missing and should be replaced as it shows the date it was done and by whom. There was a requirement at the last inspection for the home to ensure that the amount a service user is paying for their placement is stated in their tenancy agreement, and this is now been done. The service user was given a contract by the home when admitted, and this now shows all of the terms and conditions and costs to be incurred, and is signed and dated. There was a recommendation at last inspection for the Registered provider to remove the name and address of CSCI from the tenancy agreement or explain clearly CSCIs role in the regulation of the home. This is not yet been done and recommendation is repeated. (Refer to Repeated Recommendation YA5) Penberth House DS0000028074.V331082.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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users know that their needs and personal goals are reflected in their individual plan. Service users are supported to make decisions about their lives, but there needs to be a formal agreement about managing one service user’s money. Service users are supported to take reasonable risks, which maintain their independence. EVIDENCE: There was a requirement at last inspection for the Registered Provider to ensure that the care plan the service user is reviewed, and that useful notes of these reviews are made in the care plan. This has now been done. The manager has a care plan in place, which is detailed and addresses a range of health and social care needs. The service users’ plans specifically state the kind of support needed in a range of areas, such as mental health, personal care, support in the community, family visits and relationships, and daily living activities. The daily activities include cooking and shopping, and risk Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 11 assessments reflect all of the areas appearing in the care assessment. The manager has done a review of the care plan, which shows good progress prior to the service user being admitted to hospital in December 2006. The sixmonth review is now due, but the service user being in hospital presents a barrier to her involvement in this review. The social worker that was involved is also not now available. It is recommended that the home try to ensure that the review happens soon, with whatever level of participation is possible from the service user. This should also include a review of the home’s daily and weekly contact with the service user, and identify what is expected of them in providing input and support of the service users in hospital. (Refer to Recommendation YA6) There was a recommendation from the last inspection for the Registered Provider to record all notes of keyworker sessions in a separate place from the daily log, in the service users file. As a service user has been in hospital since December 2006, this has not yet been done, but the manager said when she returns to the home this will be followed through. (Refer to Repeated Recommendation YA6) As the service user has been in hospital for the past few months it was not possible to include her views in this inspection. The manager said that she was fully involved in development of care plan, and before admission to hospital had been going out, with support, on a daily basis to do shopping, meeting with her family, and had progress to going out to local corner shops alone, as part of risk assessed care planning. This shows good progress, and a wellmanaged approach to risk. The manager feels that the service user does not need advocacy, as she is able to speak of for herself. The service user is responsible for all of her benefits and had been collecting these with support from staff. The manager said that at the resident’s request, she has taken over control of her finances since she has been in hospital, to enable her to easily access money when she needs it. The manager needs to ensure that this agreement for the home to manager service users finances is put in writing, and kept on the service users file, having been agreed by the service user and social services. (Refer to Requirement YA7) There was a requirement from the last inspection for the registered provider to ensure that plans are in place to manage or minimise all risks that had been identified. This has now been done, and the service user for whom the risks applied has since left the home. The home has a full range of risk assessments in place regarding environmental risk, cooking, going out in the community, eating and medication, and these are clearly written and have been regularly reviewed. Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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. The service users are able to take part in appropriate activities, and are 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: The care plan for the service user 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 service user had agreed to go swimming as part of regular activities, but she didnt actually go swimming, out of choice, when the activity was offered. Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 13 The manager had written review notes showing the service user’s choices in activities, such as knitting, and she has said that she wanted to attend a knitting course to improve her skills. The course was identified and the service user had a place booked on it. The service user 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, and since then there be no opportunities within the hospital to do this. The care plan for the service user includes maintaining relationships with family and friends. The home is taking reasonable steps to safeguard the service user, 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 service user, to be in the home by 10 p.m. in the evening, or for the service user to notify the home in order to ensure that she is safe. The manager stated that the home does encourage and support service users to have full personal relationships. The home provides service users with keys to the front door, and to their own rooms. It is the homes policy and practice for staff to talk with service users, to be friendly and helpful, and to respect their privacy. However, as there were no service users of staff present, it was not possible to fully assess how this is done in practice. The manager said that the home helps service users with shopping and cooking in line with their care plans, and that risk is assessed to make sure they are safe. The menus maintained at the home show a good range of food being offered. A rolling menu is used, but service users are offered choices each day. Records of what is eaten are kept, and as part of the one service users risk assessment this is important, in order to ensure that the service user eats well to stay healthy. This record is currently kept in the daily log with other information about service user. It is recommended that the information about what the service user has eaten be kept separately, in order to make it easy to monitor. (Refer to Recommendation YA17) Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users 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 homes Medication policy does not adequately allow for assessment of service users wishes or abilities in relation to administration of medication. EVIDENCE: There is limited personal care support required for the service user. The care plan shows clearly that only prompting is needed, and there is no need for staff to provide support in the bathroom or toilet areas. The service user is able to choose her own clothes and dresses as she wishes, and is able to purchase her own toiletries and personal items. The home has an assessment of health care needs of the service user, which provides a lot of information on mental health support and care needs. This is reflected fully in the care plan, and in the daily notes kept by staff. The service user is registered with the GP locally, and appropriate other healthcare professionals are involved, such as mental health care professionals. An Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 15 occupational therapist is involved in helping to encourage the service user in engaging in activities, and in accessing appropriate transport. The service user is registered with a dentist and chiropodist, and receives regular care in these areas. The home has access to the local healthcare multidisciplinary team when necessary. There was a requirement at last inspection of the registered provider to ensure that the medication policy is redrafted, to include a section about how service users will be supported to self-medicate. The policy was reviewed in April 2006 and there is now a reference in the policy to self-medication, and how to support service users with medication when they are off the premises. However the policy does not describe and the system for assessing service users wishes or abilities regarding self-medication, or a methodical approach to developing their abilities to self medicate. The provider must ensure that policy is reviewed again to include these areas fully. (Referred to Repeated Requirement YA20 partially met) Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Service users feel that there are views listened to and acted on, but the homes policy on Adult Protection does not fully protect service users from abuse, neglect, or self-harm EVIDENCE: There was a requirement at the last inspection for the Registered Provider to ensure that the complaints policy be reviewed to state that all complaints will be investigated within 28 days. This policy was reviewed on the 20th of February 2006 and now includes this timescale. There has been no record of any complaints being made in the past 12 months. The complaints policy is otherwise adequate. It was not possible to check with staff or service users about their understanding of this policy, but the homes manager said that copies are given to service users and their families. There was a recommendation at the last inspection that the Registered Provider draw up a brief and simple procedure, explaining to service users how to make a complaint should they wish to. This has now been done. There have been no reports made by the home under the Adult Protection procedure or under the POVA procedures since the last inspection. As there were no staff or service users available at the inspection, it was not possible to check their understanding of the homes Adult Protection policy. There was a requirement made at the last inspection for the Registered Provider to ensure Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 17 that there be a copy of the local boroughs Adult Protection procedure in the home, and that staff be familiar with it. There is currently no copy of the local authority policy available at the home, and the homes Adult Protection policy has not been redrafted to reflect this policy. The homes current policy is dated 2004,and the local authority policy was reviewed in 2005. The registered provider must ensure that this policy is reviewed to reflect local authority policy as soon as possible. (Refer to Repeated Requirement YA23) Penberth House DS0000028074.V331082.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): 24,27 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; 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 service users. 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 service user. There are good communal spaces within the home, with a well-maintained garden at the back of the home. Since last inspection the owner has added ensuite facilities to two of the bedrooms, and has plans to do the same for the third bedroom. 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 Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 19 kitchen on the ground floor, with a ground floor toilet, and a separate bathroom on the first floor. 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. Currently 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 not yet done this and this recommendation is repeated. (Refer to Repeated Recommendation YA30) Penberth House DS0000028074.V331082.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): 32,34,35 and 36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The registered provider cannot demonstrate that the home’s staff and are competent and qualified. Service users are not fully protected by the homes recruitment procedures, and the Registered Provider cannot show that staff are being properly inducted or trained. The staff are not currently receiving regular supervision. EVIDENCE: It was not possible to fully assess this standard as no staff were present, and none have been actively employed in the past two months. The home has a list of staff that it would use on a part-time basis, should the service user return from hospital. There are currently two service user vacancies within the home, and the only service user has been in hospital for the past two months. It is therefore difficult to make a full assessment of the home’s abilities to match staff skills to service users needs. None of the care staff hold an NVQ2/3 qualification, and none are placed on a course to gain this qualification. The registered provider must put in place a Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 21 plan to ensure that the staff available to work at the home are either qualified to NVQ level 2/3, or secure a place on a course to achieve this qualification. (Refer to Requirement YA32) The home has an adequate recruitment policy in place, and the manager conducts all interviews. There has been no recruitment activity since last inspection, or for the past two years, and the manager said it is her intention to involve service users in the recruitment process in the future. The policy shows that it is the home’s practice to take up references and to carry out POVA and CRB checks for all staff prior to commencement of employment, but examination of four staff files showed that it is not happening properly. The following shortcomings in recruitment practices were identified during examination of four staff files: • • Two staff files did not have references at all. These staff had been employed on the basis that they knew the owner of the home before being employed Three files did not have adequate CRB and POVA checks completed by the employer. Two of these files had CRB checks on file, which were provided by the employee, and were a year old at commencement of employment. None of the files had POVA checks completed on staff employed. Three out of four staff did not have employment contracts or statements of terms and conditions for employment None of the staff had health clearance declarations provided as part of the recruitment process • • Three Immediate Requirements were made, requiring the Registered Provider to ensure that only care staff who had been fully CRB and POVA checked were allowed to work with service users, and that the provider ensure that all staff employed have two satisfactory written references, taken up before they are allowed to work at the home again. The Registered Provider was also asked to provide evidence that the CRB and POVA checks had been applied. (Refer to Immediate Requirements YA34) In Addition another new requirements is now made for the Provider to ensure that all staff employed have appropriate health clearance declarations taken up and placed on their individual files. (Refer to Requirements YA34) None of the staff employed currently have written contracts of employment with the home. It is recommended that all staff employed are given contracts of employment, or written terms and conditions of employment, and that copies of these are also placed on their files. (Refer to Recommendation YA34) Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 22 There was a requirement made at the last inspection asking the Registered Provider to ensure that the homes induction and foundation training is in accordance with the sector skills specifications. This requirement was not met, and none of the staff files examined showed any evidence of appropriate induction. The Registered Provider must ensure that all staff are taken through a full induction process, which is in keeping with the Skills For Care requirements. This was a requirement from the last two inspections, and is now repeated. (Refer to Repeated Requirement YA35) There were two requirements made at the last inspection asking that the Registered Provider 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 not met and are now repeated. None of the four staff files examined showed any training being planned. The home must ensure that all staff have a training and development plan in place, which reflects the assessed care needs of the service users. In particular there should be solid foundation training in relation to mental health support needs, which are main feature of the homes support provided. (Refer to two Repeated Requirements YA35) Examination of four staff files showed that no formal supervision is happening within the home. The Registered Provider needs to ensure that all staff receive formal supervision at least every eight weeks, and that written notes are kept of these supervisions. (Referred to Requirements YA36) Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 23 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 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 this is reflected in some of the home’s management practices. Service users views do not underpin the home’s self-monitoring and development practices. The home’s health and safety practices do not fully protect staff and service users. EVIDENCE: The home has good facilities for the storage of dangerous liquids and substances. There is a health and safety policy in place, which was last reviewed in 2006. 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 Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 24 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 made inquiries about the best system to use for the purpose. This requirement is now repeated. (Referred to Repeated Requirement YA42) There was a requirement from the last two 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 was not met and is now repeated. (Refer to Repeated Requirement YA42) 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.V331082.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 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 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 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 2 X 2 x 2 x x 2 x Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5.1 Requirement Timescale for action 31/07/07 2 YA7 13.6 & 16.2 L 3 YA20 13 (2) 4 YA23 13 (6) The Registered Provider must ensure that the homes Statement of Purpose and Service Users Guide is updated, to include the correct fees to be paid, an up to date description of the homes facilities, and all other information required by this standard The Registered Provider must 31/07/07 seek formal written agreement from the service user and/or her representative, for written authorisation to manage her finances The Registered Provider must 31/07/07 ensure that the medication policy is redrafted to include a section on how service users will be supported to self medicate. This was a requirement of the last inspection, Timescale 31/05/06, not met. Timescale now revised. The Registered Provider must 31/07/07 ensure that there is a copy of the local borough’s adult protection procedure in the home, and that staff are familiar with it. This was a requirement of the last DS0000028074.V331082.R01.S.doc Version 5.2 Penberth House Page 27 5 YA32 18.1 a & c 6 YA34 19.1 & 19.4 7 YA34 19.1 & 19.4 8 YA34 19.1 & 19.4 9 YA34 19.1a &19.4 10 YA35 18 (1) (c) (i) inspection, Timescale 31/03/06 not met. Timescale now revised. The Registered Provider must ensure that enough of the care staff are enrolled on an NVQ level 2/3 course to ensure that at least 50 of the staff become qualified at this level The Registered Provider must ensure that all of the current staff have satisfactory POVA First clearance, prior to recommencement of employment. This was an Immediate Requirement made at the inspection, Timescale 28/02/07 and was met The Registered Provider must submit an application for an enhanced CRB for all staff intended to work at the home, including current staff. This was an Immediate Requirement made at the inspection, Timescale 28/02/07 and was met The Registered Provider must ensure that all staff employed have two written satisfactory references placed on their files at the home. This was an Immediate Requirement made at the inspection, Timescale 28/02/07 and assurances were given that this would be addressed by the Registered Provider The Registered Provider must ensure that written health clearance statements are taken up from staff employed, and that copies are maintained on their files at the home The Registered Provider must ensure that all staff have a training plan in place, which reflects the support needs of DS0000028074.V331082.R01.S.doc 30/09/07 28/02/07 28/02/07 28/02/07 31/07/07 31/07/07 Penberth House Version 5.2 Page 28 11 YA35 18 (1) (c) (i) 12 YA35 18(1)(a) 13 YA36 18.2 14 YA42 23(4) 15 YA42 23(2)(c) service users, and send a copy of all staff’s training records to the CSCI. This was a requirement of the last inspection, Timescale 31/03/06 not met. Timescale now revised. The Registered provider must send through the home’s training and development plan to CSCI. This was a requirement of the last inspection, Timescale 31/03/06 not met. Timescale now revised. The Registered Provider must ensure that the home’s induction and foundation training is to sector skills specifications. This was a requirement of the past two inspections Timescale 31/03/06 not met. Timescale now revised. The Registered Provider must ensure that staff receive the support and supervision they need to do their jobs, at least every two months, and that written records are kept on their individual files at the home. The Registered provider must ensure that an electrical fire detection system is installed in the home as per the fire officer’s last report. This was a requirement of the last inspection, Timescale 31/05/06 not met. Timescale now revised. The registered provider must ensure that portable electrical appliances are inspected annually, and that certificates of safety are available for inspection. This was a requirement of the past two inspections, Timescale 31/01/06 and 31/03/06 not met. Timescale now revised. 31/07/07 31/07/07 31/07/07 31/07/07 31/07/07 Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 29 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 YA5 Good Practice Recommendations The Registered Provider should take the name and address of the Commission out of the tenancy agreement, or explain clearly the Commissions role in the regulation of the home. This is a Repeated Recommendation from the last inspection not met 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 the possibility of organising a care review for the service user who is in hospital, to include a review of the role of the support offered by the home The Registered Provider should consider keeping a separate record of the food consumed as an aid to easier monitoring of the service users diet. This is a Recommendation from the last inspection not met It is recommended that the registered provider seek advice from the environmental health department about the laundry arrangements in the home. This is a Repeated Recommendation from the last two inspections not met The Registered Provider should ensure that all staff employed are issued with completed contracts of employment, and that copies of these are maintained on their file at the home 2 YA6 3 YA6 4 YA17 5 YA30 6 YA34 Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI Penberth House DS0000028074.V331082.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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