Inspection on 24/02/06 for Penberth House

This inspection was carried out on 24th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 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 21/02/07

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 Lisa Wilde Unannounced Inspection 24th February 2006 10:00 Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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.V285224.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 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. The registered provider/manager currently lives at the home and at the time of this inspection there were two vacancies. Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in February 2006 with the staff member on duty. The manager was not present and the service user did not want to meet with the inspector. Generally there is a good standard of care being offered at this home although it is difficult for service to operate as a care home when there is only one service user in the home. What the service does well: What has improved since the last inspection? What they could do better: The areas assessed at this inspection showed that the home must do more to make sure that: • The information service users are given is complete (particularly around the cost of their placement). • The care plans are reviewed regularly enough. • All areas of risk are fully addressed within risk management plans. Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 6 • An electrical fire system is installed and portable electrical equipment is 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.V285224.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Service users have a tenancy agreement, which means they are being given information about their rights and responsibilities while at the home. The information they were being given was not complete as the cost of the placement was not filled in. EVIDENCE: No service users have moved to this home since the last inspection. The service user has signed a tenancy agreement that outlines their rights and responsibilities while at the home but the amount that he was to pay was not filled in. The agreement also had the name and address of the Commission at the end where parties had signed which indicated that the Commission was somehow party to that contract, which was slightly misleading. (See Requirement 1 and Recommendation 1) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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&9 Service users will know that their needs are being assessed and written in their care plans and they are involved in the drawing up of those plans. The care plans are not being reviewed regularly enough, which means that service users do not know that as their needs change staff will change the way they work with them. Risks are identified with service users and plans drawn up to help manage or minimise those risk although these plans do not cover all areas of risk which means that staff may not always know what to do in difficult circumstances. EVIDENCE: The service user has a care plan that outlines action to be taken by staff to meet any identified needs. This plan was generally very thorough and clear. Staff said there had been a recent full review of this plan but there were no notes of the meeting available yet from social services. Notes on the care plan said that certain areas of it had to be reviewed at different stages, yet there were no comments on the plan to show if it had been reviewed and what the result of those reviews had been. (See Requirement 2) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 10 Areas of risk have been identified but not all of these areas have action plans in place to manage or minimise those risks. (See Requirement 3) Staff said that they meet regularly with the service user to talk about their life at the home but they do not keep separate notes of these meetings just put the notes in the daily log. (See Recommendation 2) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 11 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): 12, 16 & 17 Service users are encouraged to get involved in the local community and plan a programme of activities for themselves. EVIDENCE: This service user has particular issues, which mean that they have specific needs in all these areas. It is not possible to discuss these issues in this report without breaking their confidentiality but the inspector was satisfied that as far as possible staff understood the needs of the service user and were working towards developing their abilities in these areas. These issues would be more usefully assessed at the next inspection when hopefully there will be more service users at the home. Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users receive support in the way that they choose and their physical and emotional needs are met. Generally, medication is handled safely, although an amendment to the medication policy would enhance this area. EVIDENCE: Staff discussed the current service users needs and showed awareness of how the staff team should meet those needs. The care plan backed up this awareness. The current service user is not on any medication but the home has a medication policy and procedure in place. This policy is fairly comprehensive but needs an additional section covering self-administration. (See Requirement 4) Staff have been trained in the administration of medication. Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There is a policy and procedure in place so that service users know how to make a complaint if they are unhappy about anything. Service user are protected because staff are trained in issues around adult protection and there are procedures in place for staff to follow if they think that someone is being abused. EVIDENCE: There have been no complaints since the last inspection. Staff said that the service user is able to voice any concerns during their keywork sessions or day-to-day conversations. The complaints policy is in place but it would be more useful to have a very simple procedure for service users as well and the policy must state that all complaints will be addressed within 28 days. Again this standard would be more usefully assessed when more service users are in the home. (See Requirement 5 and Recommendation 3) The staff training records were not available as the manager wasn’t present but the staff member on duty said that they had been trained in adult abuse issues. There is a vulnerable adult policy in the home along with additional related policies around challenging behaviour. There is not a copy of the local borough’s adult protection procedure in the home. (See Requirement 5) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 14 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): 30 The home is clean, well decorated and comfortable throughout. EVIDENCE: The service user did not want the inspector to go into his room but the other two rooms were large enough, well decorated and comfortable. On the day of the inspection the home was clean and hygienic throughout. There had been a previous recommendation that the registered provider seek advice from the environmental health department about the laundry arrangements in the home. They had contacted the environmental health but they had not as yet visited. There is an interim policy in place that no laundry will be done while people are cooking in the kitchen. The previous recommendation is repeated and staff said that they are aware that the laundry facilities will possibly need to be moved when more service users move into the home. (See Recommendation 3) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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): 34 & 35 During the inspection staff showed knowledge of the needs of the service user and said that they had been trained in all required areas. Although further paperwork needs to be sent to the Commission at this point service users know that they are being offered support by staff who know what to do for them. EVIDENCE: It was not possible to fully assess the recruitment procedures as the manager was not present. This will be more fully looked at during the next inspection. There was a previous requirement that the registered provider must obtain information about the POVA list to ensure that she is clear about the responsibilities this places on her. Staff said that she had done this and they showed awareness of the list and what it meant. No new staff have been recruited since the last inspection. There was a previous requirement that the registered provider must ensure that the homes induction and foundation training is to sector skills specifications. It was not possible to fully assess this as the manager was not present so training records were not available. Staff described an induction system that appeared to meet the requirement but further documentation is necessary. Staff were not are if the home had a training and development plan. (See Requirements 6, 7 & 8) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 16 Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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): 42 Generally the health and safety of service users is protected by the procedures in place for staff to follow. They are not fully protected however because an electrical fire system is needed along with electrical equipment being tested. This means that service users are being placed at some risk. EVIDENCE: It would be more useful to assess the standards around quality assurance and service user involvement when there are more service users at the home. There was a previous requirement that the registered provider must display fire exit signs, install smoke detectors and fire extinguishers in consultation with a fire officer. This had now been done and the fire officer report stated that an electrical fire detection system must be installed (See Requirement 9) There was a previous requirement that the registered provider must ensure that portable electrical appliances are inspected annually and certificates of safety are available for inspection. This had not as yet been done. (See Requirement 10) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 18 Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X X X X 2 X Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 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 YA5 Regulation 4 Requirement The Registered provider must ensure that the amount a service user is paying for their placement is stated in their tenancy agreement. The Registered Provider must ensure that the care plan is reviewed as required, that useful notes of these reviews are made on the plan and the plan is adjusted as required. The Registered provider must ensure that plans are put in place to manage or minimise all risks that have been identified. The Registered provider must ensure that the medication policy is redrafted to include a section on how service users will be supported to self medicate. The Registered provider must ensure that the complaints policy states that all complaints will be addressed within 28 days. The Registered Provider must ensure that there is a copy of the local borough’s adult protection procedure in the home and that staff are familiar with it. The Registered Provider must DS0000028074.V285224.R01.S.doc Timescale for action 31/03/06 2. YA6 15 (2) (b) 31/03/06 3. YA9 15 & 13 (4) 13 (2) 31/03/06 4. YA20 31/05/06 5. YA22 22 (4) 31/05/06 6. YA23 13 (6) 31/03/06 7. YA35 18(1)(a) 31/03/06 Page 21 Penberth House Version 5.1 8. 9. YA35 YA35 18 (1) (c) (i) 18 (1) (c) (i) 23(4) 10. YA42 11. YA42 23(2)(c) ensure that the home’s induction and foundation training is to sector skills specifications. Previous requirement timescale not yet passed The Registered Provider must send through all staff’s training records to the Commission. The Registered provider must send through the home’s training and development plan to the Commission. The Registered provider must ensure that an electrical fire detection system is installed in the home as per the fire officer’s last report. The registered provider must ensure that portable electrical appliances are inspected annually and certificates of safety are available for inspection. Previous requirement: Unmet timescale 31/01/06 31/03/06 31/03/06 31/05/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 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. The Registered Provider should record all notes of keywork session separately to the daily log, in the service users’ file. The Registered Provider should draw up a brief and simple procedure that tells service users how to make a complaint. It is recommended that the registered provider seek advice from the environmental health department about DS0000028074.V285224.R01.S.doc Version 5.1 Page 22 2. 3. 4. YA6 YA22 YA30 Penberth House the laundry arrangements in the home. (Previous recommendation) Penberth House DS0000028074.V285224.R01.S.doc Version 5.1 Page 23 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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