Inspection on 10/08/06 for Penerley Lodge

This inspection was carried out on 10th August 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 but made no statutory requirements on the home.

Other inspections for this house

Penerley Lodge 03/08/07

Penerley Lodge 12/01/06

Penerley Lodge 16/06/05

Penerley Lodge 03/03/05

Penerley Lodge 10/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Penerley Lodge 36/40 Penerley Road Catford London SE6 2LQ Lead Inspector Ms Rehema Russell Unannounced Inspection 10:00 10 & 11 August 2006 th th X10015.doc Version 1.40 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 DS0000025637.V295855.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 Older People. 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. DS0000025637.V295855.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penerley Lodge Address 36/40 Penerley Road Catford London SE6 2LQ 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) 0208 6956029 Mr H A Cole Mrs Maureen P Cole Care Home 27 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places DS0000025637.V295855.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 27 elderly persons of whom up to 2 may have dementia 12th January 2006 Date of last inspection Brief Description of the Service: Penerley Lodge provides accommodation and care for 27 older men and women who are physically frail, up to two of whom may have dementia. The home was formed by combining three formerly private Victorian houses and is located in a quiet residential road in Catford. It is within 10 minutes walk of a main shopping centre, which is also accessible by buses available a few minutes walk from the home. The main shopping area has good transport links to other areas of London by both bus and rail. There is a large forecourt in front of the home with space for 6/7 cars to park and nearby on-street parking is available. The home has a new large conservatory, which also has a smoking room and private meeting room, and the garden has a new decking area, raised flower beds, lawn and a newly created pathway and landscaped area to the side. Prospective service users and their relatives are given a copy of the Statement of Purpose and are given further verbal information about the home during their trial visit. The front page of the most recent CSCI inspection report is advertised on the noticeboard and a copy made available at request from the home’s office. Current fees range between £410 - £481 for non-privately paying residents. There is an additional charge for hairdressing. DS0000025637.V295855.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days on 10th & 11th August 2006. On the first day the inspector was accompanied by a Regulation Manager. During the two days the following people were spoken with: a Director of the owning Company, the acting manager, two senior healthcare assistants, three healthcare assistants, the cook, the administration assistant, the maintenance worker, six residents and two sets of visiting relatives. In addition, practice was observed, the premises were toured, documentation and records were checked and the inspector attended a meeting of the senior management team. What the service does well: What has improved since the last inspection? Improvements since the last inspection include: • A good improvement in documentation and care records • Increased staffing to enable residents to be escorted out of the home and to enable staff to spend individual time with residents • The use of two previously double bedrooms as single bedrooms. • Training given to staff in relevant topics such as dementia, death and bereavement and physiotherapy. DS0000025637.V295855.R01.S.doc Version 5.2 Page 6 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. DS0000025637.V295855.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025637.V295855.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6 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 an informed choice about the home. Residents moving into the home receive a full, recorded, assessment of needs and have an opportunity to visit and assess the suitability of the home. The home does not accept service users solely for intermediate care. EVIDENCE: The home does not have a separate Service User Guide but uses the Statement of Purpose as a combined document. The Statement of Purpose was examined at the inspection of 12th January 2006 and found to cover all of the areas required by regulation and to give prospective residents the information they need to make an informed choice about the home. One minor admission had been found (the number and qualifications of healthcare assistants employed). At this inspection the Statement of Purpose was being updated by Head Office following recent changes to the staffing establishment, and so was not available for perusal. See Requirement 1. DS0000025637.V295855.R01.S.doc Version 5.2 Page 9 Care files evidenced that new residents are admitted only on the basis of a copy of the community care/care programme assessment being received by the home and with a full assessment being carried out by the acting manager. The acting manager carries out the assessment by visiting the prospective resident in their home or at the hospital, and the health and social care assessments seen were thorough and covered all relevant areas of care. Prospective residents are encouraged to make a trial visit to the home with relatives or other interested parties. Of the three most recently admitted residents, two had visited the home with relatives and one had visited with her social worker. At the trial visit prospective residents are shown the bedroom they will occupy, offered tea and biscuits in the lounge and encouraged to spend time there meeting staff and other residents and being given any information they require. The home does not accept service users solely for intermediate care and so Standard 6 is not applicable. DS0000025637.V295855.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care files are well organised and give a clear picture of each resident’s individual needs. All care plans are regularly reviewed. Staff ensure that residents access the full range of healthcare facilities. Procedures for dealing with medicines are satisfactory. Residents are treated with respect and their privacy safeguarded. Funeral arrangements have been agreed with residents’ relatives and recorded on care files. EVIDENCE: Four care files were examined in detail. There had been a great improvement in these since the previous inspection, including bringing the care files of residents who had been at the home for several years up to the same standard as newer files. All care files seen were well laid out and ordered, containing a photo and profile of the resident, full admission details, various lists of personal items/health professional visits/multi-disciplinary team input, and agreement forms such as for newspaper deliveries/resuscitation preference/restrictions such as cot sides. All of the latter request forms were signed and dated by the service user or relatives, as appropriate. There was only one care plan item on each care file. This was called the core care plan DS0000025637.V295855.R01.S.doc Version 5.2 Page 11 and was the key area of care necessary for the resident. It consisted of the identified need, the goal/aim, and a full and clear description of the action to be taken. It was reviewed monthly. In addition to the core care plan, a health and social care assessment was completed for each resident. This gave a full picture of all areas of care required by the resident, covering areas such as mobility, washing and dressing, orientation in time and place, daily living skills, social and leisure interests, communication, continence, sleep/rest pattern and moods/concerns. The health and social care assessment gives a full and clear indication of the care needs of each resident but does not detail how the care is to be given nor whether there are any goals that are being worked towards. The manager is therefore in the process of increasing the number of core care plans. Relatives spoken with confirmed that they had seen their relative’s care plan and had attended care plan reviews. Documentation on care files evidenced that the full range of healthcare facilities are accessed on behalf of residents. These include general practitioners, optician, dentist, chiropodist, psychologist and district nurses. The home also accesses the continence advisor and falls clinic as appropriate. These visits are noted in daily care notes and the communications book but they are also recorded in individual care files on multi-disciplinary team input/district nurse intervention/hospital appointments sheets, which is good practice. The storage, recording and administration of medication was observed and procedures were satisfactory. The home uses the monitored dosage system but does have a few medications that are supplied outside of this system. In order to check the administration of these medications, the manager intends to undertake a tablet count once per week, signing the medication administration record (MAR chart) when this is done, which is good practice. This system was due to start at the end of the week following the inspection. The manager is also in the process of changing the pharmacist who supplies medication to the home as she has found some errors recently in the medication supplied and the instructions given. Observation of staff interacting with residents, and verbal evidence from speaking with the manager, two senior healthcare assistants and interviewing two healthcare assistants, indicated that residents are treated with respect and their rights to privacy and dignity upheld. Staff were observed to knock on doors before entering, to speak to residents with kindness and respect, and described care practices which ensured residents’ dignity and privacy are respected. All residents were well groomed and dressed and all clothing is labelled to ensure that residents’ individuality is maintained. Residents spoken with said that they were happy with the care given at the home, that the atmosphere was friendly and they could “have a laugh” with staff. Relatives spoken with also said that they were happy with the care given at the home, that the majority of staff were friendly and that keyworkers related well to residents. DS0000025637.V295855.R01.S.doc Version 5.2 Page 12 All care files seen had funeral preparation plans, which were signed and dated by either the resident or their relatives as appropriate and where they were willing to do so. One healthcare assistant described the care given to a resident during their last days at the home before they had died, and this care had been given with respect for the resident’s individual wishes and preferences. DS0000025637.V295855.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Daily routines are flexible to suit residents’ preferences and capacities. Residents are supported to maintain contact with family and friends and to access the community according to their capabilities and wishes. Residents are assisted to exercise choice and control over their lives and receive a balanced and nutritious diet in pleasant surroundings. EVIDENCE: Evidence was observed throughout the inspection that routines are flexible and that individual resident’s choices and preferences are respected. Residents confirmed that they were able to get up and go to bed whenever they wished and there was documentary evidence of this in daily care notes. Residents were observed to move about the home at will during the inspection, some going to their rooms to watch television or have a nap, one resident choosing to stay in his room and have his meals there on a day when he was feeling poorly. The following day when he was feeling better, he was encouraged and supported to have lunch in the dining room so that he could socialise and have company. Religious observance is respected with the home arranging for ministers to visit those residents who wish it. The home has just appointed a new part-time activities organiser, who held a singing session on the first day of the inspection. The activities organiser is currently getting to know each DS0000025637.V295855.R01.S.doc Version 5.2 Page 14 resident individually and intends to undertake more one-to-one, rather than group, activities so that resident’s individual interests and choices can be provided for. Visiting relatives were very pleased with her idea of making individual albums of personal reminiscence for residents, which would be particularly suitable for residents with poor short-term memory and dementia. The home continues to employ an exercise instructor who holds a chairaerobics class at the home twice a week. Two residents mentioned this class to the inspector, saying that they enjoyed and looked forward to it. On both days of the inspection there were visiting relatives at the home. They, plus other residents spoken with, confirmed that visitors are encouraged and made welcome at the home, offered drinks and biscuits, kept informed of matters affecting their relative, and encouraged to know what is in care plans and to come to care plan reviews. There are two rooms in the conservatory, one for smokers, which can be used by visitors if they wish to see their relative in private. At the inspection of 12th January 2006 it was found that staffing numbers prevented staff from being able to escort residents out into the community and from spending time to give them personal attention such as hand-massages. At this inspection it was found that staffing numbers had been increased and the inspector was told that at least four residents are escorted out to the shops, park or garden centre during the week if they wish to go out. Visitors mentioned how much their relatives appreciated the hand-massages given by staff. Examples of residents’ choices have been given under Standard 12 above and Standard 15 below. The inspector was told that it is the policy of the home not to manage any resident’s personal monies, which are managed by themselves or by their relatives. Two sets of relatives and two residents were asked about this and said that they were happy with these arrangements. If residents have their hair cut by the visiting hairdresser or buy clothes from the visiting shop, then the charge is invoiced to relatives. The home encourages service users to use external health and social care professionals as advocates and publicises the telephone number of a local advocacy service in the Statement of Purpose. Service users are encouraged to bring personal possessions to the home, which were observed in some bedrooms, and can access their personal records if they wish in accordance with the Data Protection Act. Over the two days of the inspection, one breakfast and two lunchtimes were observed. Residents had a choice of breakfast, some having toast, cereal and eggs, others having one or two of these selections according to preference. Porridge is also available. The lunch was sampled on both days and was tasty and well presented, the homemade chicken pie on one day being particularly tasty. The alternative to chicken pie was liver and bacon, which several residents were observed to enjoy. The fish meal on the following day had a slice of fresh lemon with it, and there was fresh fruit salad available for DS0000025637.V295855.R01.S.doc Version 5.2 Page 15 diabetic residents as an alternative to the two sweet choices. There is a choice of cooked meal each lunchtime, but there are also other alternatives available, such as ham or cheese salad, if neither cooked meal is desired. The main meal at lunchtime is always handmade, and there is a light supper in the early evening (5.30 p.m.) and a drink with biscuits later in the evening. The cook prepares homemade cakes daily, which are given to residents with a hot drink at teatime, and bakes a special cake for each resident’s birthday. Residents spoken with said that they enjoyed the food at the home and that they were never hungry. Daily care notes evidenced that residents are offered drinks if they are up late at night or if they wake in the night and cannot settle down again. Menus were seen. There is a four week menu cycle, offering varied, balanced and nutritious meals. There is currently only one resident at the home from a visible minority ethnic background but this resident has indicated that she does not wish to have non-British dishes. DS0000025637.V295855.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure but there is currently one outstanding complaint that has not met the set timescale. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure which meets the requirements of regulation and keeps a complaints book. One formal complaint has been received by the home since the inspection of 12th January 2006. This complaint is currently being investigated by the Registered Provider, who has informed CSCI that she has been unable to process the complaint within 28 days due to difficulties in obtaining pertinent information from other professionals. However, it is now several months since the complaint was made. At the time of this inspection the Registered Provider was not available and therefore the progress of the complaint could not be ascertained by the inspector. See Requirement 2. All staff have undertaken training in adult protection and staff spoken with were fully aware of the different types of abuse that may take place towards residents and were aware of how any suspicions of abuse must be handled and reported. Staff were also aware of how to deal with difficult behaviours and an incident was observed during the inspection when difficult behaviour was handled appropriately and kindly by staff. DS0000025637.V295855.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s general environment is safe and the communal areas are well maintained. Service users have access to safe and comfortable indoor and outdoor communal facilities. Bedrooms are personalised but some are not well maintained. There are problems with the physical standards in regard to insufficient bathroom and sluicing facilities, insufficiently guarded radiators, the absence of thermostatic valves for individual choice and no passenger lift. The kitchen is clean and well organised but has no dishwasher and there is a redundant wall grill that must be removed. The home is clean and hygienic throughout. EVIDENCE: The home has three communal areas, all on the ground floor and all attractive and homely. This provides residents with a choice of where to spend their time. The first communal area, the main lounge, is a large well furnished room which has a television and video area near to the kitchen hatch, and an area where service users can sit away from the television. Half of the room is used DS0000025637.V295855.R01.S.doc Version 5.2 Page 18 as the dining area, and one corner is used as a desk for senior healthcare workers who can undertake paperwork whilst still observing and interacting with residents. The second communal area, a newly built conservatory, leads off from the lounge. It is large and well lit with comfortable chairs, good quality furniture and fittings and attractive décor. Two separate rooms have been built within the conservatory. They are comfortably furnished, with one being a smoking room and the other a private visitors/meeting room. Residents were observed to use these communal areas at will and to meet with relatives in the conservatory. There is a third communal area in the home, a smaller lounge at the front of the building, which is being used as an activities room. There are problems with the physical standards in other areas of the home: • • There is a gas wall grill in the kitchen which is no longer used and which presents a safety hazard to the cook. See Requirement 3. The décor, furniture and carpet in several upstairs bedrooms, particularly in the No. 36 area of the home, are poor. The Director agreed to refurbish one of these bedrooms each month starting from September 2006. See Requirement 4. 3 bedrooms had large vertical windows without appropriate restrictors. The Director said that this would be made good within the following week. See Requirement 5. Several health and safety issues were observed such as a headboard not fixed to the bed, a wardrobe loose on its base, a wire pulled away from the skirting board and loose, 2 sinks that were not firmly fixed to the wall and a broken blind. The loose wire and sinks were fixed during the inspection and the headboard removed from the room. The Director undertook to fix the outstanding items within the following week. See Requirement 6. The commodes used in residents’ bedrooms are old and unattractive. The Director undertook to replace all of them with more modern and comfortable models. See Recommendation 1. Some towels and flannels were worn and required replacement. See Recommendation 2. One of the two assisted bathrooms on the ground floor had the fixtures for a radiator but no radiator installed. See Requirement 7. Access to upstairs bedrooms for disabled service users is currently by stair lift only. See Requirement 8. The majority of radiators in bedrooms do not have low surface temperature covers. See Requirement 9. The majority of radiators either did not have adjustable thermostatic controls or did not have useable ones. See Requirement 9. There are no communal bathroom facilities on the first floor. (There is a shower room that is inappropriate for residents’ needs and cannot be used.) See Requirement 10. • • • • • • • • • DS0000025637.V295855.R01.S.doc Version 5.2 Page 19 • • There are only two working bathrooms (excluding the 2 bedrooms with en-suite facilities) which is insufficient for 25 residents. See Requirement 10. There is no sluicing facility. See Requirement 11. The last six points in the above list have been subject to requirement since an inspection carried out on 3rd March 2005. The Registered Person has acquired the next door premises and has said that these requirements will be implemented during the major building works to be carried out once planning permission to merge the next door premises with the current home is obtained. However, the outstanding requirements directly affect health and safety and the quality of life for residents and they have been outstanding for over one year. CSCI have arranged to meet the Registered Person in September 06 to discuss the matter and agree a timetable for implementation. The previous inspection report of 12th January 2006 made a recommendation that a system should be put in place whereby keyworkers undertake a weekly check of the residents’ bedrooms and that they, or the maintenance worker as appropriate, make good any problems found. The acting manager has devised a weekly inventory form but the system has not yet been put into operation. At this inspection several wall clocks in resident’s bedrooms were not working or were showing the incorrect time, and in view of this and the other maintenance problems found, the previous recommendation is repeated. See Recommendation 3. On the days of the inspection the home was found to be clean and hygienic. The kitchen and food storage facilities were seen and found to be well ordered, clean and hygienic. As this is a large home and the cook does not have a kitchen assistant it is recommended that a dishwasher is provided. See Recommendation 4. DS0000025637.V295855.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff and residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policies and practices. Staff are trained and competent to do their jobs. EVIDENCE: Rotas were seen and showed that there were sufficient care staff on duty to meet the assessed needs of residents. The inspection report of 12th January 2006 required the Registered Person to review staffing levels and this had been done, resulting in the increase of one care assistant per early and late shift. Rotas showed that for the four weeks covering the period of the inspection there had been four care workers on duty for every early and late shift, with the exception of one morning only when there were three care workers as the fourth worker had taken sick. There are currently 3 senior healthcare assistant posts. The acting manager tries to ensure that there is a senior healthcare assistant on each shift and this will be easier when the third senior returns to work in September 2006 following maternity leave. Observation of practice, speaking with two senior healthcare assistants and interviewing two healthcare assistants indicated that staff have a good understanding of the problems associated with old age and the general and individual needs of residents of the home. DS0000025637.V295855.R01.S.doc Version 5.2 Page 21 The home employs sufficient cleaners to give 4 hours of cleaning each morning, seven days each week, and 5 hours of laundry work each morning, also seven days each week. The laundry room is small but it due to be modernised when the major building works take place. The main chef works at the home for 7 hours each day from Monday to Friday and there is another cook covering the same hours at weekends. In regard to care staff qualifications, the home has exceeded the 50 training target as all staff have NVQ Level 2. In addition, one senior healthcare assistant has NVQ Level 3 and one healthcare assistant is in the process of studying for it. The home is to be congratulated on having a fully qualified staff team. Six staff files were inspected in regard to recruitment practices. Overall, a thorough recruitment procedure was in evidence. There were application forms, interview notes, evidence of identification as well as references and CRB checks available. For the most recently appointed staff POVA First checks had been obtained pending the receipt of CRB checks. Recently appointed staff also had records (where relevant) of training received. Staff training records are kept on each staff member’s personal file. Some files were detailed and included a training log. However, the acting manager said that she is currently going through each file to add training certificates received. She said that staff had received training in many of the key training areas such as first aid, food hygiene and manual handling. During the first three months of 2006 the home provided training for all staff on vulnerable adults, dementia care and dying, death & bereavement. Staff mentioned that they had found the dementia training particularly good. Once the task of adding training certificates to staff files is completed the acting manager will be better able to demonstrate that staff are trained and skilled to provide care to residents. As this work is ongoing and there is a need to have a staff training record a requirement has been give for a training record to be drawn up covering all staff and for training certificates to be placed on staff files. See Requirement 12. One of the healthcare assistants interviewed had just finished her six months probationary period. She confirmed that there is an induction period at the home, which includes shadowing an experienced member of staff for the first week, and said that there was always a senior healthcare assistant around and that they were very approachable and helpful. DS0000025637.V295855.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is competent and experienced to run the home and provides a positive ethos, leadership and management approach. There is no established quality assurance system but formal feedback from relatives has been sought. Residents’ financial interests are safeguarded. A supervision system for staff is in the process of being established. The health, safety and welfare of service users is promoted but many of the certificates and records were not available to be inspected at the home. EVIDENCE: The acting manager was the Registered Manager of the home until the end of May 2005 when she left her post to take a break. She resumed management of the home in November 2005 but information received subsequent to the inspection indicates that she will have to re-register in order to resume as the DS0000025637.V295855.R01.S.doc Version 5.2 Page 23 Registered Manager of the home. See Requirement 13. The acting manager has six years previous experience in managing the home, is a qualified first aider, an NVQ Assessor for Levels 2 & 3 and is part-way through the NVQ qualification in Management and Care. There are clear lines of accountability in the home, which was evident at the management meeting of the acting manager and senior healthcare assistants that the inspector attended. At the inspection of 12th January 2006 it was noted that since the reemployment of the acting manager morale at the home had improved noticeably and considerably, with care staff saying that they were much happier at work now. At this inspection feedback on the acting manager’s style of management, commitment to care, ethos and leadership was equally positive, from residents, visiting relatives and staff. All staff spoken with said that the acting manager was approachable and supportive, one staff, who has several years experience in a variety of other care homes, said that the acting manager “is a very good manager”. Relatives said that the acting manager “is very caring and very efficient” and that any issues raised are sorted out “immediately”. They said that she had created “a good atmosphere” in the home. Observation evidenced that residents feel comfortable speaking and interacting with the acting manager and enjoy the attention that she gives them. The inspection report of 16th June 2005 required that the Registered Person developed an effective quality assurance system for the home. At the time of this inspection it was found that an effective quality assurance system had not been established. The Registered Person had undertaken monthly inspections of the home in May and June 2006 but although a copy of the May monitoring visit was sent to CSCI there were no records of the June 2006 or any other monthly visits at the home. See Requirement 14. At the inspection of 12th January 2006 the acting manager had sent out a questionnaire to canvas the formal views of relatives but subsequently only received 4 replies. Similarly, there had been a poor response to relatives’ meetings held. The acting manager has therefore decided to send out a newsletter every six months to relatives to keep them informed and invite feedback, and to write a simple questionnaire that residents will be asked/assisted to respond to annually. An annual summary of residents’ comments will be produced from the responses received, which will ensure that Regulation 24 (3) is fulfilled. There is an administrator at the home for one day per week, who organises the staff files and residents’ invoices. The administrator told the inspector that the home does not administer or manage any service user monies. Residents’ personal monies are handled exclusively by themselves or their relatives, or by solicitors and social workers where there are no relatives. Relatives/solicitors pay a lump sum to the Registered Person’s head office and anything a resident purchases, such as hairdressing or items from the mobile shop, is financed from petty cash, notified to head office and entered on invoices which relatives receive monthly. The inspector asked three residents and two sets of relatives DS0000025637.V295855.R01.S.doc Version 5.2 Page 24 whether they were happy with this arrangement and all confirmed that they were. A fourth resident, who was fully mobile, confirmed that he managed all of his own monies. The administrator showed a selection of invoices to the inspector and was also able to evidence receipts for items purchased, such as clothes. Neither the home nor head office have any interest in residents’ savings, which are managed exclusively by relatives or legal stakeholders. Staff supervision arrangements were discussed with the acting manager. She said that she alone provides supervision for all the staff. An example of staff supervision records was seen. This was a standard sheet which had a number of headings which would assist the supervisor to run a supervision session. A supervision schedule, covering all staff, was shown to the inspector as was an example of supervision records for one member of staff. A good standard had been achieved. The acting manager said that her next task was to extend the frequency of staff supervision sessions. The acting manager has been successful, thus far, to set up the staff supervision session and she should be able to increase the frequency of sessions over the coming months. See Recommendation 5. The arrangements for health and safety management were discussed with both the maintenance officer and the acting manager. Overall, an adequate system was in evidence but several certificates such as fire safety and the maintenance of the home’s installations and equipment were unavailable. The inspectors were told that a number of such certificates were retained at the company’s head office rather than at the home itself. Therefore, it is impossible to say that this standard has been met. A requirement is given that the missing certificates are brought to the CSCI office next month when there is to be a meeting between CSCI and the home owners, and that from now on copies of these must be kept at the home. See Requirement 15. Certificates required to be seen are: fire alarm, emergency lighting, stairlift maintenance, electricity, gas safety, legionella and small electrical appliances (PAT); environmental risk assessment and fire risk assessment must also be evidenced. The latter are particularly important as there were some hazards observed on the day of inspection, such as discarded items and wooden boards outside a fire exit door and the unguarded radiators and windows referred to under the Environment standards above. The following records were seen at the home and found to be in order: fire extinguisher checks, weekly fire alarm tests, weekly water outlet tests and COSHH data sheets. There was an environmental health kitchen inspection report dated 20/10/05 and the Registered Person must confirm in writing whether all of the recommendations arising have been implemented. See Requirement 16. The maintenance worker confirmed that wheelchairs are regularly maintained but it is recommended that records of this maintenance are kept. See Recommendation 6. There is no hoist at the home although it was noted that there is one resident who cannot weight-bear and has to be transferred by staff. The acting manager said that she was in the process of arranging a hoist via the district nurse team. This must be done as a matter of urgency. See DS0000025637.V295855.R01.S.doc Version 5.2 Page 25 Requirement 17. The acting manager has arranged for each care worker to have a portable dry handwash container, which is attached to their belt and means that they can always ensure that their hands are clean and hygienic. This is good and innovative practice. DS0000025637.V295855.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 1 X X 2 1 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 2 X 3 2 X 1 DS0000025637.V295855.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4(2) Requirement The Registered Person must supply CSCI with a copy of the updated Statement of Purpose as soon as it is available. The Registered Person must ensure the timely completion of the complaints investigation and supply of copy of it to CSCI. The Registered Person must ensure that the wall grill is removed from the kitchen and replaced by a suitable alternative model. The Registered Person must ensure that all resident bedrooms in poor condition are refurbished. The Director has undertaken to refurbish one bedroom per month from September 2006. The Registered Person must ensure that appropriate window restrictors are fitted to the three vertical bedroom windows. The Registered Person must ensure that the health and safety issues in bedrooms identified at the inspection are made good. The Registered Person must DS0000025637.V295855.R01.S.doc Timescale for action 01/11/06 2 OP16 22(8) 01/10/06 3 OP19 23(2)(c) 01/11/06 4. OP24 16(2)(c) 01/09/07 5 OP24 & OP38 12(4)(c) 01/09/06 6 OP24 & OP38 12 (4) 01/09/06 7 OP25 23(2)(p) 01/10/06 Page 28 Version 5.2 8 OP19 23(2)(k) 23(2)(n) 9 OP25 13 (4)(a) 10 OP21 23(2)(j) 11 OP26 23(2)(k) 12 OP30 18(c)(i) & Sch.2 (4) 13. OP31 9 (1) 14 OP33 24 ensure that a radiator is installed in the new assisted bathroom The Registered Person must submit a timetable to the Commission for the construction of a passenger lift. Previous timescale of 31/05/06 not met. The Registered Person must ensure that all radiators and pipe work are guarded or have low temperature surfaces. All radiators must have individually adjustable thermostatic controls. Radiator guards must give access to the radiators thermostatic control. Previous timescales of 31/10/05 and 31/08/06 not met. The Registered Person must ensure that there are sufficient bathroom facilities to meet residents needs and must consult with the Commission regarding the number and location of assisted bathrooms that are to be provided for general use in the home after the en-suite facilities are built. Previous timescales of 31/07/05 and 31/05/06 not met. The Registered Person must ensure that a sluicing facility is installed. Previous timescales of 31/07/05 and 31/01/06 not met. The Registered Person must ensure that a training record is drawn up for each member of staff and that training certificates are placed on staff files. The Registered Person must ensure that the new manager applies to the CSCI to be registered. The Registerd Person must establish and maintain an DS0000025637.V295855.R01.S.doc 08/09/06 08/09/06 08/09/06 08/09/06 01/12/06 01/10/06 01/11/06 Page 29 Version 5.2 15 OP38 12 (1) (a) & 12 (4) 16 OP38 12 (1)(a) 17 OP38 12 (5) effective quality assurance system. Previous timescale of 31/12/05 not met. The Registered Person must submit copies of the health and safety certificates and risk assessments cited under Standard 38 to CSCI and ensure that copies of these are maintained at the home from now on. The Registered Person must confirm in writing whether all of the recommendations arising from the environmental health kitchen inspection report dated 20/10/05 have been implemented. The Registered Person must ensure that the hoist for a resident who cannot weight bear is obtained as a matter of urgency. 08/09/06 01/11/06 01/11/06 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 2 3. Refer to Standard OP24 OP21 OP19 Good Practice Recommendations The Registered Person should ensure that all bedroom commodes are replaced by more modern and comfortable models. The Registered Person should ensure that all worn towels and flannels are replaced. The acting manager should ensure that keyworkers undertake a weekly check of resident’s bedrooms and that they or the maintenance worker make good any problems arising. The Registered Person should consider providing a dishwasher for the kitchen. The acting manager should continue to develop the supervision system, to ensure that care staff receive DS0000025637.V295855.R01.S.doc Version 5.2 Page 30 4 5 OP26 OP36 6 OP38 formal supervision six times per year. The Registered Person should ensure that the maintenance worker keeps records of the maintenance of wheelchairs. DS0000025637.V295855.R01.S.doc Version 5.2 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000025637.V295855.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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