Inspection on 12/01/06 for Penerley Lodge

This inspection was carried out on 12th January 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 10/08/06

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 12 January 2006 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 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 penerley@aol.com 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 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 27 elderly persons of whom up to 2 may have dementia 16th & 24th June 2005 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 two formerly private 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 space for 6/7 cars to park on the forecourt of the home and nearby on-street parking is available. The home has a decking area and garden with raised flowerbeds at the rear and a large, recently built conservatory which also has a private meeting room and a smoking room. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 12th January 2006. The inspector spoke with the new acting manager, the new administrator, several members of staff, two service users and a visiting relative. The inspector also toured the building and looked at documentation and records. The previous manager, who had been at the home for just over 4 months, was on long-term sick leave and the acting manager had been at the home for just over a month. There was also a new administrator, who was working part time at the home and had been employed at the home for only a couple of months at the time of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to continue to improve documentation and records, to continue to implement the previous inspection requirements that are currently in progress (medication reviews, quality assurance, abuse training and informal complaints recording) and to ensure that the Commission is informed of when the outstanding requirements at the home, such as the provision of a passenger lift and sluice will be implemented, of the results of the staffing level review and full details of the building works planned including the provision of suitable and sufficient communal bathrooms in the home. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 6 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. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 and 6 Prospective service users have the information they need to make an informed choice abut where to live. Service users moving into the home receive a full, recorded, assessment of needs. The home does not accept service users solely for intermediate care. EVIDENCE: The previous report noted that the Statement of Purpose was out of date and required that it be updated. This had been done and a copy was supplied at the inspection. The Statement of Purpose covers all of the areas required by regulation, and gives prospective service users the information they need to make an informed choice about the home. There has been one minor omission (the number of healthcare assistants employed) but for the intent and purposes of regulation, this Standard is met. The previous report also noted that in two of the four care files examined at the inspection, the home’s assessment was incomplete. Since the previous inspection there had been four new admissions to the home and two of the care files of the newly admitted service users were examined. These were found to have full and complete assessments carried out by the home, Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 9 covering areas such as medication, dietary requirements, communication skills, aids and adaptations, health and safety, risks, nutrition, spiritual needs and personal care needs. The home had also obtained all available external professional assessments and care plans, such as continuing care assessments and psychologist reports. The home does not accept service users solely for intermediate care and so Standard 6 is not applicable. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 and 11 A care planning system is in place and new care plans are satisfactory, with older plans needing to be updated to the new system. Service users’ are able to access a range of healthcare facilities. The home’s policies and procedures for dealing with medicines is satisfactory. Service users are treated with respect and their privacy safeguarded. Funeral plans were present on the care files examined. EVIDENCE: At the previous inspection it was found that although the basic care plan format was good, older care plans had too many individual plans and newer care plans were too sparse. It was concluded that the lack of a clear, consistent and regularly reviewed care planning system did not provide staff with the information needed to satisfactorily meet residents’ needs and did not evidence that care was being suitably provided and progressed. At this inspection it was found that good progress had been made towards improving the care planning system. The majority of staff had received external care planning training and monthly reviews were in progress. Care plans of the service users admitted since the previous inspection demonstrated that care plans had improved, and monthly reviews carried out. It is recommended that Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 11 all past care plans are reviewed and re-written/adjusted as necessary to bring them up to the new standard of care planning and review currently being implemented. It is understood that this may take some time, given that the home is just emerging from a period of considerable staffing instability, but it is hoped that this can be planned for in a systematic way, for example a few care plans per month, so that by the middle of the next financial year this can be achieved. Care files and verbal information evidenced that the full range of healthcare facilities are accessed on behalf of service users. These include general practitioners, dietician, chiropodist, dentist, psychologists, community psychiatric nurse and district nurses. The home also accesses the continence advisor as appropriate. These visits are currently noted in care plans as they occur but the manager is currently devising a form on which all healthcare visits will be noted in date order in one place, which is good practice. The Pharmacist Inspector inspected the medication system at the home during the previous inspection and made requirements in regard to gaps in recording, only trained and designated staff administering medication and regular medication reviews for all service users. All of these requirements had been progressed. The new acting manager now reviews medication sheets weekly, all healthcare assistants have had certificated medication training, and General Practitioners have been contacted in regard to medication reviews. Staff spoken with confirmed that they had attended the medication training and were able to describe the administration system followed at the home. No problems were found with this, nor with the storage of administration but on the day of the inspection there were a couple of gaps in the recording of medication for the week. The manager said she would follow up on these by tracing and speaking with the healthcare assistant concerned. The inspector spent time speaking with the daughter of a service user who had been at the home for approximately 7 months and who visited her father daily. She said that staff were very “good, nice”, kind and caring and that the new manager was “wonderful” and “really cares” about the service users. She had been shown her fathers’ care plan, had attended a relatives’ meeting and said that she is always informed of anything that happens to her father or affects him. She commented that as she visits the home daily she could see the enormous improvement in the atmosphere and care practices since the new manager had arrived at the home. She also made some comments in regard to staffing numbers at the home and these will be referred to later in the report. Staff spoken with described how they safeguard service users’ dignity and privacy when they are receiving personal care and how they ensure that service users’ are encouraged and supported to be as independent as possible in this area. At the previous inspection there were two areas where service users’ dignity, privacy and choice were being compromised. The stair lifts, which are the only means of access to bedrooms for service users unable to Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 12 climb the stairs, had been out of order for several days and this had meant that some residents were unable to access their bedrooms during the day and had to wait in line to be assisted upstairs at night. A requirement was made for the Registered Person to ensure that chair lifts were repaired in a timely manner. At this inspection the manager said that there was now no problem with getting the chair lift repaired immediately when it broke down, as had occurred on the night before the inspection when the engineer had been called out. The second area where service users’ dignity and choice were being compromised at the previous inspection was in regard to the numbers and availability of bathing facilities, and this will be referred to later in the report. The care plans seen of the service users who had been admitted since the previous inspection had funeral plan details noted and signed by both the relatives and the manager, which is good practice. The manager should ensure that these details are present on all care files. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 and 15 Daily routines are flexible but there is currently no planned activities programme at the home to interest and stimulate service users. Service users are supported to maintain contact with family and friends but access to the community is restricted for those who require escorting. Service users are helped to exercise choice and control over their lives and receive a balanced and nutritious diet in pleasant surroundings. EVIDENCE: There was evidence from observation and from speaking with staff that service users are supported to make choices in regard to waking and getting up, clothing, meals, daily occupations and going to bed. Examples were given of a service user who likes to have breakfast in their dressing gown before getting dressed and others who like to stay in bed longer and therefore have breakfast in bed. During the day, service users were observed to move around the home at will and during the afternoon choose to undertake various individual activities such as knitting, reading, chatting or napping. One service user is able to go out independently and often chooses to do this but service users who require staff accompaniment/assistance are unable to go out when they choose due to insufficient staff availability. Examples were given of one service user who was keen to go to the bank, and another who used to enjoy local shopping trips, who were now unable to do this for lack of staffing Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 14 availability. This will be addressed later in the report. In regard to planned indoor activities, the Activities Co-ordinator who had just joined the home at the time of the previous inspection had unfortunately left employment and therefore at the time of this inspection there was no regular planned activities programme to interest and stimulate service users. However the Registered Provider had advertised for a new full-time activities co-ordinator and meanwhile was encouraging some service users to start attending day centres. Staff said that they were currently organising chair aerobics and singsongs on Fridays. The home’s policy is that visitors are welcome at any reasonable hour and the relative spoken with, who visits the home daily, said that she and other visitors are made welcome. The Proprietor has built a large conservatory at the back of home which continues on from the main lounge and which has a small pleasantly furnished room that can be used for private visiting space. Examples of service users 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 service users’ monies – these are managed by themselves or by their 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 and can access their personal records if they wish in accordance with the Data Protection Act. Menus and observation at inspections evidenced that the meals provided are varied and nutritious, with the main meal at lunchtime and a light supper in the early evening (5.30 p.m.). There is a four week menu, with 2 choices each lunchtime and the choice of a hot or cold supper each evening. There is currently one service user at the home from a visible minority ethnic background but who has indicated that she does not wish to have non-British dishes. The inspector sampled the lunch on the day of the inspection. It was home-made steak and kidney pie with two vegetable dishes, mashed potato and gravy, with fresh pineapple on sponge with cream for sweet. The meal was very tasty and well presented. The relative spoken with said that there was always a “good spread” in regard to lunches at the home. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 15 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 and 18 Staff lack knowledge and understanding of Adult Protection issues, although training has been planned. The home has a satisfactory complaints system but needs to record other issues raised by residents more formally, including the action taken to address them. EVIDENCE: The home has a complaints procedure which meets the requirements of regulation and keeps a complaints book. However it was found at the previous inspection that some issues raised by service users, which were not formal complaints but were informal, had not been dealt with promptly or satisfactorily. A requirement was therefore made for all complaints/issues raised by residents to be recorded and actioned. At this inspection it was found that recording was taking place in the ‘daily comments’ section of individual care files, however this did not give a clear picture of whether action had been taken and the results. This was discussed with the new manager who said that she would start a Concerns File where informal complaints/issues/concerns raised would be listed along with space for action and results. It is recommended that issues raised continue to be noted in individual service users’ daily comments sheets but that they are repeated in the Comments File, where action taken can be noted and easily identified. At the previous inspection it was found that staff were not aware of the very many other types of abuse that can occur within a residential home apart from physical abuse. A requirement was made for all staff to receive abuse training by 30th November 2005. This deadline had not been met. At this inspection staff spoken with had a slightly broader understanding of the different types of Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 16 abuse but were not aware of adult protection procedures. The inspector was told that abuse training had been arranged for four consecutive weeks in January 2006 and that staff were expected to ensure that they attend one of these four training dates. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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 and 26 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 and generally well maintained, but access to upstairs bedrooms for disabled service users is currently by stair lift only. There are problems with the physical standards in regard to insufficient bathroom and sluicing facilities and insufficiently guarded radiators and pipework. The home is clean and hygienic throughout. EVIDENCE: The home has three communal areas, all on the ground floor. The first, the main lounge, is a large room which has recently been recarpeted. It has a television and video and an area where service users can sit quietly away from the television. It is also used for dining and all of the dining chairs have recently been replaced with new good quality new chairs. The newly built conservatory leads off from the lounge. It is large, attractive, well lit and well heated. It has comfortable chairs, good quality furniture and fittings and attractive décor. Two separate rooms have been built within the conservatory, Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 18 which are comfortably furnished, one of which is a smoking room and the other a private visitors/meeting room. There is a third communal area in the home, a smaller lounge at the front of the building, which is currently being used for activities only. As there was no activities co-ordinator in post at the time of this inspection, the room was not being used. At the previous inspection in June 2005 it was found that a few bedrooms in the home had been completely refurbished to a to a very high standard and the Proprietor said that it was her intention to refurbish all bedrooms to this standard during the forthcoming year. However, at that inspection it was found that many of the remaining bedrooms had not been well maintained in regard to furniture, fittings and carpets. It was recommended that a complete audit of bedrooms was carried out, making good as necessary, and that a system of weekly checks was implemented. This had been done and at this inspection the standard of all bedrooms had improved, with the required fixtures and fittings in all rooms and improved décor in some. In addition all of the bed linen had been renewed, new pillows obtained and each bedroom had been supplied with a cork notice board. The latter was being used for personal photographs and for an inventory in each bedroom of the individual service users’ needs/skills in regard to personal care and what particular help was needed. This ensures that all staff, including new and temporary/agency staff, know exactly what the individual service user’s needs are and how they are expected to meet them, which is very good practice. The majority of bedrooms are upstairs but access to them for disabled service users is by stair lift only as the home does not have a passenger lift. The Proprietor intends that a passenger lift will be provided once the planned development works in regard to a new wing to the home are implemented. The home, which is registered for 27 residents, currently has 2 bathrooms and 3 separate toilets on the ground floor, and one toilet and one shower room on the first floor. The two bathrooms on the ground floor have assisted baths but the inspector was told that the upstairs shower room is not used by service users as they dislike it/do not wish to shower. This means that in practice there are 27 service users using 2 bathrooms, which is insufficient to ensure adequate choice. However, at the previous inspection the Proprietor said that it was intended that all bedrooms would have en-suite facilities within a year’s time when renovation works were complete. The en-suite facilities will consist of a washbasin, toilet and new-style walk in shower that is installed over the toilet, so that the user sits on the toilet seat when showering. The completion of these plans, including a passenger lift for access, will ensure that the home has sufficient toilet and shower facilities, however the Proprietor must ensure that there are also sufficient assisted baths available to meet the needs and choices of residents. The Proprietor must consult with CSCI regarding the number and location of assisted bathrooms that are to be provided for general use. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 19 At the previous inspection it was found that radiators in lounges and some bedrooms had been guarded but the type of guards used did not give access to the thermostatic controls and therefore restricted choice. A requirement was made for radiator guards to be altered to give access to the radiators’ controls. This had not been done, however the Proprietor explained that the radiators operate on a central thermostat and that if there were any problems the maintenance man visits daily and can get access to the radiator very easily. At this inspection it was also found that no further radiator guards had been installed in bedrooms since the previous inspection and therefore the majority of bedrooms still did not have radiator guards/low surface temperatures. However, subsequent to this inspection the inspector was told that that Proprietor will provide plastic mesh guards/grills to all bedroom radiators by the end of April 2006. These guards/grills have been chosen as they will not restrict the heat radiated out as the wooden guards do. Kitchen and laundry facilities are adequate for the current size of the home but these are both planned to be expanded as they will be the two parts of the existing home that are shared with the planned new dementia unit. On the day of the inspection the kitchen was found to be clean and hygienic and the larder well stocked. The kitchen had been deep cleaned since the previous inspection and the manager said that this would be done monthly in future. The two previous report highlighted that facilities for washing commodes were inadequate as these were being washed in the communal bath. The Proprietor plans to install a sluice during the planned building works and must submit a timetable for this once the change of use for the building has been approved by the local Council. On the days of inspection, apart from the issue of separate facilities for washing commodes, the home was found to be clean and hygienic and free from offensive odours. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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, 29, 29 and 30 Service users needs are generally met by staff but staffing numbers must be reviewed to ensure that there is sufficient staff to provide mental stimulation and escorting for service users. Staff are qualified and competent to do their jobs and basic training is provided by the home. Service users are supported and protected by the home’s recruitments practices. EVIDENCE: Rotas showed that there are three care workers on duty for the early and late shifts with a fourth care worker on duty between 6 –9 p.m. to cover the peak period when many residents are preparing for bed. One of the three workers on each shift is a senior care worker. At the previous inspection several residents mentioned that there was not enough staff cover at the home and a requirement was made for the Registered Person to review staffing levels according to the assessed needs of service users. The timescale set for this review had not been met but the new manager told the inspector that the review was now in progress. At this inspection, both staff and a relative spoken with still felt that staffing numbers were too low to meet all of the needs of service users. Verbal examples given included not enough staff on the floor to assist service users who wander/”try to escape” when staff are bathing/toileting/writing reports, the manager undertaking hands on care if a member of staff is absent due to illness, staff not being able to escort service users to local shops or the bank and staff not having enough time to organise bingo or “pamper” service users by massaging their hands or varnishing their nails etc. The requirement for a review of staffing levels therefore still stands, Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 21 with the timescale extended to the end of this financial year. The Commission must be informed of the results of the review. Staff spoken with demonstrated an understanding of individual service users’ needs and a commitment to ensuring their dignity, privacy, independence and confidentiality. The home has exceeded the recommended training target of 50 of care workers having the NVQ Level 2 qualification. The inspector was informed that 10 of the 11 care workers at the home have achieved NVQ Level 2, with 2 of these having achieved NVQ Level 3. The remaining healthcare assistant is beginning NVQ Level 2 in March 2006. At the previous inspection it was found that all staff had had Criminal Bureau checks, but that in two staff files checked, not all of the required employment information was present. No new care staff had joined the home since the previous inspection but the employment files of two people in the process of being recruited were seen. These showed that thorough employment checks were being undertaken and that any gaps in information given was being followed up. The new (acting) manager had a comprehensive knowledge of CRB and Protection of Vulnerable Adults employment procedures, and was being ably assisted in the task of recruitment and getting previous files in order by the new administrative assistant. The manager explained the induction programme practised at the home. This included induction status for one week, during which reading policies and procedures and shadowing more experienced staff took place, and training in basic areas such as fire, health and safety, manual handling, food hygiene and infection control. The inspector was shown the new training schedule for ongoing training and this included 4 days each month where courses on adult abuse, dementia care, continence care, food & hygiene, fire and dying, death and bereavement are offered. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 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, and 38 The (acting) manager is sufficiently experienced and competent to run the home and both staff and service users benefit from her ethos, leadership and management approach. Progress is being made in regard to quality assurance. The home does not administer service users’ personal monies. Sufficient evidence was not available at the home to demonstrate that the health, safety and welfare of service users and staff is promoted and protected. EVIDENCE: The home had gone through a very unstable period of management over the previous 2 years, during which there had been four different managers. At the time of the previous inspection there had been no manager at the home and the manager who had been recruited shortly after that had only remained at the home for just over 4 months. This whole period had resulted in care staff Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 23 instability and low staff morale. However, at the time of the current inspection the Proprietor had recruited a previous manager of the home on a temporary acting basis. This manager had been at the home for just over a month at the time of the inspection but morale had improved considerably and noticeably, and very positive feedback was given from both care staff and visitors about her experience, attitude and management style. Care staff said they were much happier at work now and the visitor commented that the new (acting) manager was “wonderful, full of energy, knows how to deal with residents, relates to everyone and really cares”. She said that now that the new manager was in charge, the home was “like one big happy family”. The manager has six years previous experience in managing the home, is a qualified first aider, an NVQ Assessor for Levels 2 & 3 and is half-way through the NVQ qualification in Management and Care. The previous inspection report noted that the home had not established an effective quality assurance system and made an appropriate requirement. At this inspection it was found that progress had been made towards attaining formal feedback from service users, relatives and interested parties by the sending out of a questionnaire. The new manager also planned to hold regular relatives meetings, care staff meetings and auxiliary staff meetings, to canvas views and feedback and to produce a regular newsletter. As the acting manager had only been in post for just over a month, the progress of quality assurance monitoring will be followed up at the next inspection. The administrator told the inspector that the home does not administer or manage any service user monies. These are managed by the service users themselves or, as in the majority of cases, by their relatives. The inspector was unable to fully assess safe working practices at the home. Although documentation relating to COSHH, fire precautions and drills, hot water temperature testing, risk assessments and accidents and incidents were available and in order, certificates relating to annual gas safety tests, fiveyearly electricity tests and annual portable appliance tests were not available at the home. The latest copies of these must therefore be sent to the Commission. Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 4 2 X X 2 1 2 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 1 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 25 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 OP7 Regulation 15(1)&(2) Requirement The Registered Person must ensure that all older care plans are reviewed and brought up to the current standard. The Registered Person must ensure that there are no gaps in the recording of medication administration. The Registered Person must ensure that all complaints/issues raised by residents are recorded and actioned. The previous timescale of 24/06/05 was partially met and further compliance is in progress. The Registered Person must ensure that staff are trained to recognised all forms of abuse. The previous timescale of 30/11/05 was not met but training had been planned for January 2006. The Registered Person 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. DS0000025637.V257802.R01.S.doc Timescale for action 30/09/06 2 OP9 17 Sch 3 3 (i) 22 12/01/06 3 OP16 30/03/06 4 OP18 13(6) 31/01/06 5 OP21 23(2)(j) 31/05/06 Penerley Lodge Version 5.0 Page 26 6 OP25 13 (4)(a) 7 OP26 23(2)(k) 8 OP19OP26 23(2)(k) 23(2)(n) 9 OP27 18(1)(a) 10 OP38 12(1)(a) The Registered Person must ensure that all radiators and pipe work are guarded or have low temperature surfaces and that pre-set valves are fitted to ensure water is provided close to 43 degrees centigrade. Radiator guards must give access to the radiators thermostatic control. This requirement is brought forward from the previous report, including the timescale for action that was set. Previous timescale of 31/10/05 not met but plans in place to implement by 30/04/06. The Registered Person must ensure that a sluicing facility is installed. The previous timescale of 31.7.05 not met but plans are in place. At the time of the inspection the second timescale set had not yet passed. The Registered Person must submit a timetable to the Commission for the construction of a passenger life and sluice as soon after the Change of Use permission has been received from the local Council. The Registered Person must review staffing levels according to the assessed needs of residents to ensure that there is at all times sufficient staffing to meet residents’ needs.Previous timescale of 31/08/05 not met but review in progress. The Commission must be informed of the results of the review. The Registered Person must supply the Commission with copies of the most recent gas, electricity and portable appliances safety certificates. 31/08/06 31/03/06 31/05/06 31/03/06 31/03/06 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 27 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 Refer to Standard OP11 OP16 Good Practice Recommendations The Registered Person should ensure that the funeral wishes of all service users are recorded in their files. The Registered Person should ensure that informal complaints/issues/concerns continue to be noted in ‘daily comments’ sheets as well as listed (with action taken) in the Concerns File Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 28 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 Penerley Lodge DS0000025637.V257802.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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