Inspection on 03/08/07 for Penerley Lodge

This inspection was carried out on 3rd August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Penerley Lodge 10/08/06

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 01:00 3 & 14 August & 13 September 2007 rd 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 Penerley Lodge DS0000025637.V345114.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. Penerley Lodge DS0000025637.V345114.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) 020 8695 6029 Mr H A Cole Mrs Maureen P Cole Mrs. Pauleen Wickes 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.V345114.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 16th March 2007 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 several cars to park and nearby on-street parking. The ground floor, which has some bedrooms and all communal facilities, is fully wheelchair accessible. Access to the first floor bedrooms is by stair lift only. Prospective service users and their relatives are given a copy of the Statement of Purpose, a tour of the premises and are given further verbal information about the home during their trial visit. A copy of the most recent CSCI inspection can be accessed from the office in the home. Current fees are £625 per week for private residents, £457.86 for borough funded/shared/old rooms and £490 for newly furbished rooms. Additional charges include hairdressing, PAT testing, and escorts to appointments (other than emergency appointments). A full list of additional charges items is found in the Statement of Purpose. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two half days on 3rd and 14th August 2007, both visits being unannounced. On the first visit the manager was on a half-day’s leave and the inspection was undertaken with the administrator. Although she had only been at the home for a short while and this was her first inspection, she facilitated it very well and was welcoming, open and knowledgeable. On the second visit the registered manager was present, and she also facilitated the inspection well, along with the seniors and other staff spoken with. During the two visits the inspector spoke in depth with two service users, the registered manager, the administrator, two senior carers, one healthcare assistant and the cook, toured the premises and looked at documentation and records. There was a follow-up meeting with one of the owners on the 13th September 2007 to discuss the physical/environmental issues at the home and the outstanding complaint. The inspector was unable to use the Annual Quality Assurance Assessment (AQAA) form to plan the inspection as it was not received by the Commission. It had been sent to the home on 23rd May 2007 and the manager said she had filled it in and returned it to the proprietor’s head office to be sent on to the Commission. All registered adult care service providers are now legally required to complete an annual quality assurance assessment and return it to the Commission within 28 days. See Requirement 1. What the service does well: Evidence from the inspection indicated that there are several areas where the service does well: • • • • • • • • Potential residents are thoroughly assessed before admission so that the home can be sure they will be able to meet the resident’s needs The home ensures that residents benefit from the full range of healthcare facilities and that their privacy and dignity is respected. Residents choices are supported, relatives and friends are encouraged to visit the home and are made welcome, and the food provided is well cooked and presented, and nutritious. Care plans and risk assessments are regularly reviewed. The home provides good communal and garden facilities. All bedrooms are well decorated and have good furniture and fittings. Recruitment procedures are thorough so that residents are safeguarded from harm. There are good staffing levels and the majority of care staff are qualified. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 6 One resident said that he likes his bedroom, that he has regular visitors and enjoys watching football on the television in his room. Another resident said that she “feels safe” at the home and is very happy there, that she chooses not to join in activities or use the conservatory but enjoys being taken to Church every week. Other residents said that they liked the food at the home. What has improved since the last inspection? What they could do better: Several requirements have been made following this inspection, details of which can be found at the end of the report. They generally fall into the following areas: • • • Ensuring that information required by regulation is given to residents and the Commission Providing information to the Commission regarding the outstanding complaint investigation, activities at the home and staff training Improvements to the physical environment at the home such as a passenger lift, sufficient and adequate communal bathroom facilities, hot water supply to Hazeldene (no. 36), adequate and sufficient food storage facilities Health and safety considerations such as risk assessments to ensure the safety of residents in Hazeldene, and the regular cleaning of the kitchen The establishment of an effective quality assurance system. • • Recommendations were also made in regard to certain documentation, the exercise class, kitchen assistants, and more regular fire drills. Full details can be found at the end of the report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Penerley Lodge DS0000025637.V345114.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 Penerley Lodge DS0000025637.V345114.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information given to residents is comprehensive but needs to be updated and made clearer in some areas, and to meet legislation in regard to contract and fees information. A thorough assessment procedure is carried out prior to the admission of all residents. The home does not admit residents for intermediate or rehabilitative care. EVIDENCE: A copy Statement of Purpose had been sent to the Commission by one of the directors April 2007. All required areas are included, however there are some areas that should be made amended/made clear: • The Aims and Objectives state that the home accepts residents for “long term or short-term care, for convalescence, holiday stays and respite care.” The home must make clear how many beds are set aside for the Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 9 • • • • • See purposes of non-long term care, and must inform the Commission if any beds are kept for respite use only. The manager should be listed as the registered manager, not acting manager. The section on Monitoring and Quality should be updated to reflect that residents meetings do not take place monthly, but less frequently. The “Details of Staff numbers and Staff Training” should state the number of health care assistants employed at the home. This section should also clarify which staff are the “selected” staff sent on external courses for training topics. The “Accommodation” section should be updated as there is no longer a dedicated activities room at the home. The information in the “Fire Safety” section regarding a weekly fire exercise and monthly full drill was not evidenced by records kept in the home. This should be corrected so that accurate information is given. Requirement 2. A copy of the information booklet given to each resident on admission to the home was given to the inspector. This is equivalent to the Service Users Guide. It is a clearly written document which gives service users most of the information they need about the services and facilities offered by the home. It includes the complaints procedure, fire procedure and information on advocacy services. However, it does not fulfil all of the requirements of legislation. The Registered Provider must ensure that it also includes information as outlined in: • • • Regulation 5 (b), relating to accommodation fees, Regulation 5 (c), relating to contracts, and The amendment to Paragraph (1) of Regulation 5 that came into force in July 2006 requiring information, including “whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user.” This information was given to registered persons via the London Provider Newsletter of July 2006. The booklet should also include service users’ views of the home. See Requirement 3 and Recommendation 1. Three care files were seen to check the assessment process carried out at the home. These evidenced that a thorough assessment procedure is carried out, to include obtaining the placing authority’s care management assessment/continuing care assessment and a full and thorough health and social care assessment carried out by the home prior to admission. All home assessments were signed and dated and reviewed monthly for the first three months following admission. In addition to the health and social care Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 10 assessment, further assessments in regard to continence, mobility, falls and nutrition are carried out. These are carried out on forms usually used in nursing homes, for example Bartel scores. Although these are filled out diligently by staff, it is recommended that, if the manager believes it would be useful, the currently used forms are modified so that they are more practical and accessible to residential, rather than nursing, care. See Recommendation 2. Both the manager and administrator assured the inspector that the home does not admit residents for intermediate or rehabilitation care, and therefore Standard 6 is not applicable to the home. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and care needs are set out in an individual plan of care. Residents’ health care needs are met and the storage and administration of medication is satisfactory. Service users are treated with respect and their privacy upheld, although there is one current issue in regard to privacy that needs to be resolved. EVIDENCE: Three care files were seen. One did not have a care plan yet as the home was using the health and social care assessment as the care plan for the first three months following admission, updating it monthly. This was to allow the resident to adjust to his new circumstances before devising the permanent care plan. The other two care files had care plans which were generated from the health and social care assessment and were reviewed monthly. Neither of the care plans seen were signed by the resident, however residents’ signatures had been obtained for as many of the supplementary forms as possible such as the admission sheet, resuscitation form, inventory and funeral plans. All three Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 12 care files had risk assessments for manual handling and for the prevention of falls, and these had also been reviewed monthly. Verbal and documentary evidence indicated that residents’ health is promoted and the full range of healthcare facilities accessed. Evidence in care files and the communication book showed that the services of general practitioners, psychiatrists, dentists, chiropodists, district nurses, opticians and dieticians are accessed regularly and as needed. All residents seen on the days of inspection were well groomed with good personal hygiene. In order to ensure the daily personal care of each resident who requires assistance, the manager has devised a personal hygiene care plan which is kept in each residents’ bedroom to be signed daily by the keyworker/healthcare assistant providing care. This is very good practice but on the day of inspection there were several personal hygiene care plans that had large gaps where no personal care had been recorded as given. See Recommendation 3. The inspector was told that no current residents have pressure sores but if these develop they would be referred immediately to the district nurses. Also, if a resident has continence problems despite the toileting regime at the home, they would be referred to the district nurses for assessment. To ensuring that residents get some form of physical exercise the home commissions a weekly exercise class. However, this class was formerly held twice per week, which was better for residents’ physical health and which residents’ told the inspector they missed. See Recommendation 4. Medication recording, storage and administration was checked and found to be satisfactory. Random counts of three different tablets were carried out and no problems were found. One recently admitted resident had been admitted to home on no medication but had seemed to staff to be depressed. They had monitored him and called in the GP, who found he had a chest infection and prescribed medication accordingly. There was no list of specimen signatures in the medication folder, although staff said that it had formerly been there, and so it is recommended that a new list is drawn up and kept in the folder. See Recommendation 5. The inspector did not examine the medication policy and procedure for the home and would request that a copy is sent to the Commission. See Recommendation 6. There is a pay phone for residents’ use by the front door of the home. This position of the phone does not give any privacy, for example if a resident wished to speak to a helpline, but the inspector was told that in the past residents have used the phone at night when there is less staff around and that residents can pay to have a private line in their rooms if they wish. Mail is given directly to the resident for their private perusal, all medication examinations take place in the privacy of residents’ bedrooms, and all clothes are required to be labelled with the resident’s name so that their own clothes can be returned to them from the laundry. The inspector was told that if there are no relatives to label a resident’s clothes, then the home will do this on their behalf. Staff described the various measures they take to ensure residents’ Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 13 privacy and dignity, especially when receiving personal care, and were observed to speak and treat residents with respect during the inspection. One resident told the inspector she would like a lock on her bedroom door, which is one of the two bedrooms on either side of the main lounge, because “everybody walks in”. She was keen to point out that she is very happy at the home and “feels safe here”. The inspector discussed the privacy issue with the manager, who felt that it would be dangerous for the resident to lock her door as she is prone to epileptic fits. However, it is recommended that a review is carried out on this issue with the hope that it may be resolved in a way that preserves both the resident’s privacy and her safety. The review should include the resident if she is willing, plus significant others and appropriate professionals. Minutes of the review should be kept and any decisions made should be recorded in the care plan. See Requirement 4. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines are flexible to suit residents’ preferences and capacities and residents are supported to maintain contact with family and friends. Residents are assisted to exercise choice and control over their lives and receive a balanced and nutritious diet in pleasant surroundings. EVIDENCE: Although there are set times for breakfast, lunch and dinner, evidence was given from residents and staff that these routines are flexible. For example, residents can have breakfast early if they wish and one resident regularly has a late breakfast after 10 am. The home employs an activities co-ordinator and there was an activities timetable displayed on the notice board in the reception area outside the lounge. This included flower arranging, bingo, sing-along, reminiscence and games such as dominoes. The activities co-ordinator also runs a mobile shop once a week from which residents can buy sweets, crisps, drinks and toiletries. Residents confirmed that once a week the activities coordinator takes a group of residents to a local Church, and a resident who does not join this group told the inspector that he has regular visits from a priest. The activities co-ordinator was not working on either day of the inspection and rotas show that she works for the first 2/2.5 days of each. A healthcare Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 15 assistant said that healthcare assistants and seniors give residents hand massages and read books and magazines with them, but on the two afternoons of the inspection visits activities were not being undertaken. The Registered Manager should therefore provide information on how residents’ social and community activities are provided for on the days when the activities co-ordinator is not employed. See Requirement 5. The inspector was told that there is a duo of external entertainers who visit the home regularly, and who also perform at Christmas parties. Residents spoken with confirmed that they have regular visitors at the home and that visitors are made welcome by being offered tea. Visitors can be seen in the lounge, or entertained in residents’ own bedrooms or the visitor’s room off the conservatory if more privacy is wanted. There are no set times for visiting but the home requests a phone call for visits after 7 pm for reasons of safety. Residents are encouraged to exercise autonomy and choice in several ways. During both days of inspection residents were observed to move freely between the lounge, conservatory and their bedrooms as they wished, and one resident was observed to take regular walks within the home using her frame. One resident told the inspector that she chose not to join in the activities at the home, preferring to read, and that she exercised full choice in regard to the foods/meals she would and would not eat. Residents handle their own finances if they wish to, one currently doing so, or their finances are handled by family or an external representative. There is a list of advocate contact numbers on the notice board, where it is accessible to both residents and visitors. All bedrooms seen had evidence of residents bringing in personal possessions. Residents have a choice of menu at breakfast, lunch and supper, and there is a large board by the serving hatch in the lounge on which the lunch menu is displayed daily. Lunch is the main (3 course) meal and residents are asked for their choice each morning. There are four different weekly menus, which showed that residents are given a range of nutritious and well balanced meals, and including fresh fruit. There is tea and cake/biscuits during the afternoon and a light but cooked supper at 5 – 5.30 pm. Just before 8 pm residents are offered tea with cake, biscuits or sandwiches so that they do not have a long period between the evening meal and breakfast next day. All cakes offered are home-made by the cook. The inspector sampled them and found them to be delicious. There were no residents needing specialist diets at the time of the inspection, but the inspector observed a health care assistant approaching the senior carer on duty to ensure that the pudding chosen by a resident with diabetes was suitable for them to eat. Appropriate advice was given. 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 nonBritish dishes. Penerley Lodge DS0000025637.V345114.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are generally listened and responded to but there is one outstanding formal complaint that has not been resolved to date. Service users are protected from abuse. EVIDENCE: There is a simple, clear and accessible complaints procedure. It is published in both the Statement of Purpose, given to residents and relatives/interested parties, and in the admission information/service user guide given to all residents. There have been no formal complaints received by the home since the inspection of 10th August 2006. There is however an outstanding complaint made in February 2006. It is understood that the Providers were unable to complete the investigation of this complaint within normal time limits because of the difficulty of obtaining information from external parties involved. Subsequently the Providers informed the Commission that investigation of the complaint would be completed by the end of January 2007. This deadline was not achieved and a requirement was made at the random inspection of 16th March 2007. In response to this, the Director wrote to the Commission at the end of April 2007 stating that the family involved had dropped the complaint and that no further action was necessary. However, the Commission learned in July 2007 that the complainant has not received an adequate response from the Providers. This was discussed with one of the Providers at the meeting on 13th September and it was agreed that they would Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 17 retrieve all of the papers relating to the complaint and submit them to the Commission for consideration. See Requirement 6. All staff have had adult protection training as part of their NVQ Level 2 course and staff spoken with were fully aware of the different types of abuse that may take place in the home and of how any suspicions of abuse must be handled and reported. Staff were also aware of how to deal with difficult behaviours such as verbal aggression and at what stage they would need to call for support. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 18 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. 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 is generally safe and well maintained but there are problems with the physical standards in regard to the lack of a passenger lift, insufficient bathroom facilities, a small kitchen with insufficient storage facilities, and one area of the home where the bedroom facilities are of a lower standard in regard to door closures, radiator covers and hot water. The inspector was able to confirm that a refurbishment programme is currently being considered within a planning application for the redevelopment of nos. 36 & 34, the result of which prevents this Standard from being rated more highly. All bedrooms are decorated and fitted to a good standard however, and there are comfortable, accessible and homely communal facilities. The home was found to be generally clean and hygienic throughout. EVIDENCE: Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 19 The premises currently consists of three houses, numbers 36, 38 & 40, that have been combined to form one home. Numbers 38 & 40 are semi-detached and have the communal areas and refurbished bedrooms. Number 36, called Hazeldene, has not been fully refurbished because the proprietors have bought the house at no. 34 and are waiting for planning permission to gut nos. 36 & 34 internally and combining them to create a new unit. Planning permission has also been sought to build a passenger lift between the two semi detached houses (i.e. between nos. 38 & 40 and nos. 34 & 36) to replace the current two stair lifts. However, planning permission has not been granted and there remains only a stair lift for disabled residents to access upstairs bedrooms. At the meeting of 13th September 2007, the Providers said that they intend to appeal the rejection of planning permission, and will keep the Commission regularly informed of progress. See Requirement 7. Various alterations and refurbishments have been carried out over the past three years and are still in the process of being carried out, so that various areas of the home are currently being worked. Staff have been careful to ensure the safety of residents while works are being carried out but it has meant that the home is currently not fully suitable for its stated purpose nor fully accessible. The home has two indoor communal areas, which are both attractive and homely and on the ground floor. There is also a landscaped and well maintained back garden which is easily accessible from the communal areas. 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 as the dining area, and one corner is used as a desk for senior healthcare workers who can undertake paperwork whilst still observing residents. The second communal area is a large conservatory which leads off from the main 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, one being a smoking room and the other a private visitors/meeting room. Residents were observed to use these communal areas at will. There is a television in each communal area but they are relatively small and the inspector was told that the intention is to replace them with large flat screen televisions that will improve visibility for residents. Since the random inspection of 16th March 2007 the former third communal area, a smaller lounge/activities room at the front of the building, has been converted to a bedroom. There are no communal bathroom facilities on the first floor although there are a total of 15 bedrooms on this floor, 3 of which are en-suite (toilet, washbasin and shower facility). There are three communal toilets upstairs. All residents therefore use the two communal bathrooms on the ground floor, one of which was recently relocated and made larger. This is an improvement on the previous bathroom as there is now reasonable space on either side of the assisted bath for staff to help residents. The second communal bathroom is Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 20 very small and less popular with residents. Unfortunately, neither bathroom has natural light or natural ventilation. There are 8 bedrooms on the ground floor, 2 of which are double bedrooms and 2 of which are en-suite. This means that currently there are two bathrooms available for 20 residents, one of which is small and unpopular, and neither of which are on the first floor with the majority of bedrooms. The previous requirement in regard to the ratio of bathrooms is therefore repeated. See Requirement 8. All residents’ bedrooms were seen, and all were found to be well fitted and furnished and with good decoration. The 5 refurbished bedrooms have wall mounted televisions and en-suite bathrooms. All bedrooms have residents’ personal possessions and the majority are attractive, comfortable and homely. At the inspection of 10th August 2006 several problems with residents’ bedrooms were found such as several in poor condition, some windows without restrictors, some worn towels and flannels, poor quality commodes and clocks not working or set at the wrong time. At this inspection it was found that all of these defects had been corrected, and that all the fixtures, fittings and furnishings in bedrooms in nos. 38 & 40 were well maintained. The bedrooms in Hazeldene (no. 36) were also well maintained in regard to décor, furnishings and fittings, however none of the 9 bedrooms in this area of the home have automatic door closures or radiator covers. The reason given for this is that these rooms will be demolished when planning permission is obtained and the new unit is built. However, this leaves residents in these bedrooms less safe, so individual risk assessments in regard to the risk of burns from radiators must be undertaken for each of these bedrooms. These must be updated if there is any change to the occupant/s of each bedroom. See Requirement 9. At the meeting on 13th September, the Providers agreed to obtain temporary radiator covers for these radiators that can be clipped on to provide protection from hot temperatures. The inspector tested the hot water supply in residents’ upstairs bedrooms in Hazeldene and found that in 2 of the 5 bedrooms the tap had to be run for a very long time before hot water was obtained and in one of the bedrooms the water did not run hot at all. The director said that this was due to a old pump serving this area of the home (no. 36) and undertook to replace it so that all bedrooms in Hazeldene would have readily available hot water for residents’ use. See Requirement 10. On both days of the inspection the communal areas and bedrooms were found to be generally clean and hygienic. On the first day of inspection, the store cupboard used for dry goods, a freezer and fridge/freezer was warm and consequently fresh vegetables were being stored in a rack by the sink in the kitchen. The store cupboard is small and not purpose built, and the Registered Provider has said that this, plus the small size of the kitchen, will be rectified when the proposed building works take place. However, in the meanwhile the Registered Provider must ensure that there are adequate and sufficient facilities for fresh, chilled, frozen and dried foods to be stored. See Requirement 11. Both the laundry room and the kitchen are small for the Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 21 size of the home and both are due to be modernised and expanded when the major building works take place. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 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. EVIDENCE: Rotas were seen and evidenced that there are sufficient care staff on duty to meet the assessed care needs of residents. There is a senior healthcare assistant on duty every day from 8am to 8pm, and everyday there are also at least 3 healthcare assistants on duty during these hours, sometimes 4. There is therefore also sufficient staff to cover peak periods of activity. There are two waking staff every night. Rotas also showed that there are two cleaners every weekday morning, with one on each weekend morning, that there is a laundry assistant at the home every morning, and that the weekend cook assists the weekday cook alternately for 3 or 4 mornings each week. In other homes of this size there is usually at least one kitchen assistant helping the cook everyday, so it is recommended that the Registered Provider reviews whether there is sufficient daily staff cover for the kitchen. See Recommendation 7. In regard to care staff qualifications, the home has exceeded the 50 training target as 12 of the 15 care staff have NVQ Level 2. In addition, one senior healthcare assistant has NVQ Level 3 and all staff who completed NVQ 2 last year are due to begin NVQ 3 this September. The inspector observed one Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 23 senior healthcare assistant caring for residents and spoke with him about various care issues, and also spoke to a healthcare assistant who has been at the home for approximately one year. The inspector found both members of staff to be knowledgeable, caring and committed to residents’ rights, privacy, dignity and well-being. The staff files of the three new staff who had joined the home since the inspection of 10th August 2006 were inspected in regard to recruitment practices. These evidenced a thorough recruitment procedure, with all necessary checks being carried out in order to ensure the protection of service users. For the most recently appointed staff POVA First checks had been obtained pending the receipt of CRB checks. However, it was found that evidence of CRB clearance was being kept at another one of the Registered Person’s homes. These were subsequently seen at that other home, but evidence of CRBs for all employees must be kept at the home where they work. See Requirement 12. Due to an oversight by the inspector, staff training records were not examined. It is requested therefore that copies of individual staff training records from the date of the previous key inspection, 10th August 2006, are sent to the Commission. See Requirement 13. Evidence of individual induction for new members of staff was seen when examining the recruitment files. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 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 and no evidence of required monthly Regulation 26 reports. Residents’ financial interests are safeguarded. The health, safety and welfare of service users is promoted but staff fire drills should be carried out more frequently than at present. EVIDENCE: The Registered Manager has many years experience of working in and managing the care home. She is half way through NVQ Level 4 in Care & Management and after finishing this intends to obtain the Registered Manager’s Award. She is familiar with the conditions/diseases associated with old age, Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 25 has an open and caring attitude towards residents and is familiar with each resident’s individual characteristics, preferences and needs. An effective quality assurance system has not yet been established at the home. The inspection reports of 16th June 2005 and 10th August 2006 required that the Registered Person developed an effective quality assurance system for the home. The inspector was told that in April-May 2007 a questionnaire survey of residents had been held, with the activities co-ordinator and visitors assisting residents to respond. A blank questionnaire was seen and was found to be well designed and comprehensive. The administrator said that 20 responses had been received but that a summary of the analysis of the questionnaires had not been produced and published, as recommended in National Minimum Standards 1.1 and 33.6. See Recommendation 8. Similarly, there are no records of monthly monitoring visits and reports undertaken by the Registered Provider, as is required by regulation. See Requirement 14. The requirement to implement a quality assurance system was also made following two previous inspections and continued failure to meet this requirement will result in enforcement action being considered. 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/social workers receive monthly. Invoices and receipts were seen for purchases made from the hairdresser and the shop run by the activities coordinator. The following health & safety documentation/items were checked and found to be in order: • • • • • • • • • • • • • • • Storage of substances hazardous to health (COSHH) Service of central heating system Electricity safety Small electrical appliances tests (PAT) Gas safety certificate Weekly water temperature checks Prevention of Legionella Contract for the collection of clinical waste Risks from hot water/surfaces (but see Requirement 8) Provision of window restrictors where appropriate Reporting of dangerous occurrences (RIDDOR) Weekly fire call point tests Fire alarm service checks Annual fire hydrant tests Building Fire Safety Risk Assessment DS0000025637.V345114.R01.S.doc Version 5.2 Page 26 Penerley Lodge • • Monthly wheelchair safety checks Recommendations arising from the LFEPA visit of 28/11/05 One problem was found in regard to health and safety, which was that there was only one recorded fire drill for the year, on 16th January 2007. This is insufficient to ensure that all staff, including night staff and any new day/night staff, are fully familiar with the fire drill for the home. It is recommended that fire drills are carried out more frequently, so that all day and night staff attend at least 2 drills per year. See Recommendation 8. Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X 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 3 2 3 1 X X 2 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Penerley Lodge DS0000025637.V345114.R01.S.doc Version 5.2 Page 28 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 OP33 Regulation 24 Requirement The Registered Person must ensure that the AQAA information required by the Commission is provided, and that in future it is provided within the timescale set. The Registered Person must ensure that the information in the Statement of Purpose is clear and factually correct. The Registered Person must ensure that all of the information required by regulation is provided in the information given to residents/service user guide. The Registered Manager must ensure that a meeting is held to resolve the issue of privacy for the resident whose bedroom leads directly off from the main lounge. The Registered Manager should therefore provide information on how residents’ social and community activities are provided for on the days when the activities co-ordinator is not employed. The Registered Person must DS0000025637.V345114.R01.S.doc Timescale for action 01/11/07 2 OP1 4 01/11/07 3 OP1 5 01/11/07 4 OP10 12 (4)(a) 01/12/07 5 OP12 16 (2) (n) 01/11/07 6 OP16 22 01/11/07 Page 29 Penerley Lodge Version 5.2 7. OP19 23(2)(k)2 3(2)(n) 8. OP21 23(2)(j) 9. OP24 12 (4) (c) 23 (4) (a) 10. OP25 23 (2)(j) 11. OP25 16 (g) 12. 13. OP29 OP30 19 (b) 18(1)(c) 14. OP33 24 & 26 make all of the documentation relating to the investigation of the outstanding complaint available to the Commission. The Registered Person must keep the Commission regularly informed of the progress and outcome of the planning permission appeal, which will affect the timetable for the provision of a passenger lift. 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. The Registered Manager must ensure that individual risk assessments in regard to the lack of radiator guards in the bedrooms of no. 36 is undertaken, and reviewed as necessary. The Registered Person must replace the hot water pump serving the bedrooms in no. 36 so that residents have hot water when they need/wish it. The Registered Person must ensure that there are adequate and sufficient facilities for fresh, chilled, frozen and dried foods to be stored. Evidence of CRB checks for all persons working at the home must be kept at the home. Copies of individual training records for staff from August 2006 to date must be sent to the Commission. The Registered Person must establish and maintain an effective quality assurance DS0000025637.V345114.R01.S.doc 01/01/08 01/01/08 01/11/07 01/11/07 01/11/07 01/11/07 01/11/07 01/11/07 Penerley Lodge Version 5.2 Page 30 system, including undertaking Regulation 26 visits and reports. Previous timescales of 31/12/05, 01/11/06 and 01/07/07 not met. Continued failure to meet this requirement will result in enforcement action being considered. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Registered Provider should ensure that all of the information recommended under National Minimum Standards 1.2 is provided in the information given to residents/service user guide. The Registered Manager should simplify the nursing assessment forms currently used to make them more practical/accessible for residential care. Staff should ensure that the good practice personal hygiene care plans kept in residents’ bedrooms are signed daily The Registered Provider should re-instate the popular exercise class to twice per week, to prevent the deterioration of residents’ physical health. The Registered Manager should re-instate the good practice of a list of specimen signatures at the front of the medication folder. The Registered Manager should send in a copy of the home’s medication policy and procedures. The Registered Person should review staffing levels in the kitchen to ensure there is adequate staff cover everyday. The results of surveys of residents’ views should be published annually. The Manager should ensure that all staff attend at least 2 fire drills per year. 2 3 4 5 6 7 8 9 OP3 OP8 OP8 OP9 OP9 OP27 OP33 OP38 Penerley Lodge DS0000025637.V345114.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Penerley Lodge DS0000025637.V345114.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. Re-publishing this information is in breach of the terms of use of that website. 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