Inspection on 10/07/08 for Penfold Lodge

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penfold Lodge 06/12/07

Penfold Lodge 13/12/06

Penfold Lodge 21/09/06

Penfold Lodge 14/03/06

Penfold Lodge 09/02/05

Penfold Lodge 06/01/05

Penfold Lodge 24/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Penfold Lodge 8-10 Penfold Road Clacton on Sea Essex CO15 1JN Lead Inspector Ray Finney Unannounced Inspection 10th July 2008 09:00 DS0000028590.V368213.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000028590.V368213.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000028590.V368213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penfold Lodge Address 8-10 Penfold Road Clacton on Sea Essex CO15 1JN 01255 223311 01255 223311 manager.penfoldlodge@careuk.com 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Manager post vacant Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places DS0000028590.V368213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder (not to exceed 17 persons) 6th December 2007 Date of last inspection Brief Description of the Service: Penfold Lodge is a residential care home, registered to provide personal care and accommodation to seventeen persons of either sex, between the ages of 18 - 65 years, who require care by reason of a mental health problem excluding dementia or a learning disability. Although staff do provide support or assistance with personal care where required, the home does not aim to meet the needs of those with a physical disability or illness, and is not equipped to meet such needs. The passenger lift is no longer in use. The home is owned by the national organisation Care UK Mental Health Partnerships. Penfold Lodge is in the seaside town of Clacton-on-Sea and situated in the town centre, close to the sea front. A range of facilities and services such as shopping, education, leisure, public transport and the beach are within walking distance from the home. The home is an older style property made into five separate units or flats. Each flat has single bedrooms, bathroom, kitchen and dining area. Six of the bedrooms having en-suite facilities. Communal areas consist of a main lounge with dining area and an additional lounge, which was in the process of being refurbished at the time of this inspection. There are small gardens to the front and rear of the property. The front garden is laid to lawn with flowerbeds and some off-road parking in the driveways. The rear-enclosed garden is paved with shingle, a lawn and paths. The home charges between £366.00 and £611.00 a week for the service they provide. This information was given to us in July 2008. Other services such as hairdressing, dry cleaning and chiropody are available at an additional charge. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk DS0000028590.V368213.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed surveys were received from members of staff and one was received from someone living in the home. An unannounced visit to the home took place on 11th July 2008. The visit included a tour of the premises, discussions with people living in the home, the manager, members of staff and a visiting healthcare professional. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was busy, social and welcoming and we were given every assistance from the manager and the staff team. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service User Guide have been updated so that people wishing to move into Penfold Lodge receive the information they need to make an informed choice about whether the home is right for them. Care plans have been improved and now contain greater detail so that people living in the home can be confident staff are able to meet their assessed needs. The menu in Penfold Lodge has been improved and now provides people with a well-balanced and varied diet. Staff provide good home cooked food that is enjoyed by people living there. One person spoken with said, “the food’s first class”. There have been some improvements to the environment as part of the home’s programme of maintenance, repairs and renewals. There has been reDS0000028590.V368213.R01.S.doc Version 5.2 Page 6 decoration in the back lounge and some other communal areas have been painted. There have been significant improvements in the day-to-day management of Penfold Lodge. During discussions with people living in the home, one person said “things are better now”. A completed survey from a member of staff stated, “The new manager has made a huge impact for the good of service users and staff”. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000028590.V368213.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000028590.V368213.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Penfold Lodge can be confident they will receive sufficient information about the home and their needs will be assessed before admission. EVIDENCE: Since the last inspection, the manager has updated the Statement of Purpose and Service User Guide to reflect the recent changes in the management of the home. The Service User Guide is written in plain language and clearly reflects the service that they will provide at Penfold Lodge. The Service User Guide contains a ‘Residents Charter’ which summarises people’s rights as well as their responsibilities. Some of the people living in the home said that they had been there for a long time and could not remember about how much choice they had at the time. However, one person spoken with said that if they had to choose now, Penfold Lodge would be the home that they would choose. A sample of three peoples’ records who live in the home were examined on the day of the inspection. All contained an initial assessment that included an ‘Activities of Daily Living Assessment’ and information about people’s lifestyle and interests. The ‘Residents’ Charter’ in the Service User Guide states that DS0000028590.V368213.R01.S.doc Version 5.2 Page 9 people using the service will “be involved in formulating and evaluating their care plans”. Records confirm that people are consulted during their assessment, which forms the basis of the care plans. DS0000028590.V368213.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Penfold Lodge receive good quality care, which is based on their assessed and identified needs. EVIDENCE: A sample of three care plans confirms that there have been improvements in the quality of the care plans since the last inspection. The manager explained that care planning was one of the areas she had identified that needed to be improved (further evidence is recorded in the management section of this report). The care plans identify the person’s individual needs and record their own perspective on these needs as well as the carer’s perspective. Care plans identify the area in which person needs support and states what is the aim and the short term goal that they are trying to achieve. There is evidence in the records examined that there are meetings between staff and the person using the service to discuss the plan of care. The care plans examined were DS0000028590.V368213.R01.S.doc Version 5.2 Page 11 reviewed monthly so that any changes to people’s needs could be identified and the care plan updated. In the time the manager has been in post she has made good progress with updating care plans, but acknowledges that it will take time to bring them all up to a good standard. She is committed to making this a priority. During the course of the inspection, people living in the home frequently came in to the office to speak to the manager and it was evident from the conversations that people were making choices and decisions. One person spoken with said they would like to move on and live more independently but felt the time wasn’t right yet and did not want to move before they were ready. However, they were happy that they would be helped to do so when they decided they wanted to move on. When asked what the home does well, a member of staff who completed a survey stated, “provides good support to prepare [people] for living independently”. There are risk assessments and management documents in place in the care plans examined. One person’s records contained a care plan around helping in the kitchen and there was a risk assessment in place to ensure the person was able to continue with the activity with minimum risk. Overall, risk assessments would benefit from being written in greater detail to ensure that there are clear guidelines in place for staff around how to manage each identified area of risk for that individual. DS0000028590.V368213.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Penfold Lodge can expect to enjoy a lifestyle that meets their wishes and interests. EVIDENCE: The manager explained that some people living in the home are now accessing ‘Project ’89’, a local scheme that provides people with supported employment doing gardening and some factory work. Two people living in the home currently attend a local college taking part in courses in ‘Lifestyle Skills’ and ‘Literacy’. The sample of care plans examined confirmed that people are supported to take part in educational activities and work opportunities. There was information on the notice board of a range of day trips that people can put their name down if they want to go, including one to ‘Jimmy’s Farm’ in Suffolk. DS0000028590.V368213.R01.S.doc Version 5.2 Page 13 Penfold Lodge is situated close to Clacton town centre and it was obvious during the course of the inspection that people living in the home make good use of the local facilities. As reported at previous inspections, people living in Penfold Lodge feel free to come and go as they please. The manager and staff spoken with confirmed that there is no rigid routine and the wishes and preferences of people living in the home dictate what happens during the course of the day. One person said they were just going out to the shops and another person was seen to be coming and going a number of times during the course of the day. People spoken with were able to tell the inspector they enjoy visiting friends. One person spoke to the manager about a new partner they had recently started seeing. It was evident that people make and maintain friendships outside the home. The layout of the home is in separate units or ‘flats’, which consist of either three or four bedrooms, each with their own bathroom and kitchen. These are intended to encourage a degree of independence in day to day living. The manager explained many of the people living in the home would make their own breakfast and snacks or sandwiches, although the main cooked meal is prepared by staff in the home’s kitchen. People are encouraged to go out to buy milk and bread at the shops in town. It was evident that some people living in the home enjoy this level of independence and participate in keeping the communal areas in the flats clean. However, the standard of cleanliness could be better in these areas (see evidence in the area of this report relating to the environment) as over time an accumulation of grime and stains have built up in these areas and they are in need of a thorough clean. The manager plans to have these areas professionally cleaned until such time as they are able to refurbish them and she recognises that this is an area of the home’s environment that is in need of improvement. As previously reported, it is clear that there are no set routines that people are expected to follow. People said they decide for themselves what time they get up or go to bed and whether they want to eat on their own or with others. Some people in the home choose to keep pets, including a dog, a cat and reptiles. These are well looked after and people were seen to treat the animals with affection. The manager showed the inspector round the home and it was clear that staff respected people’s privacy. As previously reported no-one entered rooms without knocking and waiting for permission to enter. Some people living in the home preferred to keep their doors locked and held their own keys. The manager asked every person living in the home to complete a list of their likes and preferences around food so that they could be incorporated into new DS0000028590.V368213.R01.S.doc Version 5.2 Page 14 menus. She has prepared a four week ‘rolling menu’ which has been laminated in a booklet and is available in the flats throughout the home. The current ‘Summer Menu’ has a good range of meals which include healthy options. A choice of fresh fruit, salads and vegetables are on the menu every day. A member of staff asks people what they want each day. The manager demonstrated an awareness that providing a balanced diet which people enjoy plays an important part in ensuring they have a better quality of life. This in turn helps maintain good emotional and mental health. The manager also says she is committed to providing good quality food. During discussions with people living in the home, one person said “the food’s first class”. DS0000028590.V368213.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can expect their personal and healthcare needs to be identified and provided with the support to ensure these needs are met as they would wish. EVIDENCE: The majority of people living in Penfold Lodge do not require a high level of support with personal care. However, the manager was able to explain that one person is at risk of self neglect around personal care as a result of mental health problems. The manager explained that a considerable amount of work has been done with this person to encourage them to maintain better standards of personal hygiene, which is gradually showing signs of improvement. Some work has also been carried out to develop members of staff’s understanding around balancing their professional duty of care with the rights of the individual. When asked what the home does well, a completed survey received from a member of staff stated, “provides service users with individual care and assistance”. DS0000028590.V368213.R01.S.doc Version 5.2 Page 16 The sample of care plans examined contained information about people’s physical and psychological healthcare needs. Records confirm that people attend appointments at the hospital and referrals are made to health specialists to meet their identified physical and mental health needs. One person came in to the office to discuss a planned review with the mental health team and it was clear from the discussion that reviews happen regularly. From observations and discussion with staff it was clear that they understood people’s needs. Another person spoken with made positive comments about the way they were supported with their health needs around diabetes. A visiting healthcare professional said that there have been improvements in the home recently and that “the atmosphere is lighter”. They also said that they have no issues with the level of care provided. Community Psychiatric Nursing services said that, as the home currently has a vacancy, they would consider a placement for someone which they would not do if they had any issues. As previously reported, the home operates a robust system for the administration of medication. Personnel records contain evidence that staff have received training around medication. The manager was able to demonstrate an awareness of the importance of good practices around the storage, administration and recording of medication. It came to the attention of the manager that there had been an issue recently relating to poor practice around medication. Medication had not been administered to one service user as there was none available in the home. The carer believed the medication had gone missing but did not report this. When it came to her attention, the manager initiated an investigation, made a safeguarding referral, notified the person’s GP and informed Care UK’s Clinical Governance section according to the organisations policies and procedures. The home’s supervision and disciplinary processes were followed and the member of staff no longer works in the home. DS0000028590.V368213.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their concerns about how they are treated are listened to and acted upon as stated in the complaints and safeguarding procedures. EVIDENCE: The providers, Care UK, have an appropriate policy and procedure in place for dealing with and recording complaints. Copies of the procedure are available in people’s files. People spoken with knew about the complaints policy and said that they would know who to go to if they wanted to raise any concerns. Two people said the new manager was always there to listen to them and one person said they would have “no problems” talking to the manager if they had anything to complain about. The manager was able to demonstrate a good awareness of her responsibilities around safeguarding. Personnel records confirm staff have had training around safeguarding issues (previously referred to as Protection of Vulnerable Adults or POVA). However, there are a number of staff vacancies as a result of staff who have recently left or been dismissed and the home is currently using agency staff until the manager is able to fill the vacancies through the recruitment process. Until a permanent staff team is in place, people living in the home cannot be certain that they will be safeguarded by a consistent, stable staff team who know them well. DS0000028590.V368213.R01.S.doc Version 5.2 Page 18 Following the last inspection it was reported that previous safeguarding referrals had not followed the current local authority guidance produced by the Essex Vulnerable Adult Protection Committee (EVAPC). Since the new manager took up her post, there have been considerable improvements in the area of safeguarding. Notifications to us at the Commission under Regulation 37 of the Care Standards Act 2001 have been made appropriately. A recent safeguarding referral was made promptly and followed the guidelines (see evidence in the section of this report on Conduct and Management of the home). DS0000028590.V368213.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can enjoy living in an environment that suits their lifestyle and which is homely. However the standard of cleanliness needs to be improved if people are to enjoy and benefit from a well-maintained environment. EVIDENCE: There have been significant improvements in some areas of the home since the last inspection. The manager acknowledges that the condition of the home had become poor through lack of a programme of maintenance over a number of years and considerable improvements need to take place. As previously reported, the providers have already invested in re-wiring and electrical work, new floor covering in main communal areas and some bedrooms and redecoration in some bedrooms and bathrooms. The manager has continued the programme of redecoration to improve the environment for people living there. DS0000028590.V368213.R01.S.doc Version 5.2 Page 20 On the day of the inspection, the handyman was decorating the back lounge that was previously used as a smoking room. Other areas have been painted and some new, modern pictures have been put up, which give a brighter feel to the entrance area. The manager showed us the plans that have been drawn up to extend and refurbish the kitchen. This is a major piece of work that will considerably improve the environment for people who live in the home. It was reported following the last inspection that the condition of the carpets in some areas reflected poorly on the home. This was still evident in the kitchens in the individual flats where, over time, an accumulation of grime and stains have built up and they are in need of thorough cleaning. The manager plans to have these areas professionally cleaned until such times as they are able to refurbish them and recognises that this is an area of the home’s environment that is in need of improvement. The bathroom in one of the flats had a spray bottle of antibacterial cleaner in the room. A member of staff said that one of the people living in that flat liked to make sure the toilet area was clean before using it and said that some people did not leave it as clean as that individual liked. Bottles of cleaning fluid could pose a risk to other people living in the home whose mental health problems put them at risk of self harm. Staff need to ensure that people are kept safe and should consider how to support people living in this flat to maintain an appropriate standard of cleanliness safely. The manager discussed the possibility of replacing the cleaning fluid with anti-bacterial wipes. DS0000028590.V368213.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Penfold Lodge cannot be confident that they are cared for by an established staff team who can meet their needs. However, staff are employed following thorough recruitment checks to ensure people living at the home are protected. EVIDENCE: At the time of the last inspection there were major shortfalls in the standards relating to staffing in the home. Since that time there have been changes in the staff team and a number of staff no longer work there. The manager explained that they have a number of vacancies for care staff and at the time of the inspection were using agency staff on a regular basis. She explained that, although this was not ideal, the agency staff had been coming to the home regularly and people living in Penfold Lodge were familiar with them. Of the few remaining permanent care staff, two have now completed a National Vocational Qualification (NVQ) level 2. On the day of the inspection DS0000028590.V368213.R01.S.doc Version 5.2 Page 22 staff were seen to be carrying out their duties competently. People living in the home who were spoken with said they “get on well” with the staff. During the course of the inspection the manager took a number of telephone enquiries about vacancies. She was observed to deal with them efficiently and had application forms and information packs prepared to go out in response to enquiries. She said that she is optimistic about filling the vacancies because the response to the advertisement has been good. A sample of three staff files examined were well organised and contained all the documentation required by regulation, including an application form with no unexplained gaps in employment history, two written references, proofs of identity and photographs. Staff are given a ‘Code of Conduct’ and sign to confirm they have received it. Staff training records include evidence of training in medication, mental illness, care planning, risk assessment, manual handling, health and safety, basic food hygiene, safeguarding (previously called Protection of Vulnerable Adults or POVA) and fire safety. The manager has also identified the need for Infection Control training and is in the process of accessing distance learning packages. Staff who have received training and are knowledgeable in issues relating to infection control could support people living in the home more appropriately in maintaining a clean environment. Personnel records confirm that there have been improvements in staff supervision. The manager explained that since she took up the post of manager there had been an issue relating to poor practice around medication. Medication had not been administered to one service user as there was none available and the carer thought the medication had gone missing but did not report this. When it came to her attention, the manager initiated an investigation, made a safeguarding referral, notified the person’s GP and informed Care UK’s Clinical Governance section as per the organisations policies and procedures. The home’s supervision and disciplinary processes were followed and the member of staff no longer works in the home. DS0000028590.V368213.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Penfold Lodge benefit from good management systems and their opinions are valued. EVIDENCE: The new manager has just completed the Registered Managers Award (RMA) and has almost completed NVQ level 4 in care. She has been in post for approximately two months and has already made significant improvements to the day-to-day running of the home. The manager explained that she took some time in the first couple of weeks to identify areas for improvement and put an action plan in place to deal with a range of issues promptly. Some of the areas identified in the improvement plan included, “No holidays or day trips booked. Does not seem to be daily activities in place. This is necessary to give residents some structure to their DS0000028590.V368213.R01.S.doc Version 5.2 Page 24 day. Care plans need more detail as this is minimal. They do not give enough background to the resident. This makes it difficult for carers and professionals who do not know the resident. Décor is tired looking and needs brightening up. Garden areas are untidy, no outside seating, flowers or gardening equipment”. Progress has already been made in many of these areas including care plans, activities and redecoration. On the day of the inspection, the manager said that she wanted to improve the garden area as soon as possible so that people could enjoy the summer weather and so that those people who smoke can do so in more comfort. The manager is making progress with the Quality Assurance system. As previously reported there are meetings between the manager and people living in the home and she has also sent out surveys to seek people’s opinion of the service. However, the Quality Assurance process could continue to be developed so that all the information sought from people living in the home and other interested parties is pulled together into the home’s development plan. This would demonstrate how people’s views and wishes are taken into account and acted upon. At the time of the last inspection there were some serious concerns relating to health and safety. Among the issues identified were trailing extension leads with overloaded sockets, accumulated rubbish stored in one person’s room, exposed wiring outside another room, water temperature too hot in one bathroom and a large quantity of a cleaning substance left unattended. The environmental health officer visited the home and the majority of the health and safety issues had been addressed. A recommendation was made to Care UK that thermostatic mixer valves are fitted. The outstanding issues have now been dealt with. People living in the home were all complimentary about the new manager; one person said, “she’s great”. A member of staff who completed a survey said, “The new manager has made a huge impact for the good of service users and staff”. DS0000028590.V368213.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000028590.V368213.R01.S.doc Version 5.2 Page 26 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 YA30 Regulation 23 (2) Requirement All parts of the home must be kept clean to promote the health, safety and wellbeing of the people who live there. This requirement is outstanding from 01/02/08 People living in the home must be supported by an effective staff team with sufficient numbers and skills to meet their assessed needs. Staff must receive training in infection control to ensure they have the skills to help people living in the home understand how to keep their environment clean and safe. Timescale for action 30/09/08 2. YA33 19 (5) (b) 31/10/08 3. YA35 18 (1)(2) 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000028590.V368213.R01.S.doc Version 5.2 Page 27 1. YA6 2. YA9 3. YA23 4. YA39 The process in place for updating and improving care plans should continue until everyone living in Penfold Lodge has a care plan that contains sufficient detail to ensure their needs are met as they would wish. When areas where there may be risks for people living in the home are identified, the manager should consider whether risk assessments in place contain sufficient detail to ensure they are kept safe. The manager should ensure people are safeguarded by an established staff team who understand the needs of the vulnerable people they are supporting and are able to recognise when they are at risk of abuse. The manager should continue to develop the Quality Assurance system so that, when they seek the views of people living in the home and other interested parties, the information is used to form a development plan, which demonstrates that people’s views are being acted upon. DS0000028590.V368213.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000028590.V368213.R01.S.doc Version 5.2 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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