Inspection on 13/12/06 for Penfold Lodge

This inspection was carried out on 13th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penfold Lodge 10/07/08

Penfold Lodge 06/12/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Penfold Lodge 8-10 Penfold Road Clacton on Sea Essex CO15 1JN Lead Inspector Kay Mehrtens Unannounced Inspection 13th December 2006 10:00 Penfold Lodge DS0000028590.V326468.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 Penfold Lodge DS0000028590.V326468.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. Penfold Lodge DS0000028590.V326468.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 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 Penfold Lodge DS0000028590.V326468.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) 21st September 2006 Date of last inspection Brief Description of the Service: Penfold Lodge is a care home registered for seventeen younger adults with a mental disorder. Accommodation is in single rooms within five independent units/flats. Each unit has it’s own bathroom, kitchen and dining area, with six rooms having en-suite facilities. Communal areas consist of a main lounge, smoker’s lounge and dining room. Penfold Lodge is a large detached property situated in a residential area close to the sea front and shopping centre of Clacton-on-Sea. There are shops, churches, post office, hospital, theatre, leisure facilities and cinema in the locality. 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 was paved with shingle, a lawn and paths. Penfold Lodge is owned by Care UK Mental Health Partnerships, a national organisation that specialises in working with people who have a mental illness. The fees range from £298.00 to £512.50 per week. Additional charges are made for personal items, hairdressing, chiropody and some activities. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the statutory key inspection. This unannounced inspection took place on the 13th December 2006 at 10.00am. The inspection lasted 8 hours. The Key National Minimum Standards (NMS) for Young Adults and the intended outcomes were assessed in relation to this service during the inspection. The inspection process included discussion with the recently appointed manager, Sharon Daley, care workers and service users; examination of a sample of staff and service users’ records, supporting documentation and other records required to be kept in the home; direct and indirect observation. This report has been written using accumulated evidence gathered prior to and during the inspection. Evidence was gathered from the pre-inspection questionnaire completed by Sharon Daley and sent to the commission on the 7th November 2006. Sharon Daley also provided the commission with an amended statement of purpose, entitled “Philosophy of Care”. In addition, the commission received 5 service users’ surveys, 2 relatives’ surveys and 3 from health and social care professionals. Their comments will be included in the report. The standard with regard to the premises (NMS 24) will remain rated as “POOR” until evidence of the refurbishment is made available to the commission. Further delays in meeting requirements under Regulation 23 of the Care Standards Act will lead to the commission to consider further action. The home was previously rated as a Poor service following the last key inspection. This inspection has highlighted many areas of improvement and the home will now be rated as Adequate. What the service does well: Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 6 The home currently has 16 service users all accommodated in single rooms. The service users felt that the staff were caring and they felt well supported by them, especially with their health problems. The service users are also very supportive of each other. The new manager is working hard to develop a consistent approach to the care of service users. She is aware of the need to promote service users’ rights and effect gradual changes on the culture of the home so that the service users are more involved in the running of their home. What has improved since the last inspection? What they could do better: The requirements from the previous inspections, with regard to the standard of the furnishing, must be addressed in order that the residents are provided with a pleasant, homely environment. Care planning and risk assessments, with service users input, needs to develop. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 7 The staff team needs to further develop the service users’ independent living skills in their flats. The Service User Guide and Statement of Purpose require amending to ensure that service users have the required information available to them about the care provided. 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. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 8 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 Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 9 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): Standards 1 and 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is insufficient information available for service users to inform them of the costs and care provision for their stay in the home. There have not been any admissions since the last inspection. The home has produced new referral and assessment documentation. EVIDENCE: The manager had amended the Service Users’ Guide and a copy was provided at the inspection. However, it does not provide sufficient information regarding the services provided at the home. The information in the pack does not reflect the requirements set in Standard 1.2 of the National Minimum Standards or Regulation 5 of the Care Standards Act. For example, there is no information regarding fees and contract or information regarding the manager and staff qualifications and experience. The Statement of Purpose should reflect the care provided at the home, as stated in Schedule 4 of the Care standards Act, Regulation 4. The manager was advised to discuss an application for variation in registration with the provider, to reflect the age of some service users currently accommodate in the home. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 10 Standard 2, with regard to needs assessments for new service users was not fully inspected, as the home has not admitted any new residents since the last inspection. The manger informed the inspector that the home referral procedures were being reviewed to include information regarding the individual skills, personal and health history of prospective service users. The manager and her staff team had worked hard to address the previous shortfalls with regard to organisation of service users’ files. They had worked with placing social workers to gather information from old files. They had produced “back dated” assessment documents for current service users in order to ensure that care plans could be produced with the service users, their family and social workers. This standard will be monitored at the next inspection. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 11 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): Standards 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. Care plans did not provide enough information to assist staff in meeting the needs of service users. The health care needs of service users were well met and improvements had been made with regard to medication. Identified risks are discussed with service users. EVIDENCE: Care files were sampled and were noted to be better organised than at the last inspection. The manager had made positive links with placing social workers to gather lost information due to poor management and systems noted at the last inspection. The care files sampled indicated that the staff team had worked well to involve the service users in evidence gathering and compilation of their care plans. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 12 However, more work is still required to ensure that each service user has a working care plan they write with support from their key workers. The care plans need to contain more detail especially with regard to the mental health needs of individual service users, with clear actions to enable staff to support and work with service users effectively and consistently. The manager acknowledged that more work and staff training is needed in order to bring the care plans up to standard. The daily recording did not reflect the identified care needs of service users or the observed practice and positive comments demonstrated by the care staff. The staffs’ comments indicated that they were aware of individual service users’ difficulties, behaviours and strategies to support them, as appropriate. However, risk assessments and management strategies for individual service users had not been reviewed or recorded since the last inspection. The home does have policies and procedures with regard of any unexplained absences. The service users told the inspector that regular meeting now take place. Service users have also been involved in the interview process for new staff. The service users were aware of the local advocacy services and Mind centre where several go for support and to meet friends. The home does assist in the management of some service users’ finances and supports service users to have independent bank accounts. The manager stated, in the pre-inspection questionnaire, that she acts as an appointee for 4 service users. Several service users are supported, with their finances, by their families or legal representatives. The manager was aware of the need to develop independent living skills, including financial, for some of the service users. The manager undertakes monthly audits of service users’ monies. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 13 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): Standards 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. Opportunities are provided for service users to participate in activities in the home and the local community. Service users are supported in maintaining contact with family and friends who are made welcome when visiting. Service users’ choice is respected in many aspects of their life in the home. Catering arrangements have improved. EVIDENCE: The change in staff levels, rostered time and management strategies has led to an increase in contact time for staff with service users. The manager told the inspector that the home has a located activity budget that is now being used for group and individual activities both social and educational, as required. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 14 Individual activity plans have been written with service users and kept on their files. They were noted to reflect different needs including 1 to 1 time, shopping trips, and evening activities. The service users told the inspector that they liked shopping and this included food shopping for their flats as well as the home. Some service users attend local college courses. No service user currently has a job but staff were supporting a service user who wished to look for some paid employment. The service users are supported to attend the local Mind social centre. There was evidence of staff supporting service users in managing the cleaning of their flats and bedrooms, as part of an individual agreement. The service users were aware of the homes’ policy regarding smoking and alcohol. They are supported in having pets in their flats. They told the inspector that they can have friends and family visit them and that they are made welcome. The service users have a key to their bedroom but not the front door so sign “in and out” during the day. Staff support with service users, in their flats has increased since the last inspection. The manager told the inspector that she plans to develop staff time and support, with service users in their flats, in the New Year. The service users no longer queue for their medication or their meals. The old hatch from the kitchen to the dinning room had been closed. The manager has worked with the staff and service users to encourage more independence and dignity, with regard to mealtimes. The new regime has led to a change in the culture of the home; it is less institutional and more respectful of service users. Food is available in each flat for service users to prepare snacks, breakfast and evening meals, if they choose, with staff support. The meal prepared on the day of the inspection looked very appetising and was well presented. Penfold Lodge DS0000028590.V326468.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): Standards 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. The general and specialist health care needs of service users were well met. Medication was well managed. EVIDENCE: Information was gathered from the service users during the inspection. They said that staff help them with their health care needs. They were pleased with the support that they get from the manager and staff when unwell. The staff were very aware of the individual health needs of the service users. Their comments were well informed, professional and caring. The staff were observed to interact with the service users in a pleasant and polite manner. As previously stated, the care plans require updating. However, the sections with regard to physical health were well written, as were details of hospital and health specialist appointments. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 16 The manager and staff team had made arrangements for service users to receive a medication review and health check-up in the New Year, if they choose to attend. There was evidence of appropriate referrals to health specialists in order to meet urgent physical and mental health needs of service users. The level of Community Programme Approach (CPA) reviews was limited. The manager was aware of the need to link with the local community psychiatric services to “chase” the required statutory reviews for the service users. The systems and awareness regarding medication procedures had improved since the last inspection. The manager had organised additional training on medication for staff on both administration procedures and drug awareness. The manager undertakes a weekly audit of medication. The monitoring was thorough and well recorded. The staff demonstrated a good understanding and awareness of different types of medication used by service users. They were clear regarding particular instructions and checks required on some of the medication used by service users. Four service users are supported in self-medicating and staff have undertaken a re-assessment on these service users, as appropriate, to ensure safe practice. Lockable facilities are provided. Penfold Lodge DS0000028590.V326468.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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users felt able to voice any issues with the new manager. The manager and staff have a good understanding of the need to protect service users from abuse. EVIDENCE: The service users have been provided with individual information about the homes’ complaints procedures. They told the inspector that they felt able to voice concerns and comments with the new manager and the staff team. The staff have received training with regard to Protection of Vulnerable Adults (POVA). The manager had made an appropriate POVA referral with regard to an incident in the home. She had consulted her line manager and social services and appropriate records were maintained. The inspector requested information regarding the outcome of the referral. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 18 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): Standards 24 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The standard of the premises is poor and previous requirements have not been met. The standard of hygiene in the home had improved. EVIDENCE: The premises were in keeping with the local community. The service users live in small groups in flats within the building. Each flat has its own kitchen/dining area and bathrooms. A tour of the premises highlighted the continued failure by the provider to address the shortfalls in the accommodation. Previous inspections stated the need for improvements in carpets, décor in bathrooms and an improvement in the general state of the premises. Some redecorating had been done but the major work on the premises is still required. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 19 The manager told the inspector that the refurbishment of the home is planned for the New Year. The inspector requested a copy of the works schedule and details of how the care of the service users is to be managed during the refurbishment. The standard with regard to the premises (NMS 24) will remain rated as “POOR” until evidence of the refurbishment is made available to the commission. Further delays in meeting requirements under Regulation 23 of the Care Standards Act will lead to the commission to consider further action. The standard of cleanliness and hygiene had greatly improved since the last inspection. The home has recently employed a domestic and she is to be commended for her prompt action in dealing with the hygiene needs of the home. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 20 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): Standards 32, 33, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have a positive attitude towards the care of service users and the training provided. Staff recruitment practices ensured the protection of service users. EVIDENCE: Service users spoken to at the inspection were keen to inform the inspector that they liked the new manager and staff. They said that they were listened to and felt safe and respected in their own home. They told the inspector that they liked the changes with regard to mealtimes and medication. One service users said, ”It’s 100 better with our new manager.” Another said, “it takes time to get used to changes but it is better and I like the food”. The interaction observed between the staff and the service users was noted to be respectful, relaxed and pleasant. The comments received from a placing social worker were also complementary regarding the work done by the manager and staff since the last inspection. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 21 The relatives’ surveys were positive in their response to the care provided at the home. The manager and staff recognised that service users are treated with respect and supported to live as independently as possible in their own home. They recognised that some of the past practices and routines in the home, highlighted at the last inspection, were institutional and they looked forward to effecting change with the service users. The manager had introduced changes in the home that enabled the staff to be “out on the floor”. For example, they sat with service users completing their daily records with them. The office had become a place for administration work, not a staff restroom, and was open to service users for access to the manager or for confidential meetings. The staff files were well-organised and contained folders for training (including a training profile), applications and on-going supervision and appraisals. Examination of staff files showed that the required information, as part of the recruitment process, had been sought and copied. The provider has clear systems in place to ensure that the required checks and information is gathered as part of the recruitment process. However, the application from used by the provider does not request a full employment history. Criminal Records Bureau (CRB) checks are held at the providers’ main office. The individual homes have a signed checklist of outcomes for inspection purposes. The level of staff training had improved since the last inspection. All staff have received induction training linked into the Skills for Care standards. All the staff had been signed on to the Common Induction Standards workbooks. The inspector observed a member of staff working on their booklet. They told the inspector that they were keen to complete their training and had enjoyed the training opportunities recently provided. The records evidence d that 5 members of staff were undertaking National Vocational Qualification level 2 courses. The manager has provided training for all staff on “Values and Attitudes” following the last inspection outcomes. Additional training was planned, on understanding diabetes and mental health, in the New Year. A copy of the training programme was provided at the inspection. It included training on medication, breakaway techniques, National Vocational Qualifications, fire training and input from a McMillan nurse. An external specialist trainer is to provide the mental health training. The progress with regard to mental health training will be monitored at the next inspection. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 22 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): Standards 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management style is very much focussed on the best interests and needs of the service users. Practices and procedures ensure that the health and safety of service users are protected. EVIDENCE: The current manager has been in post for a short while following the resignation of the previous manager after the last key inspection. The providers have yet to make an application for registration for Sharon Daley as manager. The inspector was impressed by the change in attitude and approach, to the requirements from the last inspection, shown by the new manager. She had Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 23 clearly worked well with the staff team to address many of the concerns and shortfalls raised at the last key inspection. Her actions and that of her staff have enabled the service users to feel more at home, more respected and more involved. A survey returned from a health and social care professional was very complementary regarding the current management of the home. Their comments included, “through discussion it appears a very concerted effort is underway to rectify issues in respect of my client placed there. The new manager and senior staff put a lot of effort into liaising with the family and myself to get things straight. I was impressed by their honesty in outlining past failures and willingness to change this.” Two other health/social care professionals were satisfied with the care provided. The inspector had the opportunity to meet a visiting advocate. They said, ”the home feels more settled… pleased with the link and information from the manager”. The manager informed the inspector that the provider has booked a date to undertake an audit of the homes’ filing systems. The inspector noted that the manager and her staff team had already started work on re-organising the care files since the last inspection. Confidential information regarding individual service users was now securely stored. All the polices and procedures for the home were in the process of being reviewed and amended to reflect the care provided at Penfold, as well as link to the providers’ general/organisational policies. The standard with regard to quality assurance (Standard 39) will be monitored at the next inspection. As previously stated, the provider is to undertake an audit of systems alongside a full audit of the home on the 20th December 2006. The inspector requested a copy of the findings and actions following the audit. The manager and maintenance worker had worked hard to address the health and safety shortfalls noted at the last inspection. The water systems had been checked and serviced and all certificates were available for inspection. The COSHH folder had been updated and fire system checks were current. Fire drills had taken place and were recorded, though a system to ensure that all staff receive the required number of drills was recommended by the inspector. The health and safety folder contained comprehensive information and certificates with regard to electric, gas, asbestos, equipment (for laundry, kitchen and heating) and fire safety checks. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 24 Repairs and maintenance issues are now discussed with the manager and monitored, if action is to take place. Health and safety risk assessments are still required with regard to the premises. Penfold Lodge DS0000028590.V326468.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 2 2 2 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 X 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 3 X X X 2 X Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose is amended to reflect the care services and management provided in the home. The registered person must ensure that the Service User Guide is amended to reflect the care services and management provided in the home. The registered person shall ensure that new service users are admitted following a full assessment of their needs. The Registered Person must ensure that service users are involved in their care plans and that care plans reflect all assessed needs. This is a repeat requirement. The timescales of the three previous inspections were not met. The Registered person must ensure that risk assessments are comprehensively completed, reviewed and linked to care plans. This is a repeat requirement. The timescale DS0000028590.V326468.R01.S.doc Timescale for action 06/02/07 2 YA1 5 06/02/07 3 YA2 14 06/02/07 4 YA6 15 06/02/07 5 YA9 15 06/02/07 Penfold Lodge Version 5.2 Page 27 6 YA24 23 7 YA32 18 8 YA34 19 9 YA39 24 (1) (2) 10 YA42 23 of the three previous inspections were not met. The Registered Person must make improvements to the premises as detailed in this report to ensure the comfort and safety of service users. This is a repeat requirement. The timescales of the three previous inspections were not met. The Registered Person must ensure that staff training is relevant to the needs of the residents accommodated. This refers specifically to the need for training in mental health issues. This is a repeat requirement. The timescale of the previous inspection was not met. The registered person must ensure that a full employment history is requested as part of the application and recruitment process. The Registered Person must ensure that there is an annual cycle of quality assurance, monitoring and action in place. This standard was not inspected at this inspection. The registered person must ensure that the health and safety of service users is assured. This refers specifically to health and safety risk assessments. 06/02/07 06/02/07 06/02/07 06/02/07 06/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 28 No. Refer to Standard Good Practice Recommendations Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Penfold Lodge DS0000028590.V326468.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!