Inspection on 14/03/06 for Penfold Lodge

This inspection was carried out on 14th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 13/12/06

Penfold Lodge 21/09/06

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 Steve Boyd Final Unannounced Inspection 14th March 2006 09:00 Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 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.V286122.R01.S.doc Version 5.1 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.V286122.R01.S.doc Version 5.1 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) Nikki Faber Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 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) 9th February 2005 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. The gymnasium situated in the outside ’shed’ area was passed as safe for use by the fire service. Penfold Lodge is owned by Care UK Mental Health Partnerships, a national organisation that specialises in working with people who have a mental illness. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in one day in March 2006. At the time of inspection 16 service users were living in the home, 3 of those were spoken with in private and others in general. The inspector also had discussions with the senior carer on duty and other staff. A tour of the premises took place and various records and policies were looked at during the course of inspection. At this inspection 19 standards were assessed and only two were found to be fully met. What the service does well: What has improved since the last inspection? What they could do better: Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 6 Many issues still remain outstanding from the previous inspection report as can be seen from the statutory requirements section. The major issue is that the home still lacks full time management presence as the current home’s manager also manages a home in the London area and therefore only spends two days a week at Penfold Lodge. The volume of outstanding requirements is clearly exacerbated by this situation. The home continues to have limited staffing numbers at weekends and evenings, which impinges upon the homes ability to cater for resident’s needs. From an environmental perspective, there were a number of premises issues which need to be addressed to ensure that service users live in a safe and homely environment. 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. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 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 Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users’ assessments do not provide enough detail and information. EVIDENCE: The “mental state” assessment for one new service user which is supposed to be filled in within 72 hours of a persons admission was not filled in for the home’s newest resident. Initial assessments seen for other residents were poorly completed for example, under the heading social skills a typical comment was “good” with no other information. Although care plans are written,it was unclear on what basis and information these were derived. For example one service user’s care plan acknowledged they had issues with alcohol but this was not mentioned on the service user’s assessment sheets. There was clearly work to be done on redoing comprehensive assessments for many of the service users at the home. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 As indicated above, care plans, although available, are not based on extensive assessment information and therefore inevitably lack comprehensiveness. Lack of staffing at evenings and weekends mitigate against service users becoming as independent as possible. Risk assessments continue to lack sufficient detail although self-medication risk assessments were noted to be of a better standard. EVIDENCE: Care plans exist for service users but are not based upon comprehensive assessments and therefore reliability and usefulness of the care plans is called into question. One service user had a care plan that was aimed at enabling them to attend some college courses. However, the evaluation section did not say how this had been progressed and what staff help had been given regarding this end. An ethos of the home is to make service users as independent as possible and give them as much choice and decision making power in their lives as possible. However, low staffing numbers at evenings and weekends mitigates against these aims. The home’s “risk applicability test” lack detail. Again, without comprehensive assessment being available it is difficult to work out how risks had been identified and if all risks had been Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 10 identified. Risk assessments for service users self-administering medication were seen and it was evident these were of better quality than the “risk applicability test”. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 and 17 Full opportunity for service users to take part in appropriate activities both for leisure and claiming greater independence is limited through staffing levels. Food quality and quantity continues to be maintained at a good level. EVIDENCE: As indicated at the previous inspection because staffing levels are reduced to two at weekends the opportunity for planned or spontaneous social activities for residents is limited. Whilst a number of service users, it is acknowledged, like to do their own thing, the lack of staffing levels at weekends would preclude for example a staff member going with a service user to a social event where perhaps through their mental health condition they lack confidence to do this by themselves. There was no list of activities taking place within the home seen on the home’s notice board. Activities both within the home and outside of the home is clearly an area that needs to be developed. The home produces a four-week menu which shows choice of main meal being offered each day. Service uses make their own lunch and carry out shopping for this in their own units. Service users advised that they felt that the food they had at home was good in both quantity and quality. One area which clearly could be developed is service users preparing their own main meals, although again this would require additional staff input. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Service users do not receive adequate support. Service users physical and emotional health needs are generally met. The home’s system of medicine administration requires better auditing in place. EVIDENCE: Service users are expected to be as independent as they can be with regards to such tasks as cleaning and maintaining hygiene. It was clear there was not enough staff to give appropriate support in these areas. For example, a number of service users’ sinks in their bedrooms were seen to be very dirty and clearly no support had been given in how to clean these appropriately to avoid the risk of infection. One of the flat’s kitchens was seen to be very unclean at the time of the inspection, the sink was not clean, the kitchen bin was not clean, neither was the cooker hood. None of the above areas looked as if they had been cleaned for a long time and clearly staff support needed to be much better. There was evidence that service users’ health care needs are met by what was written in their care plans and other reports. However, it wasn’t easy to determine when people had last seen opticians or dentists and it was recommended that separate records sheets are maintained for these and other healthcare professionals. Some training had taken place for staff in the uses and effects of medicines since the previous inspection. However, this inspection indicated that auditing of boxes and bottles of medication was not Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 13 thorough. One service user was seen to have more tablets left of a particular medication in their box than should have been the case. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home’s policy on abuse needs to be extended to be more effective. EVIDENCE: The current policy on abuse shown to the inspector was very basic and effectively was a one page list of contact numbers. There was no mention of the Essex Vulnerable Protection Committee guidelines and no details on how for example, staff could spot abuse or what types of abuse can exist. It was acknowledged that staff have received some training in this area but the policy needs to back up the training. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 All service users like living in their individual units within the home. There are areas which could be made more homely, clean, safe and hygienic. EVIDENCE: A tour of the premises indicated a number of areas which need remedial attention to enhance the environment. For example the carpet near the main kitchen needed to be cleaned. The kitchen in Flat 1 was found in a poor state of cleanliness as indicated earlier in the report. The bathroom opposite room 17 required re-decoration and a new bath panel being fitted to the bath. Also in Flat 4 the toilet next to this bathroom was found to have no soap or hand towels. In Flat Number 3 the bathroom needed redecorating and the carpet near the dining area needed replacing. In Flat 5 the kitchen flooring was in a poor state. Room 13 needed redecorating and the sink was found to be in a very poor state of cleanliness. Curtains needed to be repaired and put back up in Room 14 and a new chest of drawers was required. While service users are encouraged to be involved in the running of their own rooms and other communal areas in the home, this clearly was not being done in various areas affectively and indicates a lack of staff/time support. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Service users could be better supported by increasing the level of staffing particularly at weekends. Particular training issues still need to be pursued. The extent to which the service users are supported and protected by the home’s recruitment policies and practices could not be ascertained at the inspection. EVIDENCE: There was evidence of various training having taken place since the previous inspection such as a course on risk assessment in February 2006, COSHH training in March 2006, customer care and moving and handling training. Medication training had also taken place in December 2005. No evidence could be seen of specific training initiatives in mental health issues having been pursued. “Statutory training plan” for each member of staff had not been filled in on an up to date basis. The staff rotas showed no change to levels of staff available within the home and as outlined in various sections of this report, the current staffing levels do not fully support the needs and aspirations of service users. The manager, who was not available during this inspection was the only person with access to the staff and recruitment records and therefore it was not possible to determine whether the recruitment practices within the home supported service users. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 Service users live in a home that lacks a full time manager and therefore do not live in the best run home they could. EVIDENCE: The home’s manager Ms Nikki Faber was, as evidenced by the rota and in discussions with staff, only available in the home for two days a week and was not seen to be rostered on at weekends. The previous inspection report had highlighted the part-time management of the home and this had not changed at the time of inspection. The proprietors had not made any contact with the Commission for Social Care Inspection over how they proposed to change this situation to ensure that a full time manager was available at the home. The inspector was advised the manager works three days a week at another home in London. Throughout this report there is evidence where the home is failing to meet standards and not providing the best support they could do for service users. The lack of a full time manager clearly exacerbated the situation. With respect to quality issues and monitoring, there was some evidence that survey forms had recently been sent out to staff, service users and other interested Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 18 parties. However, the last quality improvement plan seen was dated April 2004 with nothing apparent for 2005. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 19 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 x 2 1 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 x 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 X 30 1 STAFFING Standard No Score 31 x 32 2 33 2 34 1 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 x 14 2 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 1 x 2 x x x x Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 20 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 YA2 Regulation 14 Requirement The Registered Person must ensure that service users have comprehensive assessments and that they are involved in the process 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 two 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 of the two previous inspections were not met. The Registered Person must ensure that residents are provided with a variety of activities to meet their individual needs and choices. This refers particularly to the weekend and evenings when staff levels limit the availability of activities and DS0000028590.V286122.R01.S.doc Timescale for action 31/05/06 2 YA6 15 31/05/06 3 YA9 15 31/05/06 4 YA14YA12 18 30/06/06 Penfold Lodge Version 5.1 Page 21 5 YA20 13 (2) 6 YA23 13 (6) 7 YA24 23 8 YA30 13 (4) 9 YA32 18 10 YA33 18 11 YA34 89 of CSA 2000 support. The timescale of the previous inspection was not met. The Registered Person must ensure that the home’s medicine administration system is subject to regular and effective audits. The Registered Person must ensure that the home’s policy on abuse, neglect and self-harm is reviewed and extended to make it more effective. The Registered Person must make improvements to the premises as detailed in this report to ensure the comfort and safety of service users. The Registered Person must ensure that all parts of the home are kept in a satisfactory standard of cleanliness and hygiene. 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. The Registered Person must ensure that staff levels are sufficient to meet the needs of the residents accommodated at the home, in keeping with the home’s statement of purpose and the resident’s individual care needs. This is a repeat requirement the previous timescale was not met. The Registered Person must have access to original Criminal Records Bureau declarations and they must be available at the home for review at regulatory inspections. This is a repeat requirement and could not be assessed at this inspection due to lack of availability of records. DS0000028590.V286122.R01.S.doc 14/03/06 31/05/06 30/06/06 14/03/06 30/06/06 14/03/06 14/03/06 Penfold Lodge Version 5.1 Page 22 12 YA34 19 (1a–b) 13 YA38 10 (1) 14 YA39 24 (1 and 2) The Registered Person must ensure that all staff personnel records contain copies of their birth certificates and passports. This is a repeat requirement and could not be inspected due to lack of availability of records. The Registered Person and registered manager shall carry on or manage the home with sufficient care, competence and skill. This is a repeat requirement. The Registered Person must ensure that there is an annual cycle of quality assurance, monitoring and action in place. 14/03/06 31/05/06 30/06/06 Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 23 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 YA19 Good Practice Recommendations It is recommended that records are kept of service users visits to various health professionals including doctors, dentists, and opticians etc. to enable an “at a glance” record of who may need to see a health practitioner. Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Penfold Lodge DS0000028590.V286122.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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