Inspection on 21/09/06 for Penfold Lodge

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 21 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 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 Key Inspection 21st September/9th October 2006 10:30 Penfold Lodge DS0000028590.V305068.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.V305068.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.V305068.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) Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17) of places Penfold Lodge DS0000028590.V305068.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) 14th March 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. Penfold Lodge DS0000028590.V305068.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. The inspection process included discussion with the newly appointed manager, care staff, residents; examination of a sample of staff and residents records, supporting documentation and other records required to be kept in the home; direct and indirect observation, as well as pre inspection records. The inspection took place over two days, the 21st September and 9th October 2006. The inspection lasted 12.5 hours in total and covered 20 key standards. None were met. One standard, covering fire protection, led to the inspector leaving an immediate requirement notice. The overall judgement for the home was poor. The new manager demonstrated little understanding of the requirements of inspection, the Care Standard Act and Regulations and the National Minimum Standards. The inspector raised her concerns with the providers’ representative, Wendy Rushton. She was present, at the inspector’s request, on the second day of inspection. What the service does well: What has improved since the last inspection? The failure by the registered provider to meet the past requirements, from previous inspections, is a cause for concern. This was discussed with the providers’ representative on the second day of the inspection visit. Activities and access to college course and community projects had improved since the last inspection. Some service users told the inspector that they enjoyed different activities and they liked going to church and other social clubs Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 6 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. Penfold Lodge DS0000028590.V305068.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 Penfold Lodge DS0000028590.V305068.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. Pre admission assessments did not provide sufficient detail and information to generate a support plan appropriate to the residents’ needs. EVIDENCE: The Statement of Purpose needs to be amended to reflect the changes in the management of the home and to make clear the homes’ input into Care Programme Approach (CPA’s) for service users. A sample of two care files was examined. The file of a recently admitted resident indicated that little information had been gathered prior to admission other than from the placing authority. The “mental state” assessment for the new service user, which is supposed to be filled in within 72 hours of a persons admission, had not been done. This shortfall had been raised at previous inspections. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 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, 9 and 10 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. The quality of information recorded in care plans and care files was poor and did not provide adequate and constructive guidance to assist staff in supporting and meeting the assessed needs of the residents. The continued lack of staffing at evenings and weekends limits service users becoming as independent as possible. EVIDENCE: There was little evidence of service user input into their care planning. Care/support plans sampled were disappointing and had not improved since the last inspection. The plans were in need of a more robust approach to the specific individual needs presented by the residents for which staff need to properly respond. They contained little detail or useful information to guide staff to provide appropriate, consistent and productive support to the residents, particularly with regard to their mental health needs. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 10 There was no evidence of any care plans linking into the Care Programme Approach on the files sampled. Risk assessments were not evident on the files sampled. There was little indication of regular review of care/support plans taking place. The daily recording did not reflect all aspects of service users’ individual needs. Those sampled were very focussed on the service users’ personal hygiene with no reference to the obvious difficulties being experienced, by the service user in question, with regard to their mental health. The staff would clearly benefit from further training in the use of and formation of care planning and recording. The inspector found evidence of staff writing inappropriate comments, about service users’ personal issues, in the staff communication book. The comments also indicated an institutional and negative approach by some staff in their interaction with some service users. The inspector noted that personal information regarding service users’ was being written into different staff information books; old service users files were left out on shelves in the office; referral information on prospective service users was left on open shelves. The systems for storing and recording of service users’ personal information were poor. There was no evidence of service users’ consent to information being shared about them with their family or other agencies. There was no information regarding service users’ financial status or rights. Comments from service users and staff indicated that further investigation and advocacy may be needed to enable service users to have a better understanding and control of their finances. There was little understanding by the manager and staff of the need to seek advocacy for service users in the home, if appropriate. Care plans did not contain any documentation with regard to arrangements and service users’ consent regard infringements of their rights. For example, some service users have monies and cigarettes held for them. There was no evidence that service users’ choice regarding different aspects of their lives in the home and the community had been actively sought. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 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, 13, 15 and 16 Quality in this outcome group is adequate. This judgment has been made using available evidence including a visit to this service. More varied activities and educational opportunities had been introduced. Full opportunity for service users to take part in appropriate activities both for leisure and claiming greater independence continues to be limited through staffing levels. EVIDENCE: The standard with regard to meals (NMS 17) was not inspected at this visit and will be monitored at the next inspection. The new manager is an experienced occupational therapist. He had worked well with the service users to develop a broader choice of activities, work and educational opportunities. Links had been made with local colleges and organisations. This is an improvement on previous inspections and the development will continue to be monitored at future inspections. However, the service users’ access to more social activities is limited by the staffing levels, especially at weekends and evenings. The rota seen at the Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 12 inspection indicated that the staff shift ended at 8pm and so activities at this time of night were, therefore, limited unless planned well in advance with staff available to assist. Service users told the inspector that they liked the college courses offered to them and said that staff supported them when making new contacts, such as “Bridges”. Other service users told the inspector that they enjoyed different activities and they liked going to church and other social clubs. The service users were aware of the homes’ policy regarding smoking and alcohol. They are supported in having pets in their flats. The service users have a key to their bedroom but not the front door so sign “in and out” during the day. They are supported by staff to be independent in their flats though some routines clearly impact upon their independence such as the set communal meal times and medication administration routines. The providers’ representative, who was present on the second day of inspection, was aware of the need for service users to develop more independent living skills. She recognised the need to increase staff support to enable this for the service users as part of their care planning and in line with the homes’ Statement of Purpose. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. Health care files were poorly managed and did not reflect the physical and mental health needs of service users. The practice of medication administration was institutional. EVIDENCE: As previously stated in this report, the care plans were poor. They contained little or no information regarding the service users’ physical and more importantly their mental health needs. Staff were observed to assist and interact with service users in a considerate and caring manner but care plans did not reflect the good practice observed by the inspector. Care files contained limited information regarding appointments and outcomes of any visits to health care professionals such as dentists, doctors, psychiatrists and CPN’s. There was no evidence of any referrals for annual health checks on service users. The inspector was concerned that the manager had noted a possible physical difficulty of a service user but made no referral to the local doctor. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 14 There was no evidence of any Care Programme Approach (CPA) reviews on service users’ files. The manager did express some frustration with regard to the difficulties in organising CPA reviews for some service users. Some service users had limited monies and there was no evidence of any input into investigating their access to benefits. This clearly impacted upon their ability to maintain a standard of personal care that some clearly indicated they wished to achieve. Prescribed medication for the residents was dispensed from the chemist using the Monitored Dose System (MDS). The practice observed on the first day of the inspection was institutional, in that service users were coming down from their flats to queue for medication. This was acknowledged by the both the acting manager and staff as an institutional practice. However, at the second day of inspection this practice had not changed and the inspector shared her concerns with the acting manager who was very defensive and obstructive in their response to the inspector. He told the inspector, “staff did not like the idea of carrying medication around the home and that the inspector should wait until metal cupboards were in each flat”. He continued with these comments in spite of being advised by his line manager, (the providers’ representative), that the inspectors comments were indicators of good practice and a less institutional approach and that he should advise staff not be led by them”. Care staff had received training in the administration of medication and with regard of some specialist mental health medication used by several service users. Specialist health staff had provided this training. Examination of the medication records highlighted the need for correct transcribing of medication information and advice, from the prescription and container, to the medication administration record, and for staff to cease the use of medical shorthand when writing dosage information on the medication records. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. Policies and procedures for complaints and protection of vulnerable adults were not being followed. EVIDENCE: The home had an Adult Protection policy and procedure in place and staff were receiving training in the protection of vulnerable adults (POVA) during the inspection. The staff were enthusiastic about the training provided and highlighted the institutional practice taking place in the home regarding the administration of medication. However, nothing had been done about this practice by the second day of inspection, some 18 days later. The inspector expressed concern regarding the lack of information and contact with the commission following recent POVA incidents under investigation by the home and complaints made by service users and staff. The inspector raised some concerns regarding the lack of advocacy on behalf of service users with regard to their personal finances and benefits. The manager and staff were not aware of the individual financial issues of some service users. Service users were not aware of the complaints process. Some reported that they felt unable to talk to the previous manager. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. Penfold lodge is not a comfortable, safe and homely environment for service users. 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. They service users told the inspector that they liked their flats. 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. This work has not yet been done. The inspector was shown a works list and costing undertaken by the provider that indicated their recognition for a major refurbishment of the home. However, there was no clear timescale for the works to be completed. The providers’ representative informed the inspector that the decision regarding the start of work was being finalised. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 17 There was a malodour in several areas of the home. The overall standard of cleanliness and hygiene of the bathrooms and toilets remains very poor. The home does not employ a domestic worker. The service users are provided with a smoking room. The inspector observed several members of staff smoking outside the front of the building rather than their designated area. The inspection also highlighted an urgent need for the hot water system to be upgraded as checks showed hot water temperatures of between 50 and 64 degrees centigrade, which are unacceptably high. The inspector advised the manager to undertake risk assessments on all service users to ensure their safety and to provide information and advice to service users and staff. Inspection of health and safety records indicated that water temperature checks, completed by the home, also highlighted high temperatures up to 69 degrees in one flat. The manager had addressed some of the issues by the second day, though no risk assessments had been undertaken. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 18 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, 34 and 35 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. The registered person had not provided staff members with the training to meet service users individual and joint needs. Increasing the level of staffing, particularly at weekends could better support service users. Staff recruitment checks were not well managed. EVIDENCE: Examination of the rota indicated a minimum of two members of staff per shift and on regular occasions many worked long shifts, for example 8.00am – 8.00pm. This is not good practice. The role of the care staff also included the preparation and cooking of the meals and domestic duties. The home needs to review staffing levels as the opportunity for some service users to receive more individual support to develop their independence and life and social skills is currently reduced. The staffing levels and the length of the working day limit the opportunity for service users to develop and access social activities, especially at weekends and in the evenings. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 19 The staff on duty were observed to interact with the residents in a pleasant and respectful manner. Staff spoken with demonstrated a positive and caring attitude. The inspector requested access to two staff files for sampling with regard to recruitment practices. The manager had failed to inform the providers’ representative of the inspector‘s request to view staff Criminal Bureau Checks (CRB) and so they were not available for the second day of inspection. One of the staff files requested was not available for inspection, as the manager could not locate it. The other file sampled highlighted shortfalls in the recruitment process in that the job application did not contain a full employment history; there was no evidence of this being followed up with the staff member concerned; there was no evidence of a current photograph of new staff; no evidence of references. The staff files were poorly organised and the recruitment practices did not protect the service users or follow the organisations procedures. There was no evidence of the recently recruited staff having undertaken induction training or linking into the Skills for Care training. Their staff files did contain evidence of attendance at training courses in health and safety, record keeping and Protection of Vulnerable Adults. Additional training certificates, from external trainers ,were on file for some staff. These included attendance at fire safety, health and safety, first aid and challenging behaviour courses. The home had not been successful in accessing any training with regard to mental health issues. This had been raised at previous inspections. The manager informed the inspector that he had made links within the organisation with regard to National Vocational Qualification training. Records evidence that three members of staff had achieved level 2. The manager recognised that further NVQ training is required. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 20 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 42 Quality in this outcome group is poor. This judgment has been made using available evidence including a visit to this service. The health and safety of service users was not sufficiently protected. EVIDENCE: The standard with regard to Quality Assurance (NMS 39) was not inspected at this visit and will be monitored at the next inspection. The current manager is not registered and the commission has received no application for registration. The service users expressed dissatisfaction with the previous manager and felt that the new manager was better at listening to them. The staff told the inspector that they felt better supported by the new manager and were positive about the training opportunities provided since his arrival at the home. However, the inspection highlighted the difficulties of the new manager in meeting the standards and regulations. He demonstrated little understanding of the requirements and expectations of inspection and the need to meet the Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 21 National Minimum Standards. The inspector found some of the responses and actions by the manager to be defensive and uncooperative. He was unable to locate information regarding newly recruited staff, health and safety files and care files on new service users. He did not accept the responsibility of his post or acknowledge that he had time to improve standards and address the shortfalls raised at the last inspection and following the last visit, as part of this inspection. The systems and organisation of files, particularly with regard to staff and health and safety, were poorly managed and so failed to protect the service users. The inspection highlighted major shortfalls with regard to health and safety issues that had not been addressed, even when monitoring and examination by other agencies had highlighted the same issues and concerns on several occasions. An example of this was the poor monitoring and response to serious concerns regarding the fire and water systems in the home. Inspection of the fire systems had, on several occasions, indicated that it was not safe yet it remained in this condition for over a month. The smoke detectors on the top floor of the building were not working. No risk assessments or action had been taken to ensure the safety of service users and staff. There was no evidence of staff attendance at fire drills. The inspector served an Immediate Requirement notice regarding the fire safety in the home. The manager showed little understanding or appreciation of the importance of addressing the shortfalls with regard of health and safety issues in the home. Shortfalls highlighted by visiting maintenance agencies and from staff monitoring exercises had not been effectively pursued by the manager. As previously mentioned, the inspector checked the hot water system and several areas of the home failed to meet the required standard. The new manager was not aware of the requirements for compliance with regard to Control of Substances Hazardous to Health regulations (COSHH) or the requirements with regard to health and safety and fire safety. The manager was unable to locate the latest gas and electric installation certificates for the home, though electric equipment checks had been done. Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 22 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 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 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X X 1 X X X 1 X Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 23 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 service users have comprehensive assessments and that they are involved in the process. This is a repeat requirement. The timescales of the previous inspection was not met. 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.V305068.R01.S.doc Timescale for action 16/11/06 2 YA2 14 16/11/06 3. YA6 15 16/11/06 4. YA9 15 16/11/06 Penfold Lodge Version 5.2 Page 24 of the three previous inspections were not met. 5 YA10 12 The Registered Person must ensure that information held on service user is securely stored and written in appropriate individual records. The Registered Person must ensure that service users 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 support. This is a repeat requirement. The timescales of the two previous inspections were not met. The registered person must ensure that service users daily routines and hose rules promote independence, individual choice and freedom of movement. The Registered Person must ensure that the home is conducted in such a manner that respects the dignity and individual needs of service users. The Registered Person must ensure that the individual health needs of the service users are monitored and potential problems identified and addressed with the service users and appropriate health professionals. The Registered Person must ensure that the home’s practice in relation to medicine administration is not institutionalised. The Registered Person must ensure that the home’s complaints procedure is accessible and understood by the service users so that they feel DS0000028590.V305068.R01.S.doc 16/11/06 6. YA14 18 16/11/06 7 YA16 12 16/11/06 8 YA18 12 16/11/06 9 YA19 12 16/11/06 10 YA20 13 (2) 16/11/06 11 YA22 22 16/11/06 Penfold Lodge Version 5.2 Page 25 12 YA23 13 (6) 13 YA24 23 14 YA30 13 (4) 15 YA32 18 16 YA33 18 able to voice their concerns confidently and any comments are listened to and respected. 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. This is a repeat requirement. The timescale of the previous inspection was 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 two previous inspections were not met. The Registered Person must ensure that all parts of the home are kept in a satisfactory standard of cleanliness and hygiene. This is a repeat requirement. The timescale of the previous inspection was 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 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 timescale of the previous two inspections were not met. DS0000028590.V305068.R01.S.doc 16/11/06 16/11/06 16/11/06 16/11/06 16/11/06 Penfold Lodge Version 5.2 Page 26 17 YA34 Section 89 of Care Standards Act 2000 18 YA34 19 (1(a)(b) 19 20 YA38 YA39 9 24 (1) (2) 21 YA42 23 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 for the second time and could not be assessed at this inspection due to lack of availability of records. The Registered Person must ensure that all staff personnel records contain copies of their birth certificates and passports. This is a repeat requirement for the second time and could not be fully inspected due to lack of availability of records. The registered person must ensure that the home is well managed. 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 the fire procedures, fire systems, water checks, electric checks, premise monitoring and health and safety risk assessments and monitoring systems. 16/11/06 16/11/06 16/11/06 16/11/06 09/10/06 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 Penfold Lodge DS0000028590.V305068.R01.S.doc Version 5.2 Page 27 1. YA19 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.V305068.R01.S.doc Version 5.2 Page 28 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.V305068.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. 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. 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