Inspection on 22/05/08 for Pengarth

This inspection was carried out on 22nd May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pengarth 18/09/08

Pengarth 23/05/07

Pengarth 03/05/06

Pengarth 21/09/05

Pengarth 25/04/05

Pengarth 25/10/04

Pengarth 02/06/04

Pengarth 05/12/03

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Pengarth Windmill Hill Ellington Morpeth Northumberland NE61 5HU Lead Inspector Anne Urwin Brown Key Unannounced Inspection 22nd May 2008 08:50 Pengarth DS0000000545.V364715.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 Pengarth DS0000000545.V364715.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. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pengarth Address Windmill Hill Ellington Morpeth Northumberland NE61 5HU 01670 860475 01670 860475 steveac@ukonline.co.uk www.flexiblesupportoptions.co.uk Flexible Support Options (UK North East) Limited Manager post vacant Care Home 5 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) Category(ies) of Learning disability (5) registration, with number of places Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 persons may also have a physical disability Date of last inspection 23rd May 2007 Brief Description of the Service: Pengarth is a detached bungalow situated in the small village of Ellington and is home to five residents with severe learning and physical disabilities. A post office, shop and public house are situated nearby and a bus service is available to a nearby town centre. Off-street car parking is available at the front of the premises and there is a large garden to the rear. Disabled access is provided at both the front and rear of the building. The home is not registered to provide nursing care. The Statement of Purpose and User guide is available at the home together with a copy of the last inspection report. A fee of £769.79 per week is charged at Pengarth. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Summary: This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 23rd May 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 22nd May 2008 and another visit was made on 5th June 2008. A total of seven and a half hours were spent at Pengarth. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: Each person living at the home has had their needs assessed to make sure that the home can give them the care and support they need. Information is available to help people make a decision about coming to live at Pengarth. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 6 There are care plans that provide some information about how peoples’ needs are met. The staff treat people as individuals and support them live their lives in a way that suits them. This means that they have new experiences and know that their views are valued. There is a good variety of activities provided so that people have opportunities to build their confidence. The home is clean, warm and well furnished to suit the needs of the people living there. Residents are protected by the arrangements for administering medicines and receive these at the appropriate times. There is a procedure in place for dealing with complaints so that any concerns can be quickly investigated and resolved. Adult protection procedures are in place to protect the residents. Staff have good relationships with the residents and work hard to meet their needs in a sensitive and respectful manner. What has improved since the last inspection? What they could do better: More effective care planning is needed to show that peoples’ needs are regularly reviewed. More information is needed to ensure that staff are clear about how peoples’ needs are met. Risk assessment need to show how risks are minimised and they need to be regularly reviewed to take account of changing needs. The staffing review needs to be completed and staffing levels organised that suit the personal care and social needs of the people living in the home. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 7 A level of 50 of staff should achieve National Vocational Qualifications in care. The laundry floor should be impermeable and soiled linen should not be left on the floor. The management arrangements need to be strengthened to ensure consistency and positive support is provided for people living in the home and for the staff group. Staff should receive regular supervision six times per year. 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. Pengarth DS0000000545.V364715.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 Pengarth DS0000000545.V364715.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 good. This judgement has been made using available evidence including a visit to this service. There is a Statement of Purpose that provides clear information about the service provided and the facilities available at Pengarth to help people to make a choice about where to live. Residents’ needs are assessed before and after they move in to ensure that staff are able to provide the appropriate care and support to meet their needs. EVIDENCE: The Home’s Statement of Purpose and service user guide provides people with the information they need to make an informed decision about whether they want to live at Pengarth. Information is provided in written form and people are encouraged to visit before they decide if they want to live there. There are plans to make information available in a more user friendly picture format to suit the needs of the people cared for at Pengarth. The home has not had any new admissions since the last inspection. The manager said that people who live at the home have had their needs assessed before and after they move in. Records for the last resident admitted showed Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 10 her care needs had been assessed before she came to live at Pengarth and that staff, family and health professionals contributed to the process. Other residents’ records showed that information had been collected before their admission, however their records were not well organised and information was difficult to find. The Acting Manager said that she plans to review to care planning system to improve record keeping. Records show that relatives and care managers are actively involved in arranging admissions to the home. Pengarth DS0000000545.V364715.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. Not all care plans have enough clarity or detail to fully show how the needs of the people living at Pengarth are met. People using the service get the personal support they need and their privacy and dignity is respected Staff enable and support residents so that they can be as independent as possible. Risk assessments do not always provide enough information to show how risks are managed and reduced to safeguard the people living at Pengarth. EVIDENCE: People living Pengarth have an individual care plan, although they have not been involved in preparing them as they are not able to understand the process because of their disability. One plan was clear and had recently been prepared using a new format, while others were disorganised and there was Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 12 not enough information about how staff met identified needs. Plans lacked evidence of regular review and recording was not always consistent. The acting manager said that there are plans to review the care planning system so that information is available about how staff meet individual needs. From the records and discussion with the manager and staff it was clear that staffing difficulties have affected the quality of care planning and recording. There was evidence from discussion with staff and observation that peoples’ care needs are identified and met. One relative said she had not been consulted about or shown her daughter’s care plan, she said she did not know what it contained. However there are regular formal reviews and families are invited. Risk assessments were not consistently assessed and updated. Some were not dated and signed by staff, while others had not been updated since April 2007. There is not a consistent system for assessing risks and reviewing the action when needs change. One person’s risk assessments had been recorded using a new system which clearly showed how the staff minimised risks and there was space to review the risks and action, however for other people information was limited and at times it was not clear how staff minimise the risks identified. Staff were able to describe how they are able to help people living at Pengarth to make choices by using signs, facial expressions and the knowledge they have gained with working with individuals over a number of years. This was also observed during the inspection. Residents are assisted to manage their finances and information about how this is done is recorded in individual files. Pengarth DS0000000545.V364715.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 adequate. This judgement has been made using available evidence including a visit to this service. People living at Pengarth generally experience healthy, stimulating activities using facilities in the area to help them to maintain links with the local community, however at times staffing difficulties have limited these opportunities. Contact with friends and family is well supported and encouraged by staff to ensure that links are kept. Mealtimes are flexible to suit individual preferences. Meals are carefully planned to provide a balanced and nutritious diet that suits each individual’s taste and dietary needs. EVIDENCE: All the people living at Pengarth have individual plans, but information in these is sometimes limited and do not show the work going on with residents or clearly identify a programme for each person. From talking to staff it is clear that people do regularly experience good quality activities and outings, but Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 14 recording of these could be improved. It is also clear from talking to staff and relatives that the provision of activities and outings are sometimes dependent on having sufficient staff on duty or having a driver available. Three people were out shopping during part of this visit. People were unable to say what they thought of their activities, but they were relaxed and responded well to staff during the inspection. Daily records show that activities have taken place with each person. These show that walks, trips out for shopping, to the local pub, cinema/theatre, swimming and hydrotherapy regularly form part of peoples’ routines. Holidays are planned and information in individual records showed that people attend local events in the community. One resident is regularly involved in some simple domestic tasks in the home and records confirmed this. The tasks involved included dusting, baking and washing dishes. One relative said that the activities are usually good, but can often be affected by the lack of a driver on duty to take people out. The daily routines are organised to suit individual needs and preferences. Staffing levels usually support the residents to take part in activities individually, although sometimes this has not been possible due to staffing numbers. Staff said that recently staffing has improved, but there have been problems going out when too few staff were available. On the four week rota current when the inspection took place there were six days when only two staff were on duty. Given that staff are responsible for cleaning, laundry and cooking this means that time to spend with residents can be limited. The manager said that they are going to recruit a cleaner to assist staff and let them spend more time with the residents. Clear guidance is available for staff regarding how they should respect and safeguard the residents’ right to privacy. Staff were observed to follow this guidance during the inspection. During lunch time there was evidence of good relationships, with staff showing they knew peoples’ likes and dislikes. Talking to staff confirmed that staff are aware of the need to respect residents’ dignity and to value their individuality. Menus showed that meals are varied and nutritious. The records of meals provided indicated that they were well balanced and nutritious. Special diets were catered for and peoples’ requirements were known to staff i.e. soft/liquidised diet. Alternatives are available and peoples’ individual preferences were catered for. Healthy eating is encouraged. Staff have received food hygiene training. Pengarth DS0000000545.V364715.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. People have personal support when they need it so that they can be as independent as possible. Health care needs are well met by using a multiagency approach to ensure that they stay healthy. Good systems are in place for managing medicines to make sure that residents are not put at risk. EVIDENCE: Most care plans do not clearly identify the personal support that each person needs with everyday tasks. One care plan provides better information about how an individual’s needs are met, as it has been recorded using a new format. It is planned to review the care planning system in line with other homes in the same group the manager said. From talking with staff there is evidence that personal support is provided sensitively and the delivery of care is individual and flexible, but records are not in place to show this. Staff were well informed about peoples’ needs. It is not clear how relatives are involved in the care planning process, and one relative said she had not seen the care plan relating to her daughter, although she did attend reviews regularly. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 16 Residents have access to healthcare and remedial services. Residents have the aids and equipment available that they need and these are well maintained to support them and staff in daily living. People are supported by visits to the home by health care professionals as necessary. There was evidence that health care needs are monitored, and appropriate action and intervention taken. There are some gaps in the health care information, but staff are able to give verbal updates on individuals needs. Guidance on administration of medicines is clear and staff have had training in the safe handling and use of medicines. None of the residents self-administer medicines. Records of administration were in good order. Arrangements for the storage of medicines were satisfactory. Pengarth DS0000000545.V364715.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. There is a satisfactory complaints procedure in place to ensure that complaints are dealt with effectively and to the satisfaction of the complainant. Clear protection policies and procedures are in place to safeguard people living at Pengarth from abuse. EVIDENCE: There are clear procedures to show how complaints are dealt with. These are available to residents, their relatives and carers. Records showed that there have been no complaints made since the last inspection. Staff knew about the complaints procedures and could describe how they would assist someone to make a complaint. Discussions with staff during the visit confirmed that they have a range of strategies to identify if a resident is unhappy. Staff watch for changes in behaviour or facial expression as this often is an indicator of whether someone is unhappy or possibly ill. One relative said she had not received a copy of the complaints procedure, however she said she felt able to raise any issues or concerns. Staff had received basic training in the protection of vulnerable adults. Policies and procedures relating to the protection of vulnerable adults were in place. A copy of Northumberland Care Trust’ guidance is also available in the home. Staff knew the procedures to be followed in the event of an allegation being made. Pengarth DS0000000545.V364715.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 good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, warm and clean so people have a pleasant place to live. The standard of the accommodation, décor and furniture and fittings was good. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 19 EVIDENCE: This detached bungalow provides comfortable accommodation that suits the needs of the people living there. The home was clean, tidy and homely and is easily accessible with ramps at the front and rear doors. The furniture and fittings are of a good standard. Maintenance and redecoration is carried out at regular intervals. All accommodation is on the ground floor and residents’ rooms are personalised and attractive. Personal items including televisions, DVD players, music systems pictures and ornaments give each room a personal identity that reflects peoples’ taste. Equipment including bed rails, air mattresses and hoists are available in bedrooms to suit the identified needs of residents. Records show that equipment is regularly checked and serviced. One bedroom wall needed repainting and the manager said that a programme of redecoration is in place. In some rooms the need for additional electric sockets has been identified the manager said and a request has been submitted for this work to be carried out. Extension leads and adaptors are being used to provide sufficient power points in some bedrooms. Work has been completed since the last inspection to fit a new Parker bath that is height adjustable. A wet room has been created from part of the old bathroom that is well used by the residents, however the flooring is not level and is marked. In addition the shower tubing needs replaced as it is worn and damaged. The other half of the bathroom has been used to create a new office/sleep in room. This is a significant improvement providing a small sleep in area for staff who previously used the conservatory as a sleep in area. No odours were evident during the inspection. Cleaning materials and other potentially hazardous substances were safely stored. Policies and procedures were in place relating to the Control of Hazardous Substances and Infection Control and other Health and Safety matters. Training is provided in Health and Safety and Food Hygiene. The laundry/boiler room is off the main hall and is quite small. The flooring is not impermeable and laundry was lying on the floor during the inspection. There is a washer with sluice facility and a dryer provided. Pengarth DS0000000545.V364715.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, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been changes in the staff team that have affected the consistency of staffing arrangements. This means that people are being cared for by staff who are experienced, but sometimes staffing levels have affected the number of activities and outings on offer. Robust recruitment practices are in place to ensure that residents are kept safe. Staff supervision has been affected by the turnover of staff and change of managers so this has contributed to the feeling of low morale among staff. EVIDENCE: Rotas showed that staffing levels vary between four staff and two staff on duty during the daytime. Since the last inspection the manager said the staff turnover has been high and that the organisation is currently reviewing staffing levels and the funding arrangements so that more time is available for one to one work and to take people out. The rota showed that there were six occasions when only two staff were on duty throughout the day. This means the availability of activities and outings is limited as staff said they cannot take Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 21 people out when only two staff are on duty. In addition to caring for the residents staff have all the domestic tasks, laundry and shopping to complete, so this also affects the number of hours spent with individuals. At weekends there are regularly only two staff on duty on a Sunday. The manager says that additional hours have been funded to provide more staff on a Saturday so that people can go out and also has identified funding to recruit a cleaner to help staff with domestic work. Staff work full days starting at 8am and finishing at 9pm. The manager said that there had been problems recruiting staff because of the lack of public transport in the area at times when shifts start and finish. As part of the review of staff arrangements it is planned to reconsider start and finish times. At night there is currently one person sleeping in at the home and arrangements for dealing with emergencies have been reviewed since the last inspection so that staff are clear about procedures to be followed. The manager said during the inspection that funding has been identified to have two staff sleeping in and this will be introduced shortly. Clear guidance for the recruitment of staff is in place. Staff files were available and these showed there is appropriate practice followed when the organisation recruits staff. Reference and Criminal Record Bureau (CRB) checks had been carried out on all the staff. Staff received regular mandatory training including First Aid, Food Hygiene, Moving and Handling, Health and Safety and Fire Safety. Staff supervision has been affected by the manager leaving and staff shortages. The new manager says the supervision arrangements will be reviewed and a new programme implemented. Staff morale was low and staff said that this was linked to the changes in management and staffing shortages. At times they have not felt well supported. Three staff have national qualifications in care. One person is currently working towards completing qualifications. Staff said that there is an appropriate induction programme in place and one member of staff said that she had felt well supported by other staff when she first came to work at Pengarth. Pengarth DS0000000545.V364715.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, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new manager has recently been appointed and this follows an unsettled period when one manager left fairly soon after appointment. The organisation is committed to providing good quality care and support for the people living at the home, but the management arrangements have not been consistent since November 2007. Quality monitoring systems are in place, but these need to be developed by a consistent staff team to ensure that the service is being run in the best interests of the people living at the home. Good systems and practices are in place for health and safety that help to ensure residents and staff are safe from risk of harm. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 23 EVIDENCE: At the time of this inspection there was a new manager who had just been in the job for two weeks. She is experienced in managing a supported living service and has worked with people with learning disabilities for some time. This service has had two managers in the last year and staff and relatives say that this has affected the continuity of the service. The new manager is to undertake the Registered Manager’s training, but has experience of working with people with learning disabilities. There was evidence that she understands her role and is getting to know the residents and staff. She is aware of the need to keep up to date with practice and develop her management skills. The manager says she is well supported by her manager. She is concerned about the difficulties in recruiting staff because of the location of the home and is aware of the low staff morale. Relatives expressed concerns about the impact the management difficulties have had on the service. There is a quality assurance system in place that uses questionnaires, review of performance targets and quarterly monitoring of health and safety. Audits of records are carried out. However with the changes in management the system has not been operating as effectively as it should and the manager is aware of this. Staff take part in regular training that covered moving and handling, health and safety, first aid and basic food hygiene. Staff guidance and risk assessments were in place covering safe working practices. Accident records are kept in good order. Fire records were well maintained. Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 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 2 X 2 X 3 X X Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement The content of each resident’s care plan must be regularly reviewed. This is outstanding from the previous report. 2. YA6 15 Comprehensive care plans must be completed for each resident identifying their individual needs and how these will be met. More information is needed in Risk Assessments to clarify how risks are minimised. This is outstanding from the previous report. 4. YA33 18 The staffing review must be completed and staffing levels adjusted to provide sufficient competent staff to support the residents needs. 30/09/08 31/07/08 Timescale for action 31/07/08 3. YA9 13 31/07/08 Pengarth DS0000000545.V364715.R01.S.doc Version 5.2 Page 26 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. 2 3 4 5 Refer to Standard YA32 YA30 YA36 YA39 YA37 Good Practice Recommendations Continue with staff development to achieve 50 of the staff team with NVQ level 2 or above in care. Impermeable flooring is needed in the laundry/boiler room. Soiled linen should not be left on the floor waiting to be washed. Staff should receive appropriate supervision and support. There must be an effective quality assurance system in place that forms the basis of an annual development plan for the service. The manager needs to complete appropriate training in management and care to ensure that she has the skills to effectively run the home. 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