Inspection on 15/04/08 for Penhellis Nursing Home

This inspection was carried out on 15th April 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Penhellis Nursing Home Cross Street Helston Cornwall TR13 8NQ Lead Inspector Diana Penrose Unannounced Inspection 15th April 2008 09:30 X10015.doc Version 1.40 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 Penhellis Nursing Home DS0000070880.V360504.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 Older People. 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. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penhellis Nursing Home Address Cross Street Helston Cornwall TR13 8NQ 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) 01326 565840 Glencare Homes Ltd Post Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (5) of places Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) - maximum 26 places Physical disability (Code PD) - maximum 5 places The maximum number of service users who can be accommodated is 26. N/A 2. Date of last inspection Brief Description of the Service: Penhellis House is situated in the centre of the town of Helston. The building is a period house, which is listed, with modern day extensions that sits in extensive grounds. There is a tarmacadam driveway, footpaths through the trees, well-tended flowerbeds and fishponds. Two entrances are ramped but access is limited where the concrete chippings are; the owners have plans to improve this. The home has been open for four months and is registered to provide accommodation, personal and nursing care to 26 elderly residents, 5 of whom may have a physical disability. Accommodation is on two floors with a lift provided. There are 20 single bedrooms, 11 of these have en-suite facilities, and 3 double bedrooms with en-suite facilities. All rooms are provided with call bells, internet access, telephone points and a television. The home has been completely refurbished to a high standard with furnishings in keeping with the house. The home provides dining facilities that cannot accommodate 26 people in one sitting, however the home offers two sittings’. The kitchen has been completely replaced to the Environmental Health Officer’s satisfaction, with stainless steel fittings. There is a large lounge on the ground floor and a smaller lounge upstairs. Another room upstairs has been provided for hairdressing and chiropody services. There are two bathrooms, one with a Parker bath and one with an overhead hoist; there are separate toilet facilities. There is also a wet room shower provided. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 5 Information about the home is available in the form of a brochure that includes the statement of purpose; a copy can be supplied to enquirers on request. Fees range from £595 –780 per week, £795 for respite care. More complex care needs may incur higher fees; this information was supplied to the Commission on the day of inspection. There are no additional charges made for hairdressing, chiropody or newspapers. Any personal items purchased are invoiced to the resident or their representative. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 6 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. An Inspector visited Penhellis House Nursing Home on 15 April 2008 and spent seven and three quarter hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection thirteen people were living in the home, three of these were receiving respite care. The methods used to undertake the inspection were to meet with the people using the service, staff and the manager to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. The manager has returned a completed Annual Quality Assurance Assessment, which has informed this inspection. Also CSCI surveys have been returned in respect of 1 resident, 3 relatives, 4 staff and 2 professionals, these have also informed this inspection. This report summarises the findings of this key inspection. The people using this service expressed satisfaction with the care and services provided at the home and said they were treated with kindness and respect. What the service does well: The home provides a comfortable homely environment that is clean and safe for residents, staff and visitors. There is ample communal space and suitable washing and toilet facilities. The whole home has been decorated and furnished to a high standard. People say they are happy living in the home and they say the staff are very kind and caring. They say their independence is respected and they can choose how to live their lives. Suitable equipment is provided for moving and handling purposes and for the prevention of pressure sores, some nurses act as links with the specialist community nurse teams and doctors visit when required. Residents said their healthcare needs are met. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 7 Staffing levels are suitable for the number of people accommodated and there is a registered nurse on duty at all times. Money is not held on behalf of residents, hairdressing, chiropody and newspapers are included in the fees. What has improved since the last inspection? What they could do better: Some additions to the statement of purpose are necessary to ensure it fully informs people and complies with legislation. The assessment of prospective residents should improve when the new documentation has been implemented and tested. Care plans must be developed to fully inform and direct staff in the care to be provided. They need to be person centred rather than only focussing on problems. Any risk assessment scores need to be included as they denote a level of risk, this may mean specific directions for staff. A photograph must be kept of each resident. The care plans should be agreed and signed by the resident or their representative so that they know the care they will receive is appropriate for them. There are issues in respect of medicines to be addressed, the manager has already identified some of these and has started to address them. The nurses must ensure that all medicines received into and out of the home are recorded and can be tracked when audited. The care plans should include the administration of medicines and give instruction to nurses as to how to assess for administering ‘as required’ medicines for example. The manager must talk to the pharmacist regarding the controlled drugs cupboard to ensure the home is complying with current regulations. The temperature of the medicines room and the medicines fridge need to be monitored to ensure they are within the safe range for the medicines stored. Nurses should receive appropriate medicines training and all care staff should receive basic medicines training. The manager is hoping that activities and entertainment will improve, when she employs a co-ordinator, the previous person has left. Although the abuse policy is appropriate staff have not yet received training in this area, this could put residents at risk and must be addressed. Training in general must be addressed, as there is little evidence to show that staff have attended statutory training, required by law, or that staff attend training sessions relevant to their role. Induction appears to be very lacking although some staff said they did have an induction to the home. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 8 Recruitment procedures must be improved to comply with regulations and all the required documents must be maintained. Staff must not be employed unless satisfactory checks have been undertaken and at least a POVA first check received. Even then staff must work under supervision until a satisfactory CRB check has been received. A quality assurance policy must be in place to ensure the management strives for continual improvement of the service. With this systems must be put in place for reviewing and auditing systems and processes. The electrical hard wiring system check must be undertaken and subsequently repeated at least five yearly. 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. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. 6 is N/A Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about the home; some additions are necessary to fully inform people and to comply with regulations. Residents are only admitted to the home following an assessment of their needs, full implementation of new paperwork will help staff assess that the home can meet those needs. EVIDENCE: The home has a statement of purpose, which forms part of the home’s brochure. The homes fire precautions were not included and this was discussed with the manager who said she would address this. There is also no information regarding the home’s policy in respect of resident’s money. The manager said that she or the full time nurse visits prospective residents to assess their care needs. There is evidence of assessments on file however the manager has devised a new assessment form, which will be a more concise tool. The form does not include religious and social needs and does not have a Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 11 space for dating and signing, the manager said she would include these. Other information from external agencies was seen in resident’s files. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person using the service has a care plan, More detail, inclusion of risk assessment scoring and further attention to medicine procedures will improve systems and safeguard vulnerable people. EVIDENCE: Three people’s files were inspected; each contained a care plan, various risk assessments, pre-admission assessment details and other care information. The care planning documentation is lengthy but not detailed enough to fully inform and direct staff in the care to be provided. Plans tend to be problem based at the moment and not holistic. Some risk assessments have a scoring system which denotes the level of risk, these scores have not been included in the care plans to explain the level of care required. The manager said that care plans are compiled with the people using the service but none have been signed. People said they were not aware of their care plan; although some said the manager had asked them questions about their health and so on. The nurses write daily records and care staff inform the nurses if they need anything to be recorded. Care staff have their own paperwork to complete Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 13 each day regarding personal care. There are few photographs of people in their files. People said that doctors and other healthcare professionals visit when required and records are kept. They said their healthcare needs are met. The manager said that specialist community nurses visit as required and that some nurses employed act as links with them. Staff said there is sufficient equipment for moving and handling and pressure relief in the home. The manager stated that they aim to put in place a specialist palliative care package and gain accreditation for the Gold Standard Framework. CSCI surveys were positive about the care provision comments include “There are regular patient reviews and lots of appropriate input”, “There is genuine care and enthusiasm about helping individuals make the most of their abilities” and “The home does it’s best to provide for all individuals personal preferences”. There is a medicines policy for the home, the inclusion of insulin use and storage and oxygen therapy were discussed with the manager; neither are in use at the moment. We found that the manager has already identified some issues regarding the medicine system; she had notes in her office and a memo displayed for staff. One medicine chart for a person receiving respite care did not include the number of tablets received into the home; this was rectified during the inspection. We found that medicines prescribed to be given “when required” do not have a record of the number of tablets actually administered. We also found that there is no reference made in the care plan about the use of this medicine, nor are there any directions on how to make an assessment if this medicine is required. The manager said she would ensure that medicines are fully included in the care plans. The home has made arrangements for the safe storage of medicines, although one of the cupboards in use did not appear to comply with the current regulations. The home has a system for the storage of medicines requiring refrigeration and the temperature was within the recommended range during the inspection. However there are no records of the temperature being monitored or defrosted. There is no monitoring of the treatment room temperature to show that it is maintained within the range recommended by the manufacturers of the medicines. Some individual’s medicine records had their photograph attached. One person was self administering her own medicines but there is no evidence that a risk assessment has taken place to ensure she is safe to do so or that she has signed to agree to do this. We noted that care staff do not receive any medicines training as yet. One nurse said that she has had supervised practice in the home but no formal medicines training. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 14 People’s privacy appeared to be upheld during the inspection and they are free to move around the home. They said they are treated with respect and their privacy is maintained at all times. They said they receive their post unopened and the telephone arrangements in the home are satisfactory. Shared rooms have appropriate screening. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Efforts are being made to improve the activities and entertainment provision, visitors are welcomed and residents are encouraged to live a life of their preference. EVIDENCE: There is no activities co-ordinator employed at the moment, several telephone calls were received during the inspection regarding this post and people were invited to meet with the manager. The manager acknowledges that this is an area for improvement and the AQAA states that ‘Penhellis intends to appoint a dedicated activities co-ordinator who will implement a new activities programme into the home, re affirm links with the community and encourage local contacts to visit the home’. Some activities take place in the home and the manager said that one to one time is spent with people. Activities have included art and craft, hand massage, manicures and gentle exercise. A tour of Culdrose is to take place in May 2008 place. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 16 The people using the service said that little goes on in the way of activities but they were content to enjoy the peaceful surroundings or their own room. One person had a selection of audio books to listen to. Several people talked about Flora day and they were looking forward to the celebrations. The visitor’s records show that people come to the home regularly. Everyone spoken with said there are no restrictions on visiting times. One person said she goes out with her family regularly. People talked about a meal that was organised by the home whereby resident’s families joined them for a roast dinner. The cook said it was a great success. All people spoken with said their individual preferences are respected and they are supported to maintain their independence. They said they get up and go to bed when they like and are free to move around the home as they wish. They said they choose what they do and can to go out if they wish; one person sat outside for a while during the inspection. All residents have their own belongings in their rooms. The menu shows that choices are available. People said the cook provides good home cooking and the food is of a high standard. One said “They provide alternatives to the set menu if I don’t like or can’t eat it for health reasons”. The cook said that everything is homemade for example cakes, puddings and soups. Fresh vegetables are included and a bowl of fruit is available in the dining room. The cook ordered vegetables by phone during the inspection. The teatime meals are prepared by the cook and her assistant but re-heated as necessary and served by care staff. Plenty of drinks were seen available to people throughout the day. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are suitable policies in place for complaints and adult protection however employment checks have not been appropriate, in some cases, and staff have not received appropriate training to ensure that residents are safeguarded. EVIDENCE: There is a suitable complaints policy in place that the manager said is issued to people with the statement of purpose. There had been one complaint from a staff member that the manager has resolved. Residents said there are no barriers to raising concerns with the staff or the manager. The abuse policy is appropriate with an easy to follow flow chart included. The training records show that only one person has attended abuse training since the home opened four months ago. One person said she had done abuse training with a previous employer, one said she had recently attended a course; others said they had not done any abuse training. The manager stated that she has attended an external course and has a video and training pack. She said that all staff covered this in the basic induction however this was not confirmed by staff on duty and the induction records are poor. Of the five staff files inspected not all had appropriate CRB disclosures prior to commencement of employment (see the staffing section) Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, decorated and furnished to a high standard with no unpleasant odours making it a pleasant place to live in. The building and grounds are well maintained; access to the grounds is limited at the moment. EVIDENCE: The home provides a comfortable, warm clean environment and all residents spoken with said they are very happy with their surroundings. It is furnished and maintained to a high standard and is in keeping with the age of the building. One comment from a CSCI survey states, “The environment is maintained to high standard of comfort and cleanliness”. The grounds are beautiful with trees, lawns, ponds and colourful flowerbeds; some residents said they helped to plant the bulbs. The registered providers intend to improve accessibility and safety of the grounds. The old greenhouse Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 19 has no glass; the manager said the registered providers are deciding what to do with that space. There are two communal lounges, a large one downstairs and a smaller one upstairs complete with computers and Internet access. The dining room has round tables and residents commented that is like a hotel restaurant. Another room upstairs has been provided for hairdressing and chiropody services. All rooms are very well furbished. There are two bathrooms, one with a Parker bath and one with an overhead hoist; there are separate toilet facilities. There is also a wet room shower provided. Fourteen of the twenty-three bedrooms have en-suite facilities. The home is well ventilated with window restrictors fitted where appropriate. The people using the service said the heating can be regulated to their needs and radiators are guarded for safety. Emergency lighting is provided and we saw up to date records for testing this. The manager said that the water temperature throughout the home is thermostatically controlled to prevent the risk of scalding. Residents have their own possessions around them and have personalised their rooms. Although some rooms are smaller residents said they are happy with their rooms. People said the desk chairs are heavy to move but one person said they are sturdy to sit in. The laundry facilities are situated in a converted outbuilding; there are two washers and one drier, which the laundry person thought was suitable. There is ample space for working and storage but the manager and laundry person said it gets very cold in winter. People had no complaints about the laundry service. We saw appropriate hand-washing facilities for staff throughout the home and alcohol hand cleansing gel is in use. Protective clothing is provided and was seen in use. There is a sluice on each floor. Infection control training has not been addressed. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are suitable staffing levels for the present number of residents and evidence that staff hold nursing and NVQ qualifications. Training needs have not been identified and there is little evidence that knowledge and skills have been kept up to date. Recruitment procedures are not robust and do not safeguard the people using the service. EVIDENCE: The staffing rota shows that a qualified nurse is on duty at all times with two care staff during the daytime and one at night. The manager said she tries to ensure that the nurse who works the weekend also works on Monday for continuity and communication with doctors and so on. The manager stated in the AQAA that she has used a high level of agency staff, although the number is reducing as permanent staff are recruited. Agency nurses are now employed mainly for night duties. There are a suitable number of ancillary staff employed for cleaning and catering. People living in the home said the staff are very caring and they are well looked after. The manager said that all care staff apart from one are qualified to at least NVQ level 2 in care. The remaining person has enrolled on the course. One carer said she has recently commenced NVQ training. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 21 The recruitment policy was seen and did not include a list of the documents to be held. There is a suitable equal opportunities policy. Five staff files were examined and did not hold the records required by legislation: • • • • • • • • • • all have a completed application form and health-check four have two references but one had only one reference one has not got a reference from her previous employer, the manager stated that she had obtained a verbal reference which was recorded but it was at her home so could not be seen during the inspection. only one file has evidence of the employees start date and none held terms and conditions of employment, which the manager said are usually provided during the first month of employment. two have a full CRB disclosure prior to employment, one has a POVA first check but no evidence of a full CRB disclosure one has a CRB received after the start date one has no evidence of any CRB or POVA check. one has interview records one has a photograph of the employee The manager was aware that some documents were missing and had a list. We were shown a file, which held the staff training records for 18 people. There is an individual record per person and some copies of certificates. All of the staff training records were inspected including the manager’s and the information held is poor. Statutory training is lacking and does not ensure the safety of residents (see the management section). • Copies of most of the nurses and care staff qualification certificates are kept but not all. Nurse’s registration with the Nursing and Midwifery Council has been checked and recorded. • Some training has been listed with no certificated evidence. • Only one person has abuse training recorded within the past year. • There is evidence for most staff that they completed a fire safety training questionnaire when they started their employment but induction records are missing, not completed, or ticked with no dates or signatures. Some staff said they received induction training but others said they did not. There was no record of who was supervising individuals during their induction period. Some people said they had undertaken courses other than statutory training and there was some evidence of this in the records. We were not shown a training and development plan for staff. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team appear competent to run the home however there is no quality assurance policy or system for continual improvement of the service. Statutory training for staff is lacking and does not comply with legislation; this could compromise the safety of the people using this service. EVIDENCE: Unfortunately the registered manager in post when the home opened in December 2007 became unwell and resigned. The manager now in post is a Registered General Nurse and has applied to the Commission for Social Care Inspection to become the registered manager. She states that she has extensive knowledge of elderly care, having worked in this area since 1997. She has had management experience in the NHS and for the last 5 years has Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 23 worked as a deputy manager in two local nursing homes. She has enrolled to undertake the Registered Managers Award, which should provide further knowledge and skills for the role. She said that she is reviewing systems in the home and policies and procedures. Staff and residents said the manager is very approachable and leads the team well. Everyone spoken with also spoke highly of the registered providers and said they spend time at the home most days. The registered provider said there is a development plan for the home, which was provided for registration, the manager said she has not seen this. There is no quality assurance policy and an auditing system has not yet been developed. The manager stated that she visits the residents every day so they can air their views and she checks the incident reports daily and takes action if necessary. A feedback form had been distributed to residents and their families in February 2008, a report has been complied with an action plan, the feedback was positive. CSCI survey results were also positive. We were shown notes taken at a staff meeting, which show that issues are discussed. Resident’s meetings have not taken place but the manager hopes to commence these to enable people to have their say about the running of the home. The manager has completed and returned the Annual Quality Assurance Assessment (AQAA) to the Commission and supplied the data requested. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. No money is held on behalf of the people using the service. There is no policy in respect of resident’s money and no mention in the statement of purpose for information. Hairdressing, chiropody and newspaper purchases are included in the fees. The manager stated that people are invoiced for any personal shopping purchased on their behalf and receipts are kept, some were seen in a file. The manager has commenced appraisals for all staff and these were on file. She has also commenced formal supervision sessions for all staff with records kept. Staff said they have had an appraisal that included a self-appraisal. There is evidence that health and safety precautions are in place however staff training required by legislation does not appear to have taken place. • Ten staff have no evidence of moving and handling and four have no certificate for training recorded as done in February 2008. • There is no evidence of food hygiene, infection control, health and safety, first aid or fire safety training with the current employer, for any staff. • The registered manager has a certificate for first aid training with a previous employer that expires on 14/03/2010 • Some training has been listed with no certificated evidence. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 24 The manager said that when her deputy has completed the fire warden’s course he would provide fire training for all staff. Machinery and equipment service checks have been undertaken. The registered provider said the five year electrical wiring test is still to be done and the PAT testing is due in July 2008. At present maintenance is undertaken by an external contractor. The accident records were inspected and nothing untoward found, there have been few accidents. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 1 Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 15 Requirement Care plans must be in more detail to fully inform and direct staff on the individual care to be provided. A photograph of the resident must be included. Arrangements must be made to ensure that all medicines are stored in accordance with the current regulations All of the recruitment records required by legislation must be obtained and maintained All staff must have a satisfactory POVA check prior to employment and only work with full supervision until a CRB disclosure is received All staff must receive regular training appropriate to their role and according to legislation including: • Induction • Fire • Health and safety • Moving and handling • Infection control • First aid • Abuse • Medicines DS0000070880.V360504.R01.S.doc Timescale for action 30/06/08 2 OP9 13(2) 30/06/08 3 4 OP29 OP29 17 (2), Sch 4 13, 19 30/06/08 15/04/08 5 OP30 13 (2) (3) (4) (5) (6) 18 (1) (c) 23 (4) (d) 30/09/08 Penhellis Nursing Home Version 5.2 Page 27 6 OP38 13(4) An electrical hardwire test must be completed with a copy of the documentation forwarded to the commission. 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Care plans should be compiled with the resident or their representative and signed as agreed. The temperature of the medicines fridge should be monitored and recorded regularly to ensure it is within the recommended range The temperature of the medicines room should be monitored and recorded regularly to ensure it is within the range recommended by the manufacturers of the medicines. Penhellis Nursing Home DS0000070880.V360504.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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