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Inspection on 01/11/05 for Penhill Residential Home

Also see our care home review for Penhill Residential Home for more information

This inspection was carried out on 1st November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Penhill gives residents a good standard of accommodation in a comfortable and homely environment. Facilities and care given are based on a family run ethos. Care given to residents is of good quality, provided by an appropriate number of trained and experienced staff. The emphasis is on giving residents a wide range of social activities that are based on their requests and preferences. Of particular note was the emergency admission pack developed by the owners. This gives a quick and easy reference guide to everything needed to know about the resident, that can be used in an emergency. The use of the pack saves valuable time and resources at a time when residents may be in need of emergency admission to hospital. This is good practice. No system of recording, investigating and resolving complaints was in place and available for inspection. However it was pleasing to note that a `complaints response and action plan` sheet was sent to Commission for Social Care Inspection immediately following the visit. This will ensure residents can be confident their concerns will be taken seriously.

What has improved since the last inspection?

The one requirement and two good practice recommendations made at the last visit were met. All staff have now done training in the safeguarding of vulnerable adults. Residents and their families can be confident that staff are trained to recognise and respond to any risk of possible abuse. Care plans are now kept at the front of each resident`s file for ease of reference. Whilst the inspector didn`t take the opportunity to view supervision records, the owner and manager of the home said that staff comments and concerns are now recorded following individual supervision sessions.

What the care home could do better:

Three new requirements were made. These included: Attention is needed to make sure care records are reviewed regularly in order to protect residents. Care records must show evidence that the provider has signed to confirm they are able to meet a resident`s assessed needs, so that the resident and relatives/representatives can be confident about this. Healthcare issues highlighted in care plans must have clear actions recorded so that residents are protected from harm. Although the owners carry out regular, comprehensive quality assurance reviews, the information gained from such surveys must be collated and reports sent to Commission for Social Care Inspection. Further, findings from the surveys should be used to inform the home`s development plan, to ensure residents` views are incorporated. A number of good practice recommendations were made. These were as follows: Where residents are identified as having mild degrees of dementia, care plans should reflect how their needs in respect of this are to be met. Advice on activities suitable for people with dementia should be sought from relevant organisations. All toilet doors in the public areas of the home should be suitably marked so that residents can find them easily. Bathroom equipment used for residents should be thoroughly cleaned and added to the weekly cleaning rota, to ensure residents are kept safe from the possible spread of infection. Residents` cash sheets should be checked and balanced regularly and countersigned by a second staff member to avoid risk of error. One cash sheet containing the total balance of each resident`s monies held should be kept at the front of the file for ease of checking.Key worker records be more holistic and reflect the quality of life overall for each resident within the home.Health and safety checks should be carried out regularly to ensure residents are kept safe within the home environment.

CARE HOMES FOR OLDER PEOPLE Penhill Residential Home 81 Station Road Shirehampton Bristol BS11 9TY Lead Inspector Sandra Garrett Unannounced Inspection 1st November 2005 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 Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 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. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Penhill Residential Home Address 81 Station Road Shirehampton Bristol BS11 9TY 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) 0117 9822685 0117 9822685 jon@penhill.com Mr Stephen Francis Ann Mrs Barbara Ann Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 17 persons aged 65 years and over requiring personal care. 12th July 2005 Date of last inspection Brief Description of the Service: Penhill is a privately owned and operated care home located in a residential suburb of Bristol. The proprietors are Mr Steven Ann and Mrs Barbara Ann, who is also the registered manager. The home is registered with the Commission for Social care Inspection (CSCI) to provide accommodation and personal care for 17 persons aged 65 years and over. The property is a large, detached and extended house. The accommodation is arranged over two levels and is surrounded by well-kept gardens. Accommodation is provided in one shared and 15 single rooms. Communal space includes a lounge, conservatory and extended dining room. A passenger lift and assisted bathing facilities are also provided at the home. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to follow up the requirements and recommendations made at the announced inspection in March 2005. Seventeen residents currently live at the home and ten were spoken with. A range of records was examined including health and safety, staff training and care records. The owners Mr and Mrs Ann were on duty together with their two sons who also work at the home with them. What the service does well: What has improved since the last inspection? The one requirement and two good practice recommendations made at the last visit were met. All staff have now done training in the safeguarding of vulnerable adults. Residents and their families can be confident that staff are trained to recognise and respond to any risk of possible abuse. Care plans are now kept at the front of each resident’s file for ease of reference. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 6 Whilst the inspector didn’t take the opportunity to view supervision records, the owner and manager of the home said that staff comments and concerns are now recorded following individual supervision sessions. What they could do better: Three new requirements were made. These included: Attention is needed to make sure care records are reviewed regularly in order to protect residents. Care records must show evidence that the provider has signed to confirm they are able to meet a resident’s assessed needs, so that the resident and relatives/representatives can be confident about this. Healthcare issues highlighted in care plans must have clear actions recorded so that residents are protected from harm. Although the owners carry out regular, comprehensive quality assurance reviews, the information gained from such surveys must be collated and reports sent to Commission for Social Care Inspection. Further, findings from the surveys should be used to inform the home’s development plan, to ensure residents’ views are incorporated. A number of good practice recommendations were made. These were as follows: Where residents are identified as having mild degrees of dementia, care plans should reflect how their needs in respect of this are to be met. Advice on activities suitable for people with dementia should be sought from relevant organisations. All toilet doors in the public areas of the home should be suitably marked so that residents can find them easily. Bathroom equipment used for residents should be thoroughly cleaned and added to the weekly cleaning rota, to ensure residents are kept safe from the possible spread of infection. Residents’ cash sheets should be checked and balanced regularly and countersigned by a second staff member to avoid risk of error. One cash sheet containing the total balance of each resident’s monies held should be kept at the front of the file for ease of checking. Key worker records be more holistic and reflect the quality of life overall for each resident within the home. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 7 Health and safety checks should be carried out regularly to ensure residents are kept safe within the home environment. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 8 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 Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Attention is needed to ensure specialist needs in respect of mild forms of dementia are identified at the point of entry to the home, so that residents and their relatives/representatives can be sure such needs can be met. EVIDENCE: The home’s registration included a condition that one person with dementia can be accommodated. The owners said that this person was no longer living at the home. Therefore the condition will lapse. However it was noted that some residents are diagnosed as having dementia. The owners said that these were in mild forms and they were confident of being able to meet the respective residents’ assessed needs, that were in respect of their ages. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 10 Pre-admission needs assessments were seen together with Social Services care plans. For one resident with issues in respect of dementia, no care plan had been developed by the home that showed how needs in respect of this would be met. It was pleasing to note that a care plan was sent to Commission for Social Care Inspection immediately following this visit. However although issues in respect of dementia were generally recorded, the plan lacked evidence of how specific needs in respect of this would be met. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents’ benefit from comprehensive and detailed care plans that identify needs and risks and are designed to give quick access to information about them needed in an emergency. Healthcare recording needs attention to ensure actions needed in respect of residents’ health are taken. Medications information should be accurately kept to avoid risk of errors occurring. Residents’ benefit from being treated with dignity and respect and said they feel they are looked after well. EVIDENCE: Three care files were examined. These were person-centred and contained: • Care plans combined with risk assessments, • Medication records, • All healthcare professionals’ contact details if they are involved in a resident’s care • Further information sheets in respect of social interests, food preferences, property list and quality assurance questions. • Key worker review sheet. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 12 Care plans were comprehensive and detailed with photographs and what residents like to be called, recorded. Risks identified with specific care needs e.g. mobility were incorporated into the plans with bar charts detailing the degree of risk and prevention. This is good practice. Further each care file contained an: ‘emergency admission pack’. This included all relevant information kept together in one set of documents. These included the resident’s photograph and personal details, healthcare professionals information, emergency contact details and current medication list. The manager said that this pack is given to paramedics if a resident is admitted to hospital as any information needed could be quickly obtained from it. This is very good practice. However some issues were noted that included the following: Care plans lacked evidence that monthly reviews are carried out. The manager said that reviews are done on the computer but printed copies are not kept in care files. Further, in respect of medication it was noted that different medication lists were kept in individual care files. This was confusing and made it difficult to see which medications listed were actually being administered. Only the most recent medications record should be kept in the file to avoid possible errors. Weight and pressure area monitoring records were seen in individual residents care files. It was noted that one resident had steadily lost weight over a year. However nothing was recorded to show why the loss was occurring and what action was being taken in respect of it. The resident had no pressure areas to be treated so it was puzzling to see why this was being monitored. Reasons for any health monitoring should therefore be recorded. In particular for issues such as continuing weight loss, actions taken in respect of it should be recorded. Staff were seen interacting with residents in a respectful way. Residents’ privacy and dignity was maintained at all times during the inspection and residents spoke highly of the care they receive i.e. ‘we are looked after very well’. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Residents’ may benefit from a wide range of activities, entertainment and outings that they enjoy. However attention is needed to ensure information is gained about suitable activities for people with dementia so that they can benefit from enjoyable and stimulating activities. They also benefit from a balanced menu that meets their needs and gives them choice. EVIDENCE: The inspector joined seven residents and one staff member in the conservatory for a geography quiz. The staff member who is the activities coordinator said she comes in every Wednesday to do activities all day. Some residents were taking part in the quiz while others sat listening while knitting squares for blankets. A large blanket was in the process of being made and would then be donated to a charity. One resident said she had been teaching others how to crochet, and had also been teaching a male resident how to knit. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 14 A notice board with details of events and entertainment was seen in the dining room, together with a range of photographs covering one wall. The photographs were of residents enjoying activities, entertainment and outings. Minutes of a residents meeting held on 1 October ’05 were seen that gave lots of information about outings. A trip had been organized to see the musical ‘Annie’ plus a visit to the Zoo and boat trips. Further outings were discussed including a trip to the ballet, circus and pantomime. It had also been agreed with residents that a Christmas Carol evening would be held on 10 December. However it was not clear how residents’ with dementia would be enabled to benefit from suitable activities if this prevented them from joining in those already provided for all residents. A good practice recommendation was therefore made so that information about suitable activities for this group of residents is obtained, in order to ensure they have the same rights to and enjoyment of activities as others. Residents commented on the quality of meals: ‘ the food is lovely’ and ‘I enjoy the food’. One of the owners’ two sons was cooking lunch on the day of this visit as the home’s cook was off duty. The menu seen in the kitchen showed only one choice of meal available. However the owners said that residents could always have an alternative if they wished. The meal of chicken pie and vegetables with apple pie to follow was hot and tasty. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents’ may benefit from having clear information about how to raise any concerns about the care they receive. A new system of complaints recording will ensure residents and their relatives/representatives can be confident that any concerns will be taken seriously. EVIDENCE: Individual care plans stated that the home’s complaints procedure had been explained to residents. Copies of the procedure were seen that were in a questions and answer format, that gave clear information of how to make a complaint to the home or to Commission for Social Care Inspection. The Commission’s address details were listed on the back of the leaflet. The leaflet also included a comments/complaints sheet that residents could fill in if they wished, about any aspect of their lives in the home. However no system for recording complaints was in place. It was therefore not possible to know if complaints had been received and what action taken within clear timescales to resolve any such complaints. The need for such a system that maintains residents’ confidentiality was discussed with the owners at this visit. It was pleasing to note that a newly developed complaints recording sheet was sent to the Commission immediately following the visit. The sheet, a ‘Complaints Response and Action Plan’ contained details of all the necessary information needed to record, investigate, action and respond to any complainant within the required timescale. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Residents may benefit from having a comfortable, clean and hygienic standard of accommodation that meets their physical needs. Attention is needed to ensure residents are able to locate toilet facilities within the public areas of the home. Attention is needed to ensure bathroom equipment is kept clean to avoid the risk of contamination and infection. EVIDENCE: Penhill is situated in an established building that was once a family home. It has been extended with a newer wing that houses eight rooms, joined to the main house. An accessible passenger lift has also been installed to enable less mobile residents to access the first floor. Where possible the home has been made accessible to disabled older people and grab rails in all corridors were seen. The owners said that they plan to further extend the premises and are in the process of obtaining plans for this that they will submit to the Commission for registration. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 17 The environment, including layout, furnishings and gardens was well maintained and decorated to a good standard. Furnishings made all the rooms homely and pleasant. A conservatory adds a pleasing space for residents to use and overlooks a large mature garden that has a pond and fish. A number of bathrooms and toilets were seen on both ground and first floors. Only one of these was marked to show it was a toilet. The owners said that residents could use the en-suite facilities in their rooms and many did so. However as some residents have mild degrees of dementia and it was noted that 50 of residents need prompting to use the toilet, they may need to be clearly marked either with name or picture so that they can find them easily. In both ground and first floor bathrooms, ambulifts were seen to enable residents to use the bath easily. On inspection the undersides of these were found to be dirty and a requirement is made to ensure they are thoroughly cleaned and added to the regular cleaning rota. A number of residents’ bedrooms were seen. Two residents share a room and said they were happy with this arrangement. Bedrooms were of a good size and all included an en-suite toilet and washbasin. A unique way of using space to enable en-suites to be installed was seen. However some of these were quite small and care is needed to ensure residents can access the facilities easily. Bedrooms were pleasantly decorated and furnished according to the National Minimum Standard. Some rooms had good views over the surrounding countryside. The home was extremely clean and hygienic at this visit and smelled fresh and pleasant. Residents spoke positively of the home and the facilities offered to them. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 Residents may benefit from an appropriate number of staff, suitably trained and available to meet their needs. Improvements in ensuring staff are trained in safeguarding adults means residents are protected from risk of abuse. EVIDENCE: The owners said that the home employs ten care staff, six of which are trained to NVQ level 2 or 3. This meets the National Minimum Standard that recommends that a minimum of 50 of care staff be trained to this level of national vocational qualification in care. In addition to the care staff the owners or their sons provide sleep-in night cover. Residents confirmed that if they have any problems at night someone always comes promptly. The one requirement made at the last inspection in March ’05 in respect of staff training in adult protection issues, was met. A record of all staff training was seen that showed seventeen staff, including the owners and their sons had attended safeguarding adults training over a range of dates throughout this year. The record also showed that staff had attended fire safety awareness, First Aid, manual handling, medication administration and food hygiene training throughout the year. This is good practice. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents can be sure of living in a well managed home. Quality assurance monitoring needs attention to ensure that views of residents and their relatives/representatives are taken into consideration when developing the service. Financial monitoring needs improvement to ensure residents are protected from any untoward errors. Key time and health and safety records need attention to ensure residents’ quality of life is recorded and they are protected from risk. EVIDENCE: The owners, a married couple, both work full-time within the home together with their two sons. The wife and one son have the national vocational qualification in care level 4. Both the owners and their sons were available at this visit and were welcoming and open to the inspection process. The owners demonstrated a good level of understanding and awareness of the needs of older people in their care and were open to recommendations made to improve practice wherever possible. Actions were promptly taken to meet possible requirements as detailed elsewhere in this report. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 20 The owners said that they undertake regular surveys to monitor the quality of the service they provide. Evidence was seen of completed surveys that included residents and visitors. Residents are also regularly surveyed during their key time to ensure they are satisfied with the services available to them. (However see further information about this below). However no collated survey report was available that showed overall satisfaction levels or issues raised, about life in the home. Further it was hard to see how information gained from use of the surveys would be transferred into an overall development plan. A check of residents’ monies was requested. The owners said that they don’t keep residents’ cash separate as a good practice measure. The file containing individual cash sheets was seen. Each transaction was entered and signed for. However there was no front sheet that included each resident’s balance plus a grand total of monies held, that could be easily checked for inspection purposes. Further, although balance checks are done no regular balance checks done and signed for by two people were seen. Discussion was held about this and ensuring accurate records of all transactions are kept. Regular progress records were seen in care files. These covered issues of personal and healthcare. Key worker review sheets that are completed every month were also seen. The sheets are recorded with a series of five questions, each of which are asked and answered monthly. It was noted that the questions and responses were repetitive and gave very little information about each resident’s quality of life within the home. In the inspector’s opinion the sheets didn’t ensure a meaningful review i.e. of residents’ interaction and relationship with the key worker, how residents’ spend their time or their hobbies and pastimes. The manager said that the questions had been designed for use as guidelines, but staff were using them at every review. The manager was advised to consider a more holistic way for key workers to record details of residents’ lives within the home. A record of weekly fire safety checks was seen that included all aspects of ensuring fire safety. The last fire brigade inspection was in May 2003. A full fire safety risk assessment was in place that had been reviewed in February ’05. Two fire drills had been done between November ’04 and March ’05. However this meant that no fire drill had been carried out for nine months. A good practice recommendation was made to ensure drills are carried out at regular intervals to protect residents. A check of water temperatures was carried out at this visit and all were found to be close to 43ºc. However no records were available for water temperature checks as the owner said that all basins and baths have low temperature valves to protect residents from scalding. However it is good practice to check temperatures regularly to ensure the valves are working properly. Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 21 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 X X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 2 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X 2 2 Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO 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 14(1)(d) 15(1)(b) Timescale for action The registered provider must 31/12/05 confirm in writing that the home can meet a resident’s assessed needs. Evidence of monthly care plan reviews must be made available. Care records must show what 31/03/06 actions in respect of residents’ health issues are taken i.e. in respect of persistent weight loss Information gained from the 31/03/06 home’s quality assurance surveys must be collated and reports sent to Commission for Social Care Inspection. Requirement 2 OP8 12(1)(b) 2 OP33 24(2) Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP4 OP12 OP21 Good Practice Recommendations Care plans should reflect how needs in respect of dementia are to be met. Advice on activities suitable for people with dementia should be sought from relevant organisations. All toilet doors in the public areas of the home should be suitably marked so that residents can find them easily. The ambulifts used in residents’ bathrooms should be thoroughly cleaned on the underside and added to the weekly cleaning rota, to ensure residents are kept safe from the possible spread of infection. Findings from the quality assurance surveys should be used to inform the home’s development plan. Residents’ cash sheets should be checked and balanced regularly and countersigned by a second staff member to avoid risk of error. One cash sheet containing the total balance of each resident’s monies held should be kept at the front of the file for ease of checking. Key worker records should show how staff spend this time with individual residents and reflect the quality of their lives. Fire drills should be carried out at six monthly intervals. Water temperatures in residents’ rooms should be checked at regular intervals to ensure the temperature is kept within health and safety limits. 4 5 OP33 OP35 6 7 OP37 OP38 Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Penhill Residential Home DS0000026623.V262362.R01.S.doc Version 5.0 Page 25 - 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. 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