Inspection on 30/11/05 for Penkett Lodge

This inspection was carried out on 30th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Penkett Lodge 18/05/08

Penkett Lodge 04/05/07

Penkett Lodge 25/05/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cherryhaven Care Home 39 Penkett Road Wallasey Wirral CH45 7QF Lead Inspector Peter Cresswell Unannounced Inspection 30th November 2005 8:45 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 Cherryhaven Care Home DS0000064844.V270285.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. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cherryhaven Care Home Address 39 Penkett Road Wallasey Wirral CH45 7QF 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) 0151 691 2073 Mr Russell Stanley Oakden Mrs Susan Ward Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 May 2005 Brief Description of the Service: Cherry Haven is a detached, three storey Victorian building close to other similar properties in a quiet suburban area of Wallasey. The building has a basement which houses one of the bedrooms, the laundry and a self contained flat which was formerly used by a member of staff. The home is within a mile of Liscard town centre; local shops, a post office, other community facilities and Egremont promenade on the riverfront are only a short walk away. Bus routes to New Brighton and Seacombe run nearby. Cherry Haven provides care for 27 older people in six shared and 15 single bedrooms. On the day of the inspection there were 23 residents in the home, ten of them in shared rooms. Communal space is in three lounges, a dining room and a large rear garden. The garden at the rear of the house still needs some additional work to make it independently accessible for residents. There is car parking space and an access ramp at the front of the building. Cherry Haven was recently bought by a new owner, Mr Russell Oakden, and this is the first inspection since his registration. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this unannounced inspection the inspector spoke to several residents, a number of members of staff and the registered manager. He inspected documents - including care plans, safety records and staff records - and toured the home, including a number of bedrooms and the kitchen. What the service does well: What has improved since the last inspection? What they could do better: Cherry Haven needs a Service Users’ Guide to inform residents and prospective residents of the facilities and services in the home. Assessments of new residents need to be recorded and care plans prepared on the basis of those assessments. Care plans should be properly updated when they are reviewed to make sure that they are up to date. Radiators must be made safe either by thermostatic controls, low temperature surfaces or guards, especially in residents’ bedrooms. Cherry Haven’s medication policy needs to be properly implemented to make sure that it can always account for the administration of medicines to the residents. A quality assurance system would help the home to put in place a development plan to further improve the quality of life of its residents. Staff training needs to move ahead quickly to ensure that staff are fully equipped for the task in hand. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 6 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. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 7 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 Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 8 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): 1, 2, 3, 4, 5. Prospective residents do not receive clear written information to enable them to make a choice about whether or not they might want to live in the home. EVIDENCE: The registration certificate affixed to the wall in the entrance hall was that for the previous owners. Section 28 of the Care Standards Act 2000 (Section 28) requires that the registration certificate ‘shall be kept affixed in a conspicuous place’ in the home and it is an offence to fail to do so. This must be remedied immediately. The service user guide is now completely out of date, inaccurate and poorly presented. The information on the Registered Manager, staff qualifications and the nature of the accommodation is inaccurate and it contains no details of the Registered Person (the owner). The Statement of Purpose was not available in the home. One resident has moved into the home since the last inspection and she visited the home with her family before making a final decision. An assessment from Wirral Social Services was on the file but there was no written assessment made by the Registered Manager or other member of staff. This also had implications for care planning and these are dealt with in the next section. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 9 Cherry Haven does not provide intermediate care so standard 6 does not apply. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 10 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. Basic care plans and daily reports are adequate and are regularly reviewed, helping to ensure that service users receive care appropriate to their needs. However, some shortcomings in care plan maintenance potentially put residents’ welfare at risk. Medication procedures do not always accurately record the receipt and administration of medication so the welfare of the residents is not adequately safeguarded. Residents’ privacy is respected. EVIDENCE: There was no care plan in place for the most recently admitted resident (admitted in July). Although staff had since carried out what were described as reviews, there was in fact no care plan to review. Consequently staff had no written guide as to how to provide care for the resident in question. Fortunately the resident did appear to well cared for. Other files had care plans in place and reviews had taken place but the plans had not been amended to reflect the results of the reviews. It may be helpful to prepare care plan summaries, which can be readily updated as required, to be filed with a daily report file so that staff can readily consult the care plan in an accessible format. Residents are registered with local doctors of their choice and the Registered Manager calls in District Nurses at the first sign of anything that she Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 11 feels could lead to a pressure sore. Two residents now have pressure-relieving mattresses and the manager said that no residents have pressure sores. Medication is provided by the pharmacist in a Monitored Dosage System (MDS), with most tablets dispensed into blister packs. Records for medicines administered using this system were accurately kept. Staff check medication against the Medication Administration Record (MAR) sheets when it is delivered from the pharmacist, but do not separately record the amount of medication which is outside the MDS (i.e. provided in boxes or bottles). It was therefore impossible to check that the appropriate medication had been administered in those circumstances as it was not clear how many tablets had been received. This could be avoided if the Registered Manager arranged to record the receipt of all medicines in accordance with guidance contained in the Royal Pharmaceutical Society’s booklet The Administration and Control of Medicines in Care Homes and Children’s Services (paragraph 3.1). In addition, two tablets for one resident could not be accounted for and one set of tablets could not be found at all. One prescription had run out and although it had been reordered the Registered Manager said that it would take 48 hours to arrive and therefore none had been administered on the day of the inspection. The Registered Manager said that the resident’s GP had told her that a short break would not matter in this instance. However, it is clearly advisable that medication should be consistently administered so the Registered Manager should devise a system whereby medication outside the MDS is re-ordered in sufficient time to ensure that there is no such gap. Some prescribed cream for one resident was found in the staff toilet. Staff provide personal care in the privacy of residents’ own rooms as was seen on the day of the inspection. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 12 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, 13, 14, 15. Visitors are welcome in the home, helping residents to maintain contact with families and friends. The home arranges activities within the home, providing some stimulation and enjoyment for the residents. Food is well prepared and meets the needs and tastes of the residents. EVIDENCE: Visitors are welcome in the home at any reasonable time and a notice to this effect is prominently displayed in the hallway. The home has appointed an Activities Co-ordinator who works in the home on six afternoons a week (21 hours). Activities include quizzes, nail care, exercise sessions and bingo. She keeps a daily record of the activities and which residents took part. The programme does not include any trips out and the Registered Manager may wish to consider organising short trips out to nearby locations for small groups of residents. The residents who spoke to the inspector said that they enjoyed the food at Cherry Haven. The main meal is usually served at lunchtime but the tea-time meal has the option of a cooked snack as well as sandwiches. The residents enjoyed lunch on the day of the inspection. No choices are listed on the menu but the chef said that if a resident wanted something different then it would be provided. There is a menu board in the dining room, which displays the meal of the day. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 13 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): The home’s policies for dealing with complaints and allegations of abuse protect the interests of the residents. EVIDENCE: Cherry Haven has policies for dealing with complaints and allegations of abuse. The last report required a detailed record to be kept of complaints and the Registered Manager said that this will be done, but no complaints had been received since the last inspection. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 14 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, 20, 21, 23, 24, 25, 26. The standard of the environment in the home is on the whole adequate though some work is still needed to ensure the safety and comfort of the residents. EVIDENCE: The new owner has started a programme of redecoration that is in its early stages. Some hallways had been painted and the Registered Manager said that all of the lounges and bedrooms were to be refurbished, including new carpets where necessary. Residents will be given a choice of colours in their rooms. The Registered Manager also said that there are plans for structural improvements to the home. Some minor items of maintenance are needed, some of which are outstanding from the last inspection. (Most rooms, including toilets and bathrooms have a number – ‘Toilet 33’ for instance does not means there are 33 toilets, it is just a room number): * The extractor fans in toilet 33 and the basement ensuite are still not working. * The plaster in bedroom 32 is cracked and must be repaired. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 15 * A safety rail needs to be fitted in the garden to make it safe for independent access by residents. This has been raised at a number of previous inspections. * There are damp stains in bathroom 11, which needs to be redecorated. * The radiator in bathroom 22 was still loose – this was raised at the last inspection. Most of the toilets and bathrooms would benefit from redecoration and refurbishment. Five of the twin rooms are now used for sharing. It was not evident that those residents in shared rooms (apart from a married couple) had made a positive choice to share. It is especially important that residents who are in a room on their own and have someone else moved in with them are recorded as having made a positive choice to share. One new resident had briefly shared a room until a single room became available. Both residents had signed to say that they agreed to the sharing, which is entirely different from saying that they had made a positive choice to share with that person. The inappropriate ‘warning sign’ at the top of the stairs leading to the basement has been removed and the Registered Manager said that there are plans to replace it with a safety gate. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 16 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, 29, 30. The rota provides enough staff to meet the needs of the residents. Training needs to be developed further in order to ensure that staff have the skills and qualifications to meet the needs of the residents. EVIDENCE: Cherry Haven is adequately staffed, with the manager and three staff, including one senior care assistant, on duty in the day. At night there are two waking staff and one who sleeps in. The member of staff who sleeps in now uses a room converted from the former owner’s office. Only two care staff have NVQ2 and fourteen are currently either studying for NVQs or have just enrolled. The figure of staff with NVQ2 is lower than in previous reports as the Registered Manager said that some of the information made available to her at that time has proved to be unreliable. This leaves the home well short of the target of 50 qualified staff by the end of 2005 but the Registered Manager said that staff just starting NVQ training are on a ‘fast track’ course which should be completed in the first half of 2006. The Registered Manager has prepared a plan for the renewal of statutory training for all staff. There is a great deal of ground to be made up and no time must be lost in providing this training. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 17 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): 31, 33, 35, 36, 38. The home does not have an effective quality assurance system, so there is no development plan to further enhance the residents’ quality of life. Although the home has appropriate safety policies, action needs to be taken in respect of radiators and fire safety precautions to ensure the safety of residents. EVIDENCE: The Registered Manager has completed her NVQ4 and is experienced in the field of residential care. Cherry Haven does not have a quality assurance system. The Registered Manager has in the past issued questionnaires to relatives but says that she has not received any feedback from them. No other quality assurance mechanisms are in place so the Registered Person needs to consider the introduction of a QA system to help to ensure that the home maintains and improves its standards. The Registered Manager has begun a programme of staff supervision/appraisal but there has been little progress since the last inspection. The Registered Person deals with personal allowances and the Registered Manager said that they are passed on to families, with only Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 18 one resident retaining his own personal allowance. No residents’ money is kept on the premises. The manager said that the Registered Person pays for items such as chiropody. Fridge and freezer temperatures in the kitchen are checked every day and recorded in a hard backed book. Food stocks were stored appropriately. The Registered Manager said that the kitchen is to be included in the refurbishment programme. Smoke alarms and emergency lighting are checked weekly and recorded. The home has an up to date electrical safety certificate but the gas safety certificate was out of date and an up to date certificate needs to be obtained as a matter of urgency. There was no record of a fire drill since August 2004 and regular fire drills and training need to be held as a matter of priority. Most of the radiators in the home have protective guards but the radiator in a resident’s bedroom was too hot and steps must be taken to eliminate the potential risk to the resident in question. The Accident Book contained details of a number of incidents that had led to medical assistance being called. These incidents must be reported to the Commission for Social Care Inspection under Regulation 37 as required at the last inspection and in accordance with advice previously sent to the Registered Manager. Details of accidents must be retained in a way that complies with the Data Protection Act. Representatives of the Registered Person (members of his family) visit the home every week but no reports of the visits have been submitted to the Commission for Social Care Inspection as required by Regulation 26. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 19 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 1 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 x 2 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 2 Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Care Standards Act 2000 s.28 4 and 5 15(1) Requirement The Registered Person must keep the registration certificate ‘affixed in a conspicuous place’ in the care home. The Registered Person must maintain a Statement of Purpose and a Service User’s Guide The Registered Person must prepare a service user plan (care plan) setting out how each resident’s needs are to be met. The Registered Person must keep service user plans under review and must update them following such reviews (Originally required by 1 July 2005). The Registered Person must ensure that an accurate record is kept of all medication received and administered in the home. (Originally required by 11 May 2005). The Registered Person must ensure that the premises are kept in good repair and must therefore: *Repair the fans in toilet 33 and the basement ensuite. DS0000064844.V270285.R01.S.doc Timescale for action 30/11/05 2 3 OP1 OP7 01/01/06 01/02/06 4 OP7 15(2) 01/01/06 5 OP9 13(2) 30/11/05 6 OP19 23(2) 01/02/06 Cherryhaven Care Home Version 5.0 Page 21 *Repair or replace the cracked plaster in bedroom 32. *Fit a safety rail in the garden to make it safe for independent access by residents. *Redecorate bathroom 11 where there are damp stains. *Repair the loose radiator in bathroom 22. 7 OP38 23 The Registered Person shall ensure that unnecessary risks to the welfare of service users are eliminated by: *Obtaining an up to date gas safety certificate for the home. *Ensuring that residents are not at risk from excessively hot radiators. *Carrying out regular fire drills. The Registered Person shall arrange for reports to be submitted to the Commission for Social Care Inspection at least once a month following monitoring visits by himself or another person acting on his behalf. The Registered Person must notify the Commission for Social Care Inspection of any accidents or events which adversely affect the well being of a resident. 01/01/06 8 OP37 26 01/01/06 9 OP38 37 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP23 Good Practice Recommendations Residents should only be asked to share a room if they have made a positive choice to do and this is recorded on DS0000064844.V270285.R01.S.doc Version 5.0 Page 22 Cherryhaven Care Home 2 3 4 OP30 OP33 OP36 the care plan. The registered manager needs to further develop the staff training programme with a view to achieving at least 50 of care staff with NVQ2. The Registered Person should introduce quality assurance and quality monitoring systems into the care home. Care staff should receive formal supervision at least six times a year. Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Cherryhaven Care Home DS0000064844.V270285.R01.S.doc Version 5.0 Page 24 - 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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