Inspection on 10/08/05 for Penlea

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Penlea 16/07/08

Penlea 27/07/07

Penlea 17/08/06

Penlea 16/02/06

Penlea 11/01/05

Penlea 27/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Penlea 13 Dunheved Road Launceston Cornwall PL15 9JE Lead Inspector Ian Wright Unanounced 10 August 2005 1600 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Penlea Address 13 Dunheved Road Launceston Cornwall PL15 9JE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01566 775943 01566 775943 Royal Mencap Society Mrs Lesley Aston Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11.1.05 Brief Description of the Service: Mencap provides care for up to 8 adults with learning disabilities at Penlea. The home is situated in Launceston within walking distance of the town centre. Mencap also operates several care homes in Cornwall. The registered manager is Mrs L. Aston. All service users have their own bedrooms and there is a pleasant lounge and dining room for service users use. Access to the home and its ground floor is wheel chair accessible. Penlea has a pleasant front garden, and a patio at the rear which service users can use. Seating in the garden is provided. There is satisfactory parking at the front and rear of the home. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four and a half hours. The inspection was carried out on an unannounced basis. The inspector was able to speak to the majority of service users, the registered manager and the staff members on duty. The inspector examined care and service records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4,5 The registered persons have implemented suitable procedures and provide suitable information to assist service users to make appropriate decisions to move to the home. The registered persons have developed suitable links with external agencies so service users needs are met. Service users are provided with suitable information regarding their rights and responsibilities. EVIDENCE: Service users have a copy of terms and conditions of residency or a contract on their files. Service users also have an assured tenancy agreement guaranteeing considerable security of tenure. The registered provider has a satisfactory pre admission assessment procedure. There have been no recent admissions. The registered manager said prospective service users are able to visit before admission is arranged. This would include overnight stays as applicable. The registered manager said there was appropriate links with external professionals such as social workers, community nurses etc. Suitable records regarding these contacts were observed. The registered provider has an appropriate training programme for staff. This includes access to National Vocational Qualifications in care. The registered manager said the majority of staff had completed at least NVQ 2 in care. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 10 Appropriate policies and procedures, and documentation is in place regarding care planning and risk assessment. Documentation is stored confidentially. Service users receive appropriate support to develop their skills and take appropriate risks. Service users are consulted about major and day to day decisions. EVIDENCE: A copy of a care plan is contained in each service user’s file. These are reviewed appropriately. Service users stated they are enabled to make decisions e.g. regarding day activities and major decisions. Service users said there are regular residents meetings, which enable them to make comments about life in the home. Minutes are kept of these meetings. Service users said they are encouraged to take appropriate risks e.g. go out on their own. Suitable risk assessments are maintained on each service user’s file, and these are reviewed appropriately. All information is stored confidentially. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-16 Suitable opportunities are available for service users to be part of the local community. Service users have a wide range of day activities available to them. Visiting times are flexible. Contact with family and friends is encouraged. EVIDENCE: Service users said they are given suitable opportunities to participate in the community for example local events, and using local facilities such as leisure centres, pubs and clubs. Service users have opportunity to have paid jobs, work placements and attend further education. All service users have comprehensive day activity plans. Service users said they have appropriate opportunities to maintain links with their families and friends. Visiting arrangements are appropriate. Daily routines are flexible and tailored according to individual needs. Independence and choices are encouraged. Service users stated they felt very much at home and are supported appropriately by staff. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18-19 Service users receive personal care in a manner which respects their respect and dignity. There are appropriate links with relevant professionals so service users physical and emotional health needs are met. EVIDENCE: Service users said they were happy with how personal care and support is provided. The inspector observed staff working with service users in an appropriate manner. Care interventions are appropriately documented in care plans. No service users have pressure sores and there have been no major accidents, which have for example resulted in hospital admission. Accident and incident records are appropriately maintained. Staff stated links with general practitioners, and other professionals such as social workers are satisfactory. Suitable records are maintained regarding hospital and other health care appointments. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22-23 The registered provider has suitable complaints and adult protection policies, which are effectively implemented. EVIDENCE: Mencap has appropriate complaints and adult protection policies in place. The registered manager said the complaints procedure is regularly discussed in residents meetings so service users know how they can make a complaint. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 Penlea is a suitable environment for service users accommodated there. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. Bedrooms and communal areas are of suitable size and meet the needs of service users. The kitchen units are beginning to look shabby and will need to be replaced in the next few years. It is recommended the housing association makes provision for this in their development plan. Service user bedrooms are pleasantly decorated according to individual tastes. Furnishings in bedrooms are appropriate. There is a walk in shower on the ground floor, which can be used for people with a physical disability. Some issues regarding damp at the rear of the home were highlighted on the previous inspection. This appears to have been attended to, and the rooms concerned redecorated. The inspector met with the Head of Housing / Asset Manager of the housing association during the inspection who stated the walls will need to be tanked / dry lined if the damp reappears. It is recommended the registered provider monitors this situation, and liaises with the housing association should the problem reoccur. The home was clean and hygienic on the day of the inspection. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Appropriately recruited and qualified staff provide suitable support to service users in sufficient numbers. Staff receive appropriate supervision from management. EVIDENCE: All staff are issued with a job description when they commence employment. Staff appear to have a clear understanding of their roles. The registered manager said the majority of staff have completed at least NVQ 2 in care. Copies of NVQ certificates should be kept on staff files as evidence for when this standard is formally inspected from January 2006. Rotas indicate the registered persons provide appropriate staffing to meet service users needs. Service users stated they believed staffing levels to be satisfactory. The inspector observed information kept on staff files. The requirement in the previous report, for all staff to have some form of identification on their files, to prove their identity, has been met. The requirement for staff to receive training regarding infection control and regarding the needs of people with autism has also been met. The registered manager said staff receive formal one to one supervision on a monthly basis. Appropriate records regarding staff supervision was kept on staff files. Staff spoke positively of the training and support they received. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-42 The registered persons ensure the effective management of the home, and suitable systems are in place to evidence this. EVIDENCE: Penlea appears to be well managed, and staff and service users appear to receive appropriate support. The registered manager has suitable experience, knowledge and qualifications to manage the home. For example the registered manager has completed the registered manager’s award. Staff on duty stated they received appropriate support, and have the opportunity to contribute to how the home is managed. Staff receive regular supervision, and there are staff meetings once a fortnight. Regular residents meetings are also held. Mencap has suitable quality assurance policies in place. The registered persons facilitated a survey of the views of various stakeholders regarding how the Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 15 service is managed. The survey ascertained the views of service users, staff, external professionals etc. Responses were very positive. Mencap has a suitable range of policies and procedures, and suitable records are maintained. Mencap has a suitable approach to preventing any health and safety risks. Suitable procedures are in place to test fire prevention, gas and electrical equipment, and there is satisfactory evidence that testing is completed. For example portable appliance testing was completed in May 2005, and gas appliances were tested in June 2005. Suitable health and safety risk assessments were completed in April 2004-and now possibly need to be reviewed. Appropriate checks appear to be in place regarding the prevention of Legionella. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Penlea Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 x D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 17 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA 24 and 28 YA 24 Good Practice Recommendations The housing association should make provision in its development plan for the provision of a new kitchen within the next three years. The registered provider should monitor the damp does not reappear at the rear of the house, and liaise with the housing association to rectify the situation should it reoccur. Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Penlea D52-D04 S9213 Penlea V233135 100805 Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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