Inspection on 17/08/06 for Penlea

This inspection was carried out on 17th August 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penlea 16/07/08

Penlea 27/07/07

Penlea 16/02/06

Penlea 10/08/05

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 Unannounced Inspection 17 and 18th August 2006 15:15 th Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penlea Address 13 Dunheved Road Launceston Cornwall PL15 9JE 01566 775943 F/P 01566 775943 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) www.mencap.org.uk Royal Mencap Society Mrs Lesley Aston Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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. A copy of the inspection report is available in the dining room, and it is suggested a copy is requested from management or CSCI if required. The range of fees at the time of the inspection is £329 to £574 per week. There are additional charges e.g. for hairdressing, newspapers etc. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in ten and quarter hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track three service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: The inspection has resulted in twelve statutory requirements. These must be actioned by law within the time frame given. Three requirements regarding updating care plans, and improving staff training have been renotified from the last inspection, which took place on 16th February 2006. However it is acknowledged that some progress has been made regarding these issues since the last inspection. The ownership of the house has recently been transferred to another housing association. However service users have not been issued with a tenancy Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 6 agreement, and MENCAP needs to clarify the level of security of tenure with the housing association. Redecoration and refurbishment needs to take place to a downstairs toilet and the walk in shower. Risk assessment needs to improve to assist staff to help meet at least one service user’s needs. Some improvement needs to take place regarding the management of the medication system. This includes ensuring medication is returned when it is not required, and all medication administered to service users is recorded on medication sheets. An amendment to MENCAP’s Complaints Procedure is required, so complainants know they can approach the Commission for Social Care Inspection at any time if they have a concern or complaint. Staff in the home however have done their best to provide appropriate information to service users. For example there is a poster in the hallway outlining how the commission can be contacted. By law all staff must have a Criminal Records Bureau check / Protection of Vulnerable Adults check when they commence employment. These are not transferable between employers. One member of staff did not have the correct checks completed when they started with MENCAP; although there was evidence that a previous employer completed checks. Evidence of completion of the corporate staff induction needs to be improved. An induction checklist regarding household procedures and routines needs to be developed. The registered manager is now job sharing her role with another manager. In order to finalise the new manager’s application to be registered with the Commission for Social Care Inspection a second reference is required. 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 DS0000009213.V306755.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 8 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 the following standard(s): 2, 5 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Service users receive a copy of the terms and conditions of residency at the time of admission. This enables service users to be aware of their rights and responsibilities. However the registered provider needs to clarify arrangements regarding tenancy agreements issued by the housing association. The pre admission assessment procedure is good, and, if used, will enable the registered persons to ascertain they can meet the needs of service users, before admission is arranged. However there have not been any new admissions since the last inspection. EVIDENCE: Mencap issues a copy of terms and conditions of residency to all service users, and a copy of this is maintained on each service user’s file. The house has recently been transferred to a new housing association. Service users have not as yet been issued with a tenancy agreement. It appears the new housing association is only to issue assured short hold tenancy agreements. Previously service users received an assured tenancy agreement, which gave them greater rights of tenure. The inspector understands to offer service users less secure tenure does not meet legal and Housing Corporation guidelines. The registered provider therefore must clarify, and if necessary rectify this arrangement. Copies of social services contracts of care are also available for inspection. The home has not had any recent admissions, but the registered providers have developed a suitable assessment policy and procedure. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 6, 7, 9 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. All service users have a care plan and most are reviewed. It is evident however that some care plans need to be updated. Care plans do generally ensure staff have suitable information to provide care. Service users are encouraged to make decisions about their lives with suitable assistance as required. The registered persons approach to handling service users monies is satisfactory, so service users can be assured their financial interests are safeguarded, where staff are involved in this area of their lives. The registered persons have a suitable approach to risk, so service users can be assured they will be supported to take risks as part of an independent lifestyle. However a risk assessment needs to be developed regarding the behaviour of one service user. EVIDENCE: There is a copy of a care plan in each service user file. Staff said care plans were accessible to them. Some service users said they were aware of their care plans and are involved in drawing up them. The care plan format is comprehensive and generally gives clear guidance to staff regarding service user needs. However some of the care plans do need updating. For example there was limited information regarding one service user’s behaviour, and how staff should respond to challenges. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 10 Service users and staff said service users are encouraged to make decisions regarding their lives. Suitable risk assessments are in place to assess any risks or actions to promote independence. The registered providers look after some service user monies, for which suitable records (including a risk assessment) are maintained. However a risk assessment needs to be developed regarding a service user’s behaviour, and how this can be managed. The registered provider has a satisfactory policy regarding diversity and equality. There are currently no service users from ethnic minorities, although the registered manager stated the home would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, gender and disability seem to be suitably addressed. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12, 13, 15, 16, 17 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Service users can participate in a suitable range of activities, and are able to mix with the wider community. Service users are encouraged to maintain relationships with friends and relatives. Service users rights are respected, and service users are enabled to take a suitable amount of responsibility in their daily lives. Suitable arrangements are in place so service users enjoy a healthy and varied diet. EVIDENCE: Service users said they attend a range of day activities including attending a day centre and college. Some service users also have voluntary jobs and sheltered work placements. Service users and staff said other activities are also arranged in the evenings and at weekends. For example some service users go swimming, and visit shops and markets. One service user also said she is a member of the Women’s Institute. Service users can have an annual holiday, which they have to pay for. One service user said he went to the Isles of Scilly last year, which he really enjoyed. The home has a ‘multi purpose vehicle’ for service user use. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 12 Service users said they visit friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible, and there is suitable space for service users to receive visitors privately. Service users said they could get up and go to bed when they wish, although some may need reminding to get up on the days they attend the day centre. Service users said staff worked with them in a way, which respects their privacy and dignity. One service user said there had been a disagreement with staff, and was upset by this. The manager on duty said she would look into this. Staff knock on bedroom doors, and mail is not opened without service users’ agreement. Locks are fitted to bedroom doors. Service users and staff said service users have some involvement in household tasks for example doing laundry, cleaning tasks, shopping and cooking. The inspector shared a meal with service users, which was to a good standard. The meal consisted of chicken curry, vegetables and rice. Fresh fruit was available on the table. No sweet is served. Service users all said they enjoyed the food provided, and said it was provided in sufficient quantities. Suitable records are maintained regarding food provided. Some choice of meal is provided for example some service users had chicken stew and potatoes. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 18, 19, 20 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Personal care is delivered to a good standard, and there are suitable links with medical professionals. The management of service users medicines requires improvement so service users can be assured their medication is suitably looked after. EVIDENCE: Service users said they received suitable care and support from staff. Any personal care needs are documented in care plans. These need some updating as outlined earlier in the report. Staff the inspector spoke to seem reasonably clear regarding what assistance service users need. Care plans document appropriate links with GP’s, dentists, chiropodists and other professionals. Service users said they regularly saw medical professionals when required. The registered manager and other staff reported no problems with links with medical professionals. Medication is stored securely, and dispensed via a ‘monitored dosage system’. No service user currently administers all of their medication, although some creams and liquids are stored in service user bedrooms. However some improvements to the system are required: Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 14 • • • • There were some gaps in medication records for example signing medication sheets regarding the administration of two creams for one service user. A tablet was missing from one blister pack and there was no record why this was not present. Gaviscon medication prescribed for one service user in December 2005 was not recorded on the medication sheet. If this is no longer required it needs to be returned to the pharmacist. There were also three other items in the medication cabinet, which were not recorded as being administered on medication sheets. Four items of medication for epilepsy were stored in the medication cabinet for return but this had not been actioned. The items were dated 28/11/05 and 8/3/06. A requirement was made in the previous report regarding improving medication training. This has not been actioned although the deadline for action is 1st September 2006. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 22, 23 Quality in this area is generally good. The judgement has been made using available evidence including a visit to the service. The registered provider is renotified regarding amending its Complaints Procedure to enable service users and their representatives to have full information who to contact should they have a complaint. MENCAP has a satisfactory adult protection policy, however improvement is required in recruitment practices so all staff have a Criminal Records Bureau / Protection of Vulnerable Adults check when they commence employment. This will give service users more assurance they are in safe hands. EVIDENCE: The registered provider has developed a complaints procedure. The registered manager has included a summary of this in the service user guide. Information regarding the complaints system has been issued to service users. For example service users receive a prepaid postcard, which they can send to the organisation if they have a concern or a complaint. The complaints procedure is regularly discussed in residents meetings. The inspector read the organisation’s complaints policy in the ‘Operations Manual.’ This requires updating, for example the organisational policy refers to the National Care Standards Commission, which has now been superseded by the Commission for Social Care Inspection. The policy also regards complainants right to contact the Commission as the last stage of the procedure, rather than stating complainants can contact the Commission at any time as outlined in NMS 22.3. This requirement was notified in the previous report dated 16/2/2006 although no action appears to have been taken by the registered provider. However, the registered manager has put up Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 16 a poster in the hallway regarding how service users and their representatives can contact CSCI if they have a concern or complaint. Mencap has an appropriate adult protection policy. New staff attend the Mencap training regarding abuse (Protect Me) as part of the organisation’s foundation training. All staff have a Criminal Records Bureau (CRB) check. One member of staff had not had a Protection of Vulnerable Adults (POVA) check since starting employment with MENCAP, although this had been completed in January 2004 with a previous employer. The manager on duty did not seem aware that CRB /POVA checks are not transferable between employers, and perhaps MENCAP needs to improve awareness regarding this issue. Staff and service users showed some awareness of the complaints and prevention of abuse procedures, and were able to say whom they would approach if they had a complaint or were concerned about abuse. Staff and service users all said they had not witnessed any bad or abusive practices. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 24, 30 Quality in this area is generally good. The judgement has been made using available evidence including a visit to the service. Penlea provides a generally pleasant, homely and clean environment for service users. However some refurbishment is required to toilet and bathroom facilities. EVIDENCE: The building was inspected. The home offers a generally pleasant and homely environment for service users. Bedrooms and communal areas are of suitable size to meet the needs of service users. However, the dining room could do with some more plants / ornaments / decoration etc. to help it to be a more ‘welcoming’ environment. The home was clean and hygienic on the day of the inspection. Suitable cleaning routines are in place. Service user bedrooms are pleasantly decorated according to individual tastes. Furnishings in bedrooms are appropriate. One service user said he wanted his towel rail fixed, and the Registered Manager said she would address this. The downstairs toilet (adjacent to the dining room), and the walk in shower on the ground floor, need redecoration. There are some signs of damp in the toilet next to the dining room, which needs to be attended to by the housing association. Someone with a physical disability can use the downstairs shower room. However this facility is unappealing to use and needs refurbishment and redecoration. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels appear satisfactory so service users can be assured they will get suitable levels of staff support. Recruitment records are generally satisfactory although procedures regarding criminal records bureau / protection of vulnerable adults checks need improvement. Staff training needs improvement so staff receive appropriate training as required by regulation. This would assure service users that staff have suitable skills and knowledge to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem appropriate. EVIDENCE: Rotas indicate the registered persons provide appropriate staffing to meet service users needs. Service users stated they believed staffing levels to be satisfactory. There is usually two staff on duty between 1500 and 2100 during the week. At weekends there are two staff on duty during the day until 2000. This level of cover is appropriate considering the number and current needs of the service users living at Penlea. The inspector observed information kept on staff files. The registered persons obtain suitable information regarding the recruitment of staff. This includes two references and generally correct evidence confirming the person’s identity. However improvements are required to ensure all staff have a Criminal Records Bureau (CRB) check and Protection of Vulnerable Adults (POVA) check when they commence employment. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 19 A staff induction system is in place for new staff. This involves staff working ‘shadow’ shifts with managers / more experienced staff. Mencap has a comprehensive induction and foundation course programme, which all new staff have to complete. However records evidencing completion of this training were limited or non-existent. It remains difficult to ascertain if staff have completed the induction package and foundation modules. The Penlea ‘Induction Checklist’ (e.g. demonstrating staff have been inducted regarding household procedures and routines) is very limited, and needs expansion. It is recommended that regular staff supervision should be a part of any induction period (e.g. weekly or fortnightly). Mencap has a suitable training programme. There are however some gaps in training received as required by regulation. This includes fire training, first aid, food hygiene, manual handling, medication and infection control. There has however been significant staff turnover since the last inspection. Some training records show some staff have received training required by regulation but there are no certificates to evidence this. If possible the registered manager should try and get duplicate certificates of the courses attended. MENCAP has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. However, due to staff turnover, only 25 of staff have either a NVQ 2 or 3. Some staff need to have training in epilepsy and autism. Staff need to have this training during their induction / foundation period with refresher training as appropriate. The registered manager has obtained a video regarding the needs of people with epilepsy, and is in the process of showing this to staff. Discussion took place with the manager on duty, regarding developing an in house training programme. However this should to be agreed with the registered provider and MENCAP’s training department. It would also be advisable to seek professional advice e.g. from the healthcare trust. Mencap may wish to consider delivering some of the above training at an area/ regional level as there is also a need for this training at other Mencap homes e.g. in Cornwall. Previous requirements regarding training requirements are renotified, and now need to be fully actioned. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered manager appears to be suitably experienced, skilled and qualified to manage the home. However, the application for the second registered manager (job share) is still yet to be determined. There is a suitable quality assurance system in place to enable service users and other stakeholders to be consulted about their views. The management of health and safety issues is good so service users can be assured they live in a safe environment. EVIDENCE: Mrs Lesley Aston is suitably qualified, experienced and skilled to manage the home. She currently job shares the manager post with Ms Michelle Dawe. Mrs Aston works for 17.5 hours per week, and Ms Dawe is manager for 20 hours per week (Ms Dawe is Deputy Manager for the other 17.5 hours of her post). Service users and staff were positive about the registered managers’ approach. The Commission for Social Care Inspection is currently processing an application for Ms Dawe to be registered as manager with the commission. It has taken a significant period of time to process the Criminal Records Bureau check, which has delayed the commission’s decision. The commission is Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 21 awaiting a reference from MENCAP regarding Ms Dawe’s capability. This needs to be sent to the commission as a priority so the application can be determined. MENCAP has a suitable approach to quality assurance. A survey was completed in 2005 regarding stakeholder views and these were positive. A summary report of the findings, and a development plan was subsequently produced. A survey has recently been completed for 2006, and a further development plan will be developed. This is currently being finalised, and on the days of the inspection the information was not available for inspection. The registered managers also arrange regular staff meetings and regular residents meetings. The registered provider has a suitable health and safety policy. Regular health and safety checks are completed. Other records kept of checks required by regulation are satisfactory. For example there are suitable records of the testing of fire equipment, the central heating system, portable electrical appliances and the electrical hardwire circuit. Accident records are suitably maintained. Health and safety risk assessments are satisfactory. However the fire risk assessment was not available and this must be available for inspection in future. Suitable insurance cover appears to be in place. Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 23 YES 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 YA5 Regulation 5, 7 Requirement The registered provider must ensure: • Service users are issued with tenancy agreements. • All service users have satisfactory security of tenure in line with legal and Housing Corporation guidelines. All care plans must be reviewed and updated regularly. Previous deadline of 01/04/06 not met. Second Notification. 3. YA9 12, 17 Risk assessments must be developed for one service user regarding how staff should manage difficult / aggressive behaviour. This must be regularly reviewed. The operation of the medication system needs to be improved in line with professional guidance (e.g. Royal Pharmaceutical Society Guidelines). The registered provider must DS0000009213.V306755.R01.S.doc Timescale for action 01/12/06 2. YA6 15 01/12/06 01/12/06 4. YA20 13 01/09/06 5. Penlea YA20 7, 12, 13, 01/09/06 Page 24 Version 5.2 19 review its medication training. Coverage of issues such as administration and record keeping should be improved. There should be a practical assessment, by a suitably qualified person, of staff skills after completion of the course to verify staff competence. The registered provider must 01/09/06 update its complaints procedure to state complaints can be referred to the CSCI at any stage should the complainant wish to do so. Details regarding contacting the CSCI must be provided. 6. YA22 22 7. YA23 8. YA27 9. YA42 10, 12, 13 The registered persons must 01/09/06 ensure all staff have a Criminal Records Bureau / Protection of Vulnerable Adults check when they commence employment. 16, 23 The registered persons need to 01/12/06 redecorate and refurbish some of the bathroom and toilet facilities on the ground floor of the building (as outlined in the body text of the report.) 12, 13, 18 The registered manager must 01/12/06 ensure staff receive training required by regulation. This must include fire training, manual handling, food handling, first aid and infection control. There must be suitable evidence of this e.g. copies of certificates of attendance. Previous deadline of 01/06/06 not met. Second Notification. 10. YA42 12, 13, 18 The registered provider must provide all staff with training in epilepsy and autism, and ensure this is updated as appropriate. DS0000009213.V306755.R01.S.doc 01/12/06 Penlea Version 5.2 Page 25 11 OP34 OP35 OP36 18, 19, 12 YA37 9 Previous deadline of 01/06/06 not met. Second Notification. The registered persons must: • Ensure there is evidence available for inspection that MENCAP induction and foundation packages are completed by all new staff • Provide evidence of in house induction of the homes routines, policies and procedures. MENCAP must provide a second referee so the Commission for Social Care Inspection can determine the application for a Registered Manager (job share). 01/12/06 01/09/06 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 YA36 Good Practice Recommendations The registered manager should provide frequent staff supervision for new staff (e.g. weekly / fortnightly) Penlea DS0000009213.V306755.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office 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 DS0000009213.V306755.R01.S.doc Version 5.2 Page 27 - 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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