Inspection on 27/07/07 for Penlea

This inspection was carried out on 27th July 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penlea 16/07/08

Penlea 17/08/06

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 27th July 2007 15:00 Penlea DS0000009213.V340487.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.V340487.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.V340487.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 Miss Michelle Ann Dawe Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 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 Ms Michelle Dawe. All people who use the service 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 home, 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.V340487.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 six hours. All of the key standards were inspected. The methodology used for this inspection was: • To case track three people who use the service. This included, where possible, meeting and discussing with the people who use the service their experiences, and inspecting their records. • Discussion with other people who use the service. • 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: Please contact the provider for advice of actions taken in response to this inspection. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Penlea DS0000009213.V340487.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.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of admission, people who use the service have been issued with a tenancy agreement and a copy of Mencap’s terms and conditions of residency. People who use the service subsequently receive suitable information regarding their rights and responsibilities. The pre admission assessment procedure is good, and enables the registered persons to ascertain they can meet the needs of prospective residents, before admission is arranged. EVIDENCE: Copies of tenancy agreements, and an individualised copy of terms and conditions of residency, are contained in peoples’ files. Copies of social services contracts of care were available for inspection on some files. There have been no admissions since the last inspection. However Mencap has a satisfactory assessment procedure, which should ensure the process of assessing and helping people to move in to the home is appropriate, should further admissions occur. Penlea DS0000009213.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people who use the service have a care plan and these are regularly reviewed. Care plans ensure staff have suitable information to provide care. People who use the service are encouraged to make decisions about their lives with suitable assistance as required. The registered persons approach to handling residents’ monies is good, so people living in the home can be assured their finances are maintained appropriately where staff are involved in this area of their lives. The registered persons have a suitable approach to risk, so people who use the service can be assured they will be supported to take risks as part of an independent lifestyle. EVIDENCE: There is a copy of a care plan in each resident’s file. Care plans are accessible to staff and are regularly reviewed. The registered manager said she would shortly introduce a new care planning system. The registered manager said review meetings would occur in August 2007. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 10 People who use the service said they are encouraged to make decisions regarding their lives; for example regarding small decisions such as what to eat to larger decisions such as how to spend their time. The inspector checked monies kept on behalf of people living in the home. Suitable records of monies are kept, and monies are kept securely. A risk assessment is maintained where staff are involved in this area of peoples’ lives. Where appropriate people living in the home look after their own monies. Suitable risk assessments are in place to assess any risks or actions to promote independence. Some people who use the service are able to go out on their own and use public transport etc. The registered provider has a satisfactory policy regarding diversity and equality. There are currently no people who use the service from ethnic minorities, although the registered provider stated the home would be more than happy to accommodate people who use the service from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Women people who use the service have equal opportunity compared with their male counterparts. Issues regarding sexuality seem to be suitably addressed. Penlea DS0000009213.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can participate in a suitable range of activities, and are able to mix with the wider community. People who use service are encouraged to maintain relationships with friends and relatives. People who use the service have their rights respected, and are enabled to take a suitable amount of responsibility in their daily lives. Suitable arrangements are in place so people who use the service enjoy a healthy and varied diet. EVIDENCE: People who use the service said they attend a range of day activities including attending work placements, educational courses and leisure facilities. Activities are also arranged in the evenings and at weekends. The home has a car for residents’ use. People who use the service said they visit friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 12 People who use the service 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 activities. Staff were observed to be respectful in the manner they worked with people living in the home, and residents the inspector spoke to say they had no concerns regarding staff conduct. Locks are fitted to bedroom doors so people living in the home can lock their doors if they wish. People living in the home said they were involved in household tasks for example doing laundry, cleaning tasks, shopping and cooking. People living in the home said they enjoyed the food provided. People living in the home are involved in the preparation of food with appropriate staff support. The inspector shared a meal with people living in the home and this was to a good standard. Penlea DS0000009213.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is delivered to a good standard, and there are suitable links with medical professionals. The management of medication is to a satisfactory standard so people who use the service can be assured their medication is suitably looked after. However there have been some declared errors regarding medication administration, and extra care and attention needs to occur to ensure these are not repeated. EVIDENCE: People who use the service said they received suitable care and support from staff. Any personal care needs are documented in care plans. Care plans document appropriate links with GP’s, dentists, opticians, chiropodists and other professionals. People who use the service said they regularly saw medical professionals when required. Some people who use the service have support from a community learning disability nurse, who the registered manager said provides advice and support regarding peoples’ needs as appropriate. Medication is stored securely, and is generally administered appropriately. Some errors in the administration of medication have occurred since the last inspection. These have however been declared by staff to management, and Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 14 suitable advice obtained from medical professionals. However greater care must be taken by care staff to ensure such errors do not occur. Additional staff training and supervision should be given if this is required. Medication records are kept to a good standard. Staff have received suitable external training regarding medication. Penlea DS0000009213.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately although the registered provider’s complaints procedure does not meet the national minimum standard. Mencap has a satisfactory adult protection policy, which should provide a suitable framework to protect people who use the service if they are at risk. EVIDENCE: The registered provider has developed a complaints procedure. The manager has included a summary of this in the statement of purpose / service user guide. 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, which will subsequently be superseded by Ofcare in April 2009. 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. The registered provider has been notified regarding this in several CSCI reports on a significant number of occasions for Mencap care homes in Cornwall. The manager has put up a poster in the hallway regarding how residents and their representatives can contact CSCI if they have a concern or complaint. However this now needs amendment as the Commission’s local office is now in Ashburton, Devon rather than St Austell. People who use the service said they would have confidence in staff / management if they had a concern or a complaint, and they felt the matter would be dealt with appropriately. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 16 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 and where appropriate a Protection of Vulnerable Adults (POVA) check. People who live in the home were positive about the attitudes and actions of the staff that worked with them. Penlea DS0000009213.V340487.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Penlea provides a clean, well maintained and a homely environment for the people who live there. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for the people who live there. The home is a large Victorian property. There is a large front garden, with a wheel chair ramp to enable access to the home for wheelchair users. There is a small yard at the back of the building, but no garden. There is car parking available at the front and rear of the home. Bedrooms and communal areas are of a satisfactory size to meet the needs of people living there. The home is currently registered for eight although only seven people are currently routinely accommodated. The downstairs of the home is accessible to wheelchair users. There is also a bedroom on the ground floor. There are suitable toilet and bathroom facilities on both floors. The shower room at the rear of the home has recently been refurbished. All bedrooms and communal rooms are well decorated, individual and homely. The home was clean and hygienic on the day of the inspection. Suitable Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 18 cleaning routines are in place. There is no cleaner employed as people living in the home complete the cleaning with staff support. Two of the people living in the home stated they wanted the registered persons to attend to a couple of maintenance issues in their bedrooms. These matters (filling a hole and checking a radiator was working suitably) were discussed with the manager who said the matters would be addressed promptly. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be reviewed and improved. This will ensure the needs of people who use the service are met, and the risk to the safety of staff and people who live in the home is minimised. Recruitment records are good. Suitable recruitment procedures and records help to ensure people who use the service know they are in safe hands. Staff training is generally good, although there are some gaps in training required by law. Suitable training ensures staff have appropriate skills and knowledge to meet residents’ needs. Equal opportunities issues regarding recruitment and work practices seem appropriate. EVIDENCE: Rotas indicate there is usually one person on duty at one time. On most occasions there are two staff on duty in the afternoon / evening (from 1500 hrs). However on the day of the inspection there was only one person on duty in the afternoon and evening. Rotas show this is the case on other occasions. Some of people who live in the home can exhibit behaviour, which can be deemed as challenging. This has resulted in some aggressive behaviour, which could present a health and safety risk to other people living in the home and to Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 20 staff. Subsequently the Commission does not believe that current staffing levels are satisfactory to ensure suitable levels of support are available at all times, and to ensure people are safe at all times. The registered persons are subsequently required to review staffing levels, and provide the Commission with proposals to improve the level of staffing within a satisfactory timescale. Staff files were inspected. The registered persons obtain suitable information regarding the recruitment of staff. This includes two references and evidence confirming the person’s identity. Staff also have a Criminal Records Bureau (CRB) check and Protection of Vulnerable Adults (POVA) check (as applicable) when they commence employment. 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. There is also a brief ‘in house’ induction checklist so new staff can be inducted regarding the home’s routines. Mencap has a suitable training programme. This includes fire training, first aid, food hygiene, manual handling, and infection control. The majority of staff have attended these courses, although some gaps were identified in training required by law. For example of the five staff files examined two staff needed to have food handling training, and one member of staff required infection control training. All other training required appeared to have been received. The manager was able to state how those who still required training in these areas would receive it within the next three months. The registered manager said all staff currently employed have had training regarding challenging behaviour, and training regarding autistic spectrum disorders. This was required following the last key inspection in August 2006. However this needs to be documented. Staff are also due to have training regarding epilepsy in August 2007. All of this training needs to be repeated for other staff who will be employed in future, so they have satisfactory skills and knowledge to work with the people accommodated in the home. Mencap has a suitable approach to ensuring staff have the opportunity to obtain a National Vocational Qualification in care. According to the manager 33 of staff currently have either a NVQ 2 or 3. Some of the other staff have or will be commencing NVQ training so at least 50 of staff will then have an NVQ. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed by a suitably skilled, experienced and knowledgeable manager. A quality assurance system in place. This should ensure there is a process of continuous improvement, and people who use the service and other stakeholders are consulted about their views. However the registered persons must ensure notifiable incidents are always reported to the Commission as required in the regulations. The management of health and safety issues needs some improvement so people who use the service can be assured they live in a safe environment. EVIDENCE: Ms Michelle Dawe appears to be suitably experienced, knowledgeable and skilled to manage the home. People who use the service were positive about her leadership. However the manager is due to leave in the next few months. The registered provider will need to inform the Commission when this occurs, Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 22 and what management arrangements will be put in place until a new manager is recruited. The registered manager is currently working a considerable number of ‘care’ hours. For example on the day of the inspection the manager was sleeping in and was the only member of staff on duty. Although the manager working some of their time with people living in the home is good, the manager needs to have more time dedicated to the management of the home. The Commission would usually expect the registered manager’s hours to be supernumerary. However currently the manager can do several sleep in shifts a week, and this is essential for ensuring the home has basic staff cover. This is not really satisfactory on an on going basis. This issue needs to be addressed as part of the staffing review. MENCAP has a suitable approach to quality assurance. A survey has been completed regarding stakeholder views and these were positive. The results however should be collated and, if necessary, any required actions are included in the homes continuous improvement plan. Monthly monitoring takes place to ensure the home complies with Mencap’s standards. A continuous improvement plan is in place, and a service development plan has been developed. The manager also arranges regular staff meetings and regular residents meetings. There is evidence of a staff supervision system in place. However the registered persons are not providing reports regarding incidents to the commission. This is required under regulation 37 of the Care Homes Regulations 2001. A full list of what incidents are notifiable is outlined in the regulations. The registered provider has a suitable health and safety policy. Records kept of checks required by regulation are only adequate. There are satisfactory records regarding portable electrical appliance testing and the servicing of gas appliances. Accident records are maintained to a satisfactory standard. Health and safety risk assessments are generally satisfactory. Fire alarms and emergency lighting appear to be tested appropriately and suitable records are maintained. There appears to be a satisfactory fire risk assessment. There is satisfactory insurance in place. There is a risk assessment regarding the prevention of legionella. However records show tests are not being carried out regularly and these need to be recommenced. Monitoring of hot water thermostatic valves also needs to occur on a regular basis. An electrical hardwire test was completed in 2004, but the overall result stated remedial work was needed to ensure the system was safe. This needs to be completed as necessary, the system retested, and a certificate of compliance obtained. The new certificate should subsequently be forwarded to the Commission within the timescale set. Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 23 Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 24 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X 3 X 2 X X 2 X Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 25 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 YA33 YA42 Regulation Requirement Timescale for action 01/09/07 2. OP37 3. YA42 12, 13, 18 The registered persons shall having regard to the needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the home, in such numbers as are appropriate for the health and welfare of service users. (For example the current staffing levels must be reviewed. A copy of the report outlining the review, with recommendations and timescales must be submitted to CSCI) - Requirement completed satisfactorily. 37 The registered person shall give 01/08/07 notice to the Commission without delay of the occurrence of matters required in this regulation. Any notification made in accordance with this regulation, which is given orally, shall be confirmed in writing. - Requirement completed satisfactorily. 13, 23 The registered persons shall 01/10/07 ensure that— Unnecessary risks to the health DS0000009213.V340487.R01.S.doc Version 5.2 Penlea Page 26 or safety of residents are identified and so far as possible eliminated. Equipment provided at the care home for use by residents or persons who work at the care home is maintained in good working order; For example there must be: Evidence the electrical hardwire circuit is safe, and retested if necessary. Evidence of this must be forwarded to the commission. Evidence that thermostatic valves, which control the temperature of hot water, must be tested on a regular basis. There must be a suitable risk assessment regarding the prevention of legionella and satisfactory precautions are put in place. Documentary evidence of testing must be available for inspection. - Requirement completed satisfactorily. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Penlea DS0000009213.V340487.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!