Inspection on 14/09/06 for Penlee

This inspection was carried out on 14th September 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 but made no statutory requirements on the home.

Other inspections for this house

Penlee 08/05/09

Penlee 12/09/08

Penlee 04/10/07

Penlee 04/04/07

Penlee 26/09/05

Penlee 25/04/05

Penlee 11/10/04

Penlee 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Penlee 21 Uphill Road North Weston Super Mare North Somerset BS23 4NG Lead Inspector Patricia Hellier Key Unannounced Inspection 09:00 14 September 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Penlee DS0000020337.V317460.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penlee Address 21 Uphill Road North Weston Super Mare North Somerset BS23 4NG 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) 01934 632552 0117 9400657 Dr Harmandar Singh Gupta Mrs Diljeet Kaur Gupta Mrs Demelza Beryl Louise James Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 29 persons requiring nursing care Staffing Notice dated 23/04/02 applies. Manager must be a RN on part 1 or 12 of the NMC Register The provision of one interim care bed for service users 50 years and over. 26th September 2005 Date of last inspection Brief Description of the Service: Penlee is a Victorian building renovated in 1992 situated along from the main sea front and overlooking the Weston Golf Club. It provides nursing care for up to 29 older people. The building and décor is of a high standard providing a comfortable and homely environment. Accommodation is provided over three floors with a passenger lift giving easy access to all floors. There are twenty-three single rooms, and three that may be shared. Eighteen of these have en-suite facilities and all have a call bell system. Communal space is provided in a lounge and dining room in the main building, and a recently built conservatory. This looks out onto an enclosed garden with a feature fountain. Provision is made within the home for a variety of activities and outings, which also enable close links with the local community to be maintained. All local facilities are within easy walking distance but some are closed in winter. The enclosed garden allows for good weather activities outside. Garden furniture is provided. Dr and Mrs Gupta have owned Penlee for many years. They are very involved in the day-to-day running of the home. They make information available through a brochure about the home that incorporates key information from the Statement of Purpose and Service User Guide. CSCI reports are displayed in the entrance to the home and available for all to read. The fess range from £494 - £560 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and some transport. This information was provided in June 2006. Penlee DS0000020337.V317460.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 over 8 hours with the manager present throughout. The provider was away on holiday at this time. Before the inspection the information about the home was received from the pre inspection questionnaire. It was not possible to send comment cards to residents, relatives and Health Care Professionals that visit the home as the information requested was not supplied to CSCI, as requested prior to the inspection. The last inspection report was reviewed together with all correspondence and complaints since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 11 residents, 4 relatives and 4 staff, observation of practices, tour of the premises, review of documents relating to care, recruitment, health and safety; review of policies; inspection of medication records and storage. Relatives spoken with said of the home “it’s really nice, my relative is well cared for”; “the staff are very kind and caring”: “it’s the best Mum’s been in a long time since coming here”. All residents and staff spoken with told the inspector that the home was good and the staff very kind. Comments received were “it is very homely and comfortable”; “my care needs are well met”. What the service does well: What has improved since the last inspection? Care plans have been reviewed and show more clearly the actions required to meet identified residents needs, ensuring their comfort and consistency of care for them. Care plans are now being reviewed monthly to note changes in care needs and to provide clear information for staff, enabling them to give best care to the resident. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 6 Medication administration practices have been revised, and medicines only signed for when residents have taken them to safeguard residents from missed or extra doses. A record of complaints made is now kept showing the actions taken to deal with them and if the complainant was satisfied. Fire doors that were being wedged open have had door guards fitted. These devices are attached to the fire alarms so that the doors can be held open during the day, but in the event of a fire would close automatically thus safeguarding the residents. 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. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The quality outcome in this area is adequate. The Statement of Purpose and Residents’ guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they, or their relatives, have access to the relevant information at all times. This also enables them to make an informed choice. One new resident and her relative said, “the information was good and told us all we wanted to know”. There were no recent residents’ contracts available to view during the inspection; as they are kept with the provider who was away. These will be inspected at the next inspection. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 9 Care needs are well met through an assessment process and the completion of a care plan from this information. Of the three care records and assessments inspected two were incomplete and one had been fully completed. In discussion with the manger she said that while there were documentation gaps, she had fully assessed the needs of the prospective residents and was clear that the home could meet their needs. It was agreed attention would be given to recording all assessment information in the future to ensure all care needs can be met. The assessment includes all the elements listed in the standard. One resident who had been admitted for respite care said that the care was “excellent.” “The staff were very attentive, kind and caring and fully met their needs”. Social Services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, The quality outcome in this area is adequate. Residents’ benefit from care plans that give clear information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are well managed. The system in place for the management of medicines is poor. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Three care plans were inspected and all clearly reflected current identified health and social care needs. Clear actions to meet identified needs were recorded and regular evaluation noted. None of care plans showed resident or relative involvement. This practice needs to be implemented. All care plans contained Manual Handling risk assessments. Two instances of poor practice were witnessed during the inspection. One was when two members of staff were observed using an under arm lift for transferring a resident from a wheelchair to an armchair. This had also been highlighted in the staff communication book as causing discomfort to the resident. Another instance was seen with a member of staff wheeling a resident through the Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 11 home without any footplates on the wheelchair. When discussed with the manager she said the staff always remove the footplates. Risk assessments for falls were seen with actions to take and considerations identified. Outcomes had not been measured – this was recommended. Pressure risk assessment had been recorded using an identified tool, but these had not been used to inform the care plan of pressure area care actions needed, or evaluated. The appropriate use of pressure relieving equipment was seen in the home and staff demonstrated good knowledge and practice in relation to this thus ensuring the residents’ needs are met. Daily records were up to date and written in a respectful manner. Not all information recorded in the daily records e.g. that which showed a new need for a resident, is transferred to care plans. Thus not all care need are fully recorded on care plans and actions to meet those needs for the benefit of the resident. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with ten of the residents confirmed a satisfactory standard of nursing and personal care. Two residents said, “ it’s a lovely home” another resident said, “people are very kind, we are well looked after”. One relative said, “my mum’s condition has improved since her admission to Penlee”. One of the resident’s spoken with expressed concerns about the length of time it takes for call bells to be answered and the distress it appears to cause to other residents. Call bells were answered promptly during the inspection. The management of medicines is poor. Although the manager says regular audits of Medication Administration Record (MAR) charts are undertaken, it is not possible to clearly trace all medication received, administered and disposed of, in the home. An example of this was seen where there was a discrepancy between the number of tablets supplied, administered and disposed of and the number remaining for administration. This amounts to a loss of medication, and was seen to have occurred on more than one occasion from entries in the staff communication book and MAR sheets. This is poor practice and potentially puts residents at risk. The manager informed the inspector that she is trying to find the cause and rectify it. The morning medication routine observed was safe and complied with the guidance. An entry in the nurses’ diary, which read “do not leave tablets in rooms for residents’ to take later” demonstrates that good practice, is not always observed for the safety of residents. Variable dose medications do not have the dose recorded and this does not allow for the resident to fully benefit from the medication prescribed. The recording of doses is recommended. The homely remedies policy was seen and these remedies that had been administered were seen on the individual Medication Administration Record Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 12 Sheets. The Homely Remedies policy is clear, was reviewed this year and is signed by the local GP’s to demonstrate their agreement with it. It does not state the number of doses that can be administered before medical advice is sought. This is recommended. Hand transcribed prescriptions were seen on the Medication Administration Records and these had not been signed by two members of staff when written thus not providing the recommended safeguard for residents. The medications fridge was locked and temperatures recorded satisfactory, thus providing for the safe storage of medicines. All residents spoken with felt that kind and caring staff respected their dignity and privacy. One resident stating “they always knock on the door”, and another saying “they are very kind, I am well looked after”. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality outcome in this area is adequate. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Friendly staff always welcomes relatives and visitors EVIDENCE: Many residents commented on the atmosphere of the home. One person described it as nicely informal, and residents’ felt that their visitors are also helped to feel relaxed and at home. The home employs a part time activities co-coordinator who spends time with the more able residents and seeks to encourage and enable activities they wish to undertake. A singer and keyboard player visits the home several mornings a week to play for the residents. Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt “their relatives were well looked after by friendly staff”. Relationships between residents and staff were observed to be satisfactory. A number of residents spoke of language difficulties with staff from overseas. The manager told the inspector that staff receive language skills training. One member of staff from overseas told the inspector that her English has improved over the time she has been at Penlee. One issue regarding staff Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 14 interactions with residents was discussed with the manager who was keen to be proactive about this. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they arise. Records of recent admissions to the home contained clear information about their likes and dislikes. All of the care records reviewed contained information about the residents’ preferred daily routine. All the residents said that the ‘food is good’ and “they liked the daily choices offered”. For example one resident said ’if you don’t like something they’ll change it’. Menus showed a varied, balanced and nutritious diet. The meal on the day of inspection reflected this. The dining room is homely and tables well presented. Good practice was observed in the dining room where care staff were helping residents with their meal Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is adequate. Residents feel that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. Whilst complaints policies are in place, procedures have not always been followed. EVIDENCE: The home has a satisfactory complaints process with evidence that complaints are listened to and acted upon. Residents spoken with were aware of the procedure for making a complaint, and several people commented on how flexible and open to discussion staff are. The home has had 7 complaints since the last inspection. Resolving complaints satisfactorily had not always been a quick and smooth process, but the examples that residents gave to the inspectors had mostly been resolved in due course. A record of complaints is held but this is not analysed for trends to inform care practices. A complaint regarding potential abuse is currently under investigation by the home, however feedback from the manager and records examined confirmed that procedures had not always been followed robustly.. Bed rails and recliner chairs were observed in use for residents, however consent for the use of these had not been obtained from the resident or their relative. This is required to protect residents from potentially abusive practices. The home has a copy of the North Somerset ‘No Secrets’ guide and an abbreviated local policy /procedure for the home specifically for responding to allegations of abuse. One member of staff interviewed told the inspector they Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 16 had witnessed verbal abuse in the home and had reported it to the manager. All staff demonstrated a good understanding of what abuse is and have received training, for the protection of residents. Four residents said ‘the staff are very kind and take time, I can’t fault them’. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24,26 The quality outcome in this area is adequate. Residents are provided with homely and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Robust infection control practices are followed for the most part. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable. During the inspection the inspector was made aware that the home’s boiler had recently broken down with the result that there was no hot water in one area of the home. The manager described adequate alternative measures that had been put in place to cope with the difficulty. The manager told the inspector that the boiler had been broken for a few days and that the system would be up and running in three days time. A complaint was received from a relative about this, following the inspection, and the length of time it took to repair the system. The complaint was upheld and repair work completed on the day of the complaint. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 18 The ground floor bathroom was out of action as upgrading work had been commenced to install a new bath that would assist staff in bathing frail residents. The manager said the bathroom would be redecorated following the installation. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility and aid independence within the home. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. The home has good facilities for ensuring that staff can maintain good hand washing practices between caring for residents. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality outcome in this area is adequate. The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are inadequate and do not provide the safeguards to protect residents. Staff access external training to ensure training is matched to the residents needs. EVIDENCE: Staff went about their duties in an unhurried manner and had time to deal with surprise visitors, numerous phone calls, and to spend with residents. Residents reported “staff never rush us through personal care tasks but always go at our pace”. Copies of two weeks staffing rosters were supplied to the inspector. Staffing levels rostered are in accordance with CSCI requirements. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. Staff interviewed said that they were kept busy, but still had time to chat with the residents. 50 of care staff have their NVQ level 2 training or above. A number of staff from overseas are employed and the provider promotes a multicultural staff team approach within the care team. Residents and staff said, “Communication can sometimes be difficult”. A visiting Health Care Professional, who was not understood on arrival at the home, echoed this. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 20 The home supports staff to attend college to develop their language skills. Overseas staff interviewed said they ‘felt very welcomed in the home, enjoyed their jobs and were improving their English’. Recruitment practices are poor and put residents at risk, as necessary safeguards are not undertaken before employment commences. Of the four personnel files inspected 2 did not have 2 written references or recorded evidence of qualifications. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen in personnel files. A wall planner in the nurses’ office showed planned training and dates completed for all staff. Discussions with staff confirmed that mandatory and specialist training had been obtained. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38 The quality outcome in this area is adequate. The management provide a happy and relaxed atmosphere to the home. The underpinning management structures of the home for the safety of residents are not robust. Residents’ views are sought and acted on, but a formalised system is not in place. The management of resident’s monies are handled safely by the home. Health and safety issues are regularly monitored in the home thus issues are identified and addressed as they arise. EVIDENCE: Dr and Mrs Gupta have a number of year’s experience of caring for the elderly and running Penlee, and the registered manager has recently gained her Registered Manager’s Award. Dr and Mrs Gupta are around daily in the home and support the manager in running the home. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Many Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 22 residents’ said they liked seeing Dr and Mrs Gupta on a daily basis and that their involvement in the home was helpful. Staff felt that their efforts are valued and that they are encouraged to develop their skills and try out their ideas. The home does not have a formal quality assurance system. Samples of resident satisfaction surveys from earlier in the year were seen, however there was no evidence to indicate how their suggestions were to be incorporated into an improvement plan, thus providing an effective framework to ensure that monitoring and reviewing of the various aspects of quality assurance, are undertaken and acted upon. The management of resident monies by the home were inspected. A satisfactory system of recording was seen and all entries and monies inspected tallied. Each member of staff has an element of their practice directly supervised by the manager or her deputy. The system for this is not fully formalised and happens on an ‘ad hoc’ basis, which does not ensure standards of practice are understood and maintained. Supervision records inspected were sporadic. Staff interviewed verified that supervision takes place “as and when”, “if there is something to discuss”. A formalised system of supervision needs to be implemented to monitor practice. The homes records and stored securely and used in accordance with the Data protection Act 1998. A number of records e.g. the care plans, staff files are not accurately maintained and up to date. This is recommended. Regulation 37 notifications are not supplied to CSCI as required for any event in the care home that adversely affects the well being or safety of residents, to ensure that appropriate systems are in place for their safety. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place, although the last documented fire drill was in January 2006. A number of staff have received First Aid training. All other service and safety checks inspected had been completed as required. A record of accidents is kept which complies with Data Protection to maintain staff and resident confidentiality. The inspector observed that the laundry room fire door was wedged open throughout the inspection. Also observed was the storage of combustible materials e.g. oxygen cylinder and a mattress in corridors. These pose a fire risk and safety hazard to residents. Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 2 1 1 Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15.1 Timescale for action Unless it is impracticable to carry 20/11/06 out such consultation, the registered person shall after consultation with the service user or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. This relates to the lack of service user or relative involvement in care planning. Previous timescale of 31/10/05 not met Unless it is impracticable to carry 20/11/06 out such consultation, the registered person shall after consultation with the service user or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. This relates to the need to ensure all care needs are record on the care plan. The registered person shall make 20/11/06 arrangements for the recording, handling, safekeeping, safe DS0000020337.V317460.R01.S.doc Version 5.2 Page 25 Requirement 2. OP7 15.1 3. OP9 13.2 Penlee 4. OP9 13.2 5. OP8 13.5 6 OP18 13.6 7 OP29 19.1 & Schedule 2 8 OP33 24 administration and disposal of medicines received into the care home. This relates to medication administration practices and the missing medications. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This relates to the storage of medication that requires refrigeration. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. This relates to the poor practices observed and recorded. The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. This relates to the lack of consent for the use of bed rails and recliner chairs. Also to staff practices. The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1-7 of Schedule 2 The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and (b) improving the quality of care provided at the home, including the quality of nursing where nursing ins provided at the care home. DS0000020337.V317460.R01.S.doc 20/11/06 20/11/06 20/11/06 20/11/06 20/01/07 Penlee Version 5.2 Page 26 9 OP37 37.1 (e) 10 OP38 23.4 (c) (i) This relates to the lack of formalised Quality Assurance systems The registered person shall give notice to the Commission without delay of the occurrence of (e) any event in the care home that adversely affects the well being or safety of any service user This relates to the boiler breakdown The registered person shall after consultation with the fire authority (c) make adequate arrangements (i) for detecting containing and extinguishing fires This relates to the wedged open laundry room fire door. 20/11/06 20/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP9 OP16 OP36 Good Practice Recommendations All hand transcribed entries on the MAR sheets to have two signatures. Complaints records are analyses periodically to observe for trends. The implementation of a formalised and regular supervision system Penlee DS0000020337.V317460.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Penlee DS0000020337.V317460.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!