Inspection on 26/09/05 for Penlee

This inspection was carried out on 26th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Penlee 08/05/09

Penlee 12/09/08

Penlee 04/10/07

Penlee 04/04/07

Penlee 14/09/06

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 Announced 26 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Penlee Address 21 Uphill Road North Weston Super Mare North Somerset BS23 4NG 01934 632552 0117 940 0657 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dr & Mrs H S Gupta Mrs Demelza James Care Home with Nursing 29 Category(ies) of Old Age - (29) registration, with number of places Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 29 persons requiring nursing care 2. Staffing Notice dated 23/04/02 applies 3. Manager must be a RN on part 1or 12 of the NMC register Date of last inspection 25 April 2005 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 which 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 commumity 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. Demelza James has recently been appointed home manager. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the second statutory inspection of the current year and took place over seven and a half hours. Part of the inspection was an investigation into a recent complaint regarding poor care practices. The complaint was unresolved as the information available was not comprehensive enough to clarify the issues. Before the inspection the information about the home was received from the pre inspection questionnaire and comment cards from relatives and residents. All 7 of the residents who returned cards were happy with the home and care provided; saying “I am satisfied with the care given”. Of the 16 relatives cards returned all felt very welcomed in the home and that their relatives were receiving very good care. Comments stated, “the owners and staff are very welcoming.” All residents and staff spoken with told the inspectors that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “my relatives care needs are well met”. The inspector toured the premises; spoke to 5 members of staff, 14 residents 3 relatives and inspected a number of records. What the service does well: This is a family run home that has a group of staff who work well as a team, are resident focused and provide continuity for residents. During the inspection a good rapport was seen between staff residents and their relatives. Dr and Mrs Gupta are actively involved in the day-to-day running of the home and residents said how much they liked this. The majority of residents are very frail. Their personal and health care needs are well met, by the staff team. They ensure the well being and comfort of the residents’ and treat them with great respect and kindness. Residents spoke of the “lively atmosphere” and “happy home” The home have good links with the local GP, district nurses and nurse specialists in the hospital whom they involve appropriately to ensure all care needs are well met. All residents’ spoken with praised the care they received from the staff. Thank you letters from relatives praised the care at the home. The standard of meals provided in the home is consistently high. Residents said that the chef is very good, and gave numerous examples of staff ‘going out of their way’ to tempt their appetite. The local council has awarded the home a ‘healthy eating’ certificate. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 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 standard(s) 1,3,4 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. Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. 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 assessments A comprehensive assessment was seen for a recently admitted resident. The resident when spoken to said ‘I am well looked after they know what I need’. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7,8,9,10 The health and personal care needs of residents are well met. Care plans do not always contain clear actions to meet needs, or evaluation of actions, to ensure residents’ health and social care needs are fully met. Risks to residents are not fully assessed and actions to minimise these planned, which potentially places residents at risk. Medicine recording and administration systems are poor, and place residents at risk. Residents feel they are treated with respect and dignity. EVIDENCE: Of the six care records inspected good standardised ‘core’ care plans were provided for the majority of identified needs. Staff have added guidance regarding individual needs to these core care plans. In three files inspected core care plans however did not fully state actions to meet needs e.g. pressure area care – but did not state how this care was to be given. Another had identified a mental health issue but no actions had been written to meet these needs, and a third had not recorded social interests. Individual risk assessments had been completed in some cases, but not all. Service users or relative involvement in care plans was not evidenced. 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. Staff interviewed and observed Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 10 demonstrated good understanding of residents needs and were observed meeting them Most of the medicine administration records (MAR sheets) were clearly printed by the community pharmacist. Staff in the home had handwritten some amendments. These were not signed or dated. On checking the Controlled Drug (CD) records it was noted that there was a discrepancy in the amount in the cupboard and that recorded in the CD book. In discussion with staff it was clear that the returns and disposal of medicines is unclear and therefore it was not possible to follow and audit trail of all medicines into and through the home. There must be a clear audit trail of all medicines received into the home and disposed of to ensure the safe handling of medicines. Staff must check the medicine administration record before giving a prescribed medicine to ensure correct dose is administered to the correct person at the correct time. Medicines prescribed and dispensed for one resident must not be given to another. The medications fridge did not have a lockable facility and contained excessive amounts of stock of insulin and eye drops. These level need to be reviewed. Pharmaceutical guidelines must be adhered to in respect of opened eye drops and ointments. The home has a “Homely remedies” policy that states there will be a clear list of medication agreed with the GP to be administered under this policy. No agreed list was available. There is no clear evidence of competency assessment of staff in relation to medicines administration potentially leaving residents open to harm from poor practice. The self medication documentation referred to in the policy needs attention to include all keys aspects of administration. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,14,15 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents right to choice and control over their lives is well respected, and encouraged. Autonomy and personal choice is promoted via advocacy services helping residents to maintain independence. Relatives and visitors are always welcomed by friendly staff. EVIDENCE: 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. During the inspection, he was observed taking a session in the conservatory and this appeared to be for more significantly dependant residents and those with memory deficits. Residents were seen enjoying themselves and joining in. In the afternoon a Flexercise class was taking place and this had a good mixture of residents of all abilities and they were seen to be enjoying themselves. A clear record of activities that have taken place is recorded. There is no activities plan as the manager states the activities are planned on the day depending on the residents wises and capabilities on that day. All the residents said that the ‘food is good’ and that 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 Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 12 kitchen is clean tidy and well organised. The dining room is homely and tables well presented. A recent Environmental Health Officer’s report praised the standards of the kitchen. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents are confident that they are listened to and their requests acted upon. Residents are protected from abuse by knowledgeable and competent staff EVIDENCE: The home has a comprehensive complaints policy that is given to residents in their admission pack. However it does not include timescales for response to a complaint and it is not displayed in the home. From discussion with the manager and provider it is clear that all complaints are taken seriously and acted upon. However there are no records of these actions and outcomes. These records must be kept. Staff and residents spoken to, say ‘the manager is very approachable and understanding’ and the providers are always about to listen and respond to concerns. Feedback received from all residents and relatives spoke of the caring and responsive approach of the management. There has been one complaint since the last inspection and the investigation of this formed part of the inspection. The home has a copy of the North Somerset ‘No Secrets’ guide. There is no abbreviate local policy /procedure for the home specifically for responding to allegations of abuse. Staff said they had never seen any signs of abuse in the home and demonstrated a good understanding of what abuse is. However none have had any specific training in the recognising and handling of abusive situations – this is recommended. Three residents said ‘the staff are very kind and take time, I can’t fault them’. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,26 Residents are provided with safe, 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 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. Carpet on the back staircase is worn and a potential trip hazard. A maintenance plan is recommended to evidence the ongoing routine maintenance and renewal of the fabric for the benefit of residents. 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. All resident rooms are personalised and one resident said how much she enjoyed the calm of the quadrant garden over which she looked from her window. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 15 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. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The home’s staffing levels are sufficient to manage the current care needs of residents. Specialist training could be improved to ensure training is matched to the residents needs. EVIDENCE: The home has a staffing notice agreed between the CSCI and the home’s management. 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. The home has a Key worker system in place for all residents. Residents and staff were aware of the role and said, “it worked well”. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen in personnel files. Evidence of specialist training e.g. Care of the elderly, diabetes, was not seen either in training files or through discussion with staff. This is recommended. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. There is a good system for residents’ consultation and residents feel their views are heard and acted upon. The system for the management of resident’s monies in the home is not robust and potentially leaves residents open to abuse. The safety of residents is not always risk assessed and ensured in a safe environment EVIDENCE: Residents and staff stated that the manager is good at her job, approachable and one resident said she ‘can’t do enough’, ‘she is always helping.’ Residents and staff interviewed stated that they felt well supported by an approachable and available manager. Residents said how nice it was that Dr and Mrs Gupta took such an interesting them and their needs. Residents felt that their views were asked for and acted upon. A more formal process of an annual questionnaire has been completed in the past but never analysed and used to inform an action plan to ensure continuing quality Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 18 provision. Arrangements to formally feedback these results to residents and their relatives are not in place at present, and this process needs to be implemented. Residents spoken with and comments received clearly showed resident satisfaction with all aspects of the home. . The management of resident monies by the home were inspected. Audit trails of residents’ monies in and out were not clear. It is recommended that a clearer more formal audit trail is arranged for the protection of resident’s monies. Entries for monies removed lacked two signatures. Staff spoken with were aware of the procedures in the home for ensuring the safe management of resident’s monies. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. A number of staff have received First Aid training. A record of accidents is kept however the format does not comply with data protection and should be replaced with the recommended record book as soon as possible to maintain staff and resident confidentiality. Environmental risk assessments for wedged open fire doors had not been completed and this potentially puts residents at risk. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 4 COMPLAINTS AND PROTECTION 3 x x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 2 x 2 x x 2 Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 20 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 Timescale for action Care plans must be reviewed and 31/10/05 updated at least once a month.The invlovement of residents or their representatives in the care planning process must be documented Previous timescale of 25/05/05 not met Care plans must clearly state 11/11/05 action to meet needs and show evaluation of these actions Staff must sign and date 31/10/05 handwritten amendments to the medicine administration records. Correction fluid must not be used. There must be a clear audit trail of medicines received into the home, and administered to residents. Previous timescale of 25/04/05 not met Medicines prescribed and 31/10/05 dispensed for one resident must not be given to another. Previous timescale of 25/04/05 not met The prescription on the MAR 31/10/05 chart must be checked prior to the adminisration of medicines to ensure safe administration Fire doors must not be wedged 31/10/05 Version 1.40 Page 21 Requirement 2. 3. op7 OP9 15 13 4. OP9 13 5. OP9 13 6. Penlee OP38 23 D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc open. Previous timescale of 25/04/05 not met 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. 4. 5. 6. Refer to Standard OP16 OP33 OP35 OP35 OP38 OP38 Good Practice Recommendations A record of all complaints together with the actions and outcomes should be kept for all complaints . A formalised system of Quality Assurance that analyses the results of a resident survey, produces an action plan and feedback to residents and staff, should be developed. The implementaion of records for resident monies that enable a clear audit trail to be followed. To ensure that two members of staff sign for any transactions pertaining to resident monies to ensure resident protection. The home obtains the current accident record book that meets with Data Protection standards The completion of environmental risk assessments to esnsure resident safety in the home. Penlee D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53-D02 S20337 Penlee V243655 26.09.05 Stage 4.doc Version 1.40 Page 23 - 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!