Inspection on 04/10/07 for Penlee

This inspection was carried out on 4th October 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 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 04/04/07

Penlee 14/09/06

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 16:00 4 & 5th October 2007 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 DS0000020337.V349279.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. DS0000020337.V349279.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 01934 412711 penlee@freeuk.com 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 DS0000020337.V349279.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. 4th April 2007 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 good 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 conservatory. This looks out onto an enclosed garden with a feature fountain. Provision is made within the home for some 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 £523.57 - £560 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and some transport. This information was provided in April 2007. DS0000020337.V349279.R01.S.doc Version 5.2 Page 5 DS0000020337.V349279.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place with over two days and 11 hours with the manager present throughout. The provider was present for the second day. Before the inspection the information about the home was received from the AQAA returned by the provider and surveys returned by residents, relatives, staff and health Care Professionals. The last inspection report was reviewed and all correspondence since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 9 residents, 5 relatives, and 5 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Of the 16 resident surveys sent 3 were returned and all were satisfied with the care they received. All said the home is clean and fresh, and that they would know who to speak to if they were unhappy. Comments from residents were “the staff are very kind and efficient”. Of the 12 relative surveys sent 10 were returned and all felt they received enough information about the home and that their relative gets the support they expect. They all knew how to make a complaint and felt that any concerns raised were dealt with satisfactorily. Comments about what the home does well were: “provides a personal relationship in a homely atmosphere”; “provides care with respect and affection”. Other comments received were: “some staff are more helpful than others”; “the staff team are constantly overstretched”: “residents are well looked after no matter what their social background”. Relatives spoken with during the inspection were satisfied with the overall care their relatives receive at the home. All knew how to make a complaint and felt that it would be listened to and resolved as far as the home is able. Of the 10 staff surveys sent four were returned. All staff felt they are given information about the needs of the people they are to care for, and felt they are well supported through management and training to do the job. Comments about the home were: “it provides a happy and secure environment”; “would benefit from a suggestion box in the hall area of the home”. 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”. DS0000020337.V349279.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: DS0000020337.V349279.R01.S.doc Version 5.2 Page 8 Make staff aware of snack foods available for residents between teatime and breakfast. Encourage staff to offer to resident’s snacks so that they will not feel hungry. Increase staffing levels at busy times of the day to ensure all residents’ needs are met in a timely way. Provide bedrails that fit the beds without any gaps for the safety of residents. 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. The summary of this inspection report can be made available in other formats on request. DS0000020337.V349279.R01.S.doc Version 5.2 Page 9 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 DS0000020337.V349279.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is satisfactory 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 Service User Guide 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. One relative said, “the information was good and told us all we wanted to know”. DS0000020337.V349279.R01.S.doc Version 5.2 Page 11 Resident files inspected showed that all privately funded residents receive a contract of Conditions of Admission and Terms of Business, and those who are publicly funded receive a copy of the Terms and Conditions document which forms a contract of agreement. In these documents the breakdown of fees, and who is responsible for their payment is clearly stated. Since the last inspection the care needs assessment documentation has been revised and now provides for a person centred approach to assessments. In the two records inspected medical, social and psychological needs were clearly documented and personal preferences also recorded. A brief personal history and record of hobbies and interests is also recorded to assist staff in providing person centred care. The risk assessment documentation was incomplete and did not provide clear information regarding the potential risks to the residents (e.g. the risk of developing a pressure sore) and how they were to be minimised. The assessments seen while person centred did not evidence the outcome of the assessment. It is recommended that this information be completed. A plan of care to meet the new residents needs is developed from the assessment information. The assessment includes all the elements listed in the standard. One recently admitted resident when spoken to said, “I like it here, the staff are kind. Sometimes you have to wait for them to come when called”. Care practices observed showed that staff were aware of the residents needs as stated in their assessments. Prospective residents are encouraged to visit the home and assess the quality and facilities of the home for themselves. While the recently admitted residents had not been able to do this, their relatives confirmed that they had visited and been given an opportunity to see the home meet the staff and discuss any queries with the staff and management. DS0000020337.V349279.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 Care plans give person centred information to enable staff to meet residents’ health and social care needs. The system in place for the management of medicines is satisfactory. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents and include details of personal preferences and interests. Since the last inspection a more person centred approach to care has been adopted. Four care plans were inspected and all showed clearly identified needs with aims to meet them, and actions to enable staff to do this. Not all identified needs were recorded in the care plans. One resident at risk of developing pressure sores had not been assessed and no pressure relieving equipment was seen in place for this resident. In discussion with staff regarding the resident’s care needs they were aware of the need to assist them in standing DS0000020337.V349279.R01.S.doc Version 5.2 Page 13 but did not identify the potential for the development of pressure sores. Another care record did not clearly identify the residents medical condition as a need, and how best for staff to meet that need. In discussion with staff they seemed unaware of the medical condition underlying the resident’s admission to the home and key aspects of care needed. . Visits by the dentist, chiropodist and optician were recorded in all of the care plans. Wound care plans are clear and contain all necessary details of the wound and its progress. One of the nursing staff said they had recently undertaken a wound management course. In discussion with staff it was clear that they do not see the care plans as working documents to enable them to provide good person centred care. A handover book and word of mouth is used to convey care routines. All care plans contained Manual Handling, and falls risk assessments, with the outcomes being used to inform the provision of care. Nutritional and pressure sore risk assessments were present but had not always been fully completed, to assist staff in understanding the risks and actions to minimise them. The manager told us that she has been using the handover sessions to discuss with care staff, risk management. Pressure risk assessments 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 some areas of the home. None of the care plans showed resident or relative involvement. This practice needs to be implemented. Residents spoken with said, “the home is nice and the staff are good”. None of the residents knew about their care plans and only one relative spoken with said the care plan had been discussed with them, but they had not signed it. The manager showed us a care plan and development review form that has been developed to demonstrate regular reviews and resident or relative involvement, but this was not seen in use in the care records. The home has a key worker system and residents and staff felt that this worked well. Residents interviewed knew who their special carer is and staff interviewed said they liked the opportunity to be closer to some residents. Care practices observed showed caring interactions from staff. One episode of poor practice was observed when a carer put a finger food meal in front of a resident who is unable to see, and did not describe what was on the plate and where it was. Choices and preferences were observed being discussed and offered and had been recorded in the care plans. We observed that all residents in the lounge and conservatory were offered a variety of drinks throughout the day. DS0000020337.V349279.R01.S.doc Version 5.2 Page 14 Daily records were up to date and written in a respectful manner. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with nine of the residents confirmed a satisfactory standard of nursing and personal care. Two residents said, “ it’s homely” another resident said, “people are very kind, we are well looked after”. Five of the resident’s and two relatives spoken with expressed concerns about the length of time it takes for call bells to be answered. Call bells were answered promptly during the inspection. The management of medicines has improved since the last inspection and good practice was observed in the dispensing and disposal of medication during the lunchtime period. Medication Record Sheets (MAR) showed no gaps and clearly recorded when medication had been refused or omitted for some reason. The homely remedies policy was seen and these remedies that had been administered were seen on the individual Medication Administration Record 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. 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 always polite and ask what I would like”. Two relatives spoke of the kindness and care they felt their relatives receive. Two other relatives felt that they need to visit regularly to ensure that their relative gets the care she needs. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. The staff team is international and has experience of equality and diversity issues. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs of residents as and when they should arise. One relative commented, “there are all nationalities here and they get on well”. DS0000020337.V349279.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 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, helping residents to maintain independence. Friendly staff always welcomes relatives and visitors. EVIDENCE: All residents commented on the atmosphere of the home. Feedback from surveys returned spoke of the happy and homely environment. Two relatives spoke of their delight that their relatives can do what they like and choice and independence is encouraged. One person described it as nicely informal, and residents’ felt that their visitors are also helped to feel relaxed and at home. During the inspection a group of residents were seen engaged in making Christmas cards. The activities lady facilitated it. She was also observed spending time talking with other residents in the conservatory. The following day the activities lady brought her dog to see the residents and was seen visiting various residents DS0000020337.V349279.R01.S.doc Version 5.2 Page 16 with it. They seemed to be enjoying this. Residents when spoken with said they usually had something to do. One pointed to the new large screen television saying “we like that”. The manager told us that the provision of this had come out of resident and relatives meeting. It was not possible to evidence this through discussion with residents or relatives. In discussion with the activities lady she told us that she comes four afternoons a week, and provides a variety of activities according to what the residents want to do. A remembrance book for past residents has been made to assist in the mourning process when fellow residents die. A record of all activities done, and one to one visits and activities provided was seen. A scrapbook of these has also been compiled and is kept in the conservatory for staff and residents to look at. 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”. All the residents said that the ‘food is good’. 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. A choice of meal is offered and likes and dislikes catered for. On the day of the inspection one resident told us that she had changed her mind three times about what she wanted for lunch and it was provided. On the first day of inspection tea was served at 16.45hrs. Residents told us that they would not have anything else to eat before breakfast the next day. Two residents said they sometimes did feel hungry in the night. On speaking with the chef, and viewing the kitchen store cupboards, sufficient supplies of varied snack foodstuffs are available for residents if they wish. He informed us that it is up to the staff on duty to provide it. Staff when interviewed said they gave the residents drinks and biscuits if they wanted later in the evening. Since the last inspection most staff have received training in Food Hygiene and handling to ensure safe practice. DS0000020337.V349279.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 16,17,18 Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. Since the last inspection copies of the complaints procedure have been placed on the back of every resident’s door together with a complaint form, should they wish or need to use it. Residents spoken with were aware of the procedure for making a complaint, and felt they would be able to tell staff or the owners if they had a complaint. The home has had no complaints since the last inspection. There has been one allegation of abuse and this was appropriately managed following the homes abuse policy. Documentation evidenced this. There are no current concerns in this area. Staff and residents spoken to, say the manager is very approachable and understanding. Three residents said ‘I’ve nothing to complain about, it’s a lovely home”. 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. Since the last inspection all the staff have received training in the recognition and management of abuse. DS0000020337.V349279.R01.S.doc Version 5.2 Page 18 The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. Staff said they had never seen any signs of abuse in the home and demonstrated a good understanding of what abuse is. Staff said they have received training in the recognition and handling of abusive situations for the safeguarding of residents. This was verified during inspection of training records. Care plans inspected showed that consent for the use of bedrails had been obtained from residents or relatives thus safeguarding choice. It is recommended that the home consider how they are addressing consent issues under the Mental Capacity Act 2005. The main door to the home is double locked. Three relatives raised with us their concern about this both from a time point of view when they are visiting, and also in relation to the liberty of the residents. This issue was discussed with the management and we were assured that alternatives are being looked at. All residents spoken with said ‘the staff are very kind’. DS0000020337.V349279.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 19,22,26 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. Good infection control practices are followed to prevent residents from risk of cross infection. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation décor is homely. Residents’ rooms are personalised and comfortable. Since the last inspection maintenance and refurbishment plans and records are kept, to ensure the homes’ environment is maintained at a good standard. Two part time maintenance men are employed and at least one visits the home DS0000020337.V349279.R01.S.doc Version 5.2 Page 20 on a daily basis to ensure maintenance issues are dealt with, as soon as possible. This was verified in discussion with one of the men and on inspection of records. He also told us that he would visit the home if there were a maintenance problem at the weekend. On a tour of the premises we noted that secure storage space is now provided for mobility equipment on the ground floor and ensures a secure internal space. Hoists and other equipment in the home were seen to be stored in appropriate places to ensure a safe environment. 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 sluice areas have been cleaned up since the last inspection and new clinical waste bins installed to prevent the spread of infection. In the first floor bathroom the raised toilet seat was observed to having flaking paint and therefore pose a risk of harbouring infection, for spreading. There was also a trolley in this bathroom that had flaking paint. There were carpet rugs stored under it. These pose a potential risk of spreading infection. On touring the premises bed rails in two rooms were observed to be ill fitting and potentially put residents at risk of entrapment. In some cases bed rail bumpers were in use however the risk of entrapment was still possible. This was discussed with the manager. The home was clean and free from offensive odours throughout. The laundry facilities were well organised and a door guard has been fitted to the laundry door since the last inspection. Staff interviewed demonstrated good understanding of Infection Control procedures and practices and the use of personal protective equipment (PPE). Since the last inspection dispenser soap and paper towels have been installed in all communal areas for good hand washing practices to be followed. Alcohol gel is also provided in these areas and throughout the home. At points where this is provided there are posters about handwahsing and the importance of this and the use of the gel. Staff observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. DS0000020337.V349279.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are insufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff access training to enable them to provide safe and knowledgeable care to residents. EVIDENCE: Staff went about their duties in an unhurried manner and were observed spending time talking with residents. Residents reported, “staff make time for a chat when they can.” Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “ the staff are very good”. Copies of two weeks staffing rosters were seen. Staffing levels in the morning appear adequate to meet the needs of the residents. A team of ancillary staff supports them. In the afternoon staffing levels drop to three care staff. The manager is aware that current staffing levels are not sufficient to meet the dependency needs of the residents. She has instigated a short shift to cover the busy time of breakfast and getting up, and also in the evening to assist residents in getting to bed. No extra staff have been employed to fill these DS0000020337.V349279.R01.S.doc Version 5.2 Page 22 shifts, the manager asks the current staff team to do this, as and when they can. The rotas show that the shifts are not always filled and therefore staffing levels are poor and inadequate to meet residents’ needs. Feedback from resident and relatives’ surveys as well as interviews confirmed the lack of staff. One resident said, “you sometimes have to wait a long time when you want the toilet”. A few of the staff team employed at the home are from overseas. Residents and staff said, “they fit into the team well”. Recruitment procedures are robust and all three files inspected contained the required documentation. All staff interviewed stated they had contracts of employment and job descriptions. This was verified on inspection of recruitment records. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen in their personnel files. Since the last inspection the home provides in house mandatory training with clear records of attendance and renewal dates. Records inspected and staff interviewed verified they have received fire training, health and safety, food hygiene and handling, abuse and infection control. In one file evidence was seen of attendance at a Continence Management course. The home now views training as very important and almost half of the care staff have an NVQ qualification. Interviews with staff verified they had undertaken a wide range of training and had good knowledge with which to meet residents’ needs. DS0000020337.V349279.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 31,32,33,35,36,38 The management provide a happy and relaxed atmosphere to the home. Underpinning management structures have improved since the last inspection. Residents’ views are sought and acted on, and a formalised system has been developed. The management of resident’s monies are handled safely by the home. Health and safety issues are regularly monitored in the home and a safe environment is maintained. 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 her Registered Manager’s Award. Dr and Mrs Gupta are around daily in the home and support the manager in running the home. The management team have developed their DS0000020337.V349279.R01.S.doc Version 5.2 Page 24 knowledge and skills since the last inspection and give clear leadership and guidance to the staff. Staff interviewed said, “things have improved since the last inspection”. Staff interviewed stated that they felt well supported by an approachable manager. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Many 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 they are encouraged to develop their skills. Staff were enthusiastic about the training received. Since the last inspection the home has developed a formal quality assurance policy and system. New resident surveys have been developed and the manager told us that she would be distributing them in the coming months to obtain resident and relatives’ views to feed into the running of the home. 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, her deputy or one of the senior care staff. The system for this is now formalised but entries do not relate to areas of practice and the aims and objectives of the home to ensure best practice care is being provided. Supervision records were seen in the four staff files inspected. Staff interviewed verified that supervision takes place and “feel well support by the manager”. The home records and stored securely and used in accordance with the Data protection Act 1998. Information in some care plans inspected was incomplete. Records should be accurately maintained to ensure clear information for the provision of knowledgeable care to residents. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. Records indicating regular maintenance to gas and water systems were seen, together with servicing records for all equipment. Two health and safety hazards identified during a tour of the building were loose and ill fitting bed rails observed, and some ill-fitting fire doors. A current fire risk assessment has been undertaken and is in place for the safety of residents. DS0000020337.V349279.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 3 X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 1 DS0000020337.V349279.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP27 OP38 Regulation 18.1(a) 13.4 Requirement Timescale for action 10/11/07 That there are sufficient staff at all times to meet the health and welfare needs of residents. All bed rails are fitted correctly 30/11/07 to ensure the safety of residents. Previous timescale of 10/05/07 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 Refer to Standard OP3 OP7 OP9 OP15 Good Practice Recommendations To document the outcome of needs as to how the home can /cannot meet their needs. Attention to detail in recording care needs and actions to meet needs. All hand transcribed entries on the MAR sheets to have two signatures. The provision of a snack for residents in the evenings so DS0000020337.V349279.R01.S.doc Version 5.2 Page 27 that they are no without food for more than 12 hours. 5 6 7 OP26 To ensure bathroom areas can be adequately cleaned to prevent the spread of infection. To implement the Quality Assurance system developed. Supervision discussions to be linked to the aims and objectives of the home to ensure knowledgeable and competent staff. All written records are maintained up to date with full relevant information. OP33 OP36 8. OP37 DS0000020337.V349279.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000020337.V349279.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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