Inspection on 07/12/04 for Penlee

Care Home For Older PeoplePenlee56/57 Morrab Road Penzance Cornwall TR18 4EPAnnounced Inspection7th & 9th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Penlee Address 56/57 Morrab Road, Penzance, Cornwall, TR18 4EP Email address Name of registered provider(s)/company (if applicable) Mr Robert David Putterill Mrs Kathleen Mary Lucy Putterill Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 22 Tel No: 01736 364102 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (6), Mental Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (22) Registration number D040000194 Date first registered Date of latest registration certificate 25th May 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 25th June 2003 YES NO 4/05/04 If Yes refer to Part CPenleePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 37th December 2004 09:30 am Richard CoatesID Code075480Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr R Putterill Mrs K PutterillPenleePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementPenleePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Penlee. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.PenleePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Penlee is a substantial Victorian building formed from two houses in a terrace. It is situated in Morrab Road, a pleasant residential area between the town centre and the promenade, and next to Penlee park, a popular public amenity. Penlee is close to local GP surgeries and to Penzance Public Library. Pengarth day centre is nearby. Penlee offers full personal care and residential accommodation to older people. The owners, Mr and Mrs R. Putterill live on the premises. The home is registered to provide accommodation for 22 older persons including six who may have dementia or a mental disorder, which is not learning disability. There are 18 single rooms and two double rooms. However, 18 rooms are in regular use as Mr and Mrs Putterill reside on the top floor. The providers intend that a double room would only be used as a double for two partners or relatives. The provider describes the aims, services and facilities clearly in the Statement of Purpose. The home sets out to provide a high quality service that responds to individual needs and preferences. Mr and Mrs Putterill are generally able to take their residents to hospital and medical appointments.PenleePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)PenleePage 6 This announced inspection took place over two weekdays. The inspection was facilitated by the kind assistance of the registered providers, staff and service users. The last inspection was unannounced and as carried out on 4 May 2004. The report for that inspection set three requirements and three recommendations. The providers have since met two of the requirements and all of the recommendations. The outstanding requirement has been renotified in this report. This inspection report includes those standards not inspected in May and some key standards which are reported on again. This inspection sets one requirement and three recommendations. 1 Choice of Home (Standards 1-6) Five standards were met; one standard does not apply. The home has a well-presented statement of purpose and service users guide, which comply with the standard and regulations. The providers had drawn up statements of terms and conditions with recently admitted service users. Records sampled for these recently admitted service users contained detailed needs assessments, risk assessments, admission records and records of preferences. Service users discussed with the inspector the visits they had made to the home to assist their choice. 2 Health and Personal Care (Standards 7-11) Four standards were met; one standard was not assessed. All service users have detailed care plans which advise, inform and direct care staff. These care plans contain risk assessments which address, for example, where service users have had falls. Service users made positive comments about the skills and sensitivity of staff and felt that staff respected their privacy and dignity. The arrangements and procedures for the handling of medicines comply with the standard. 3 Daily Life and Social Activities (Standards 12-15) One standard was assessed and met. Service users made positive comments about the standard of meals and catering. The inspector joined service users for a well-presented and appetising lunch. Nutritional screening is carried out and care plans include plans for healthy eating. 4 Complaints and Protection (Standards 16-18) One standard was assessed and met. A number of service users manage their own affairs; other service users have made arrangements for family or representatives to manage their finances. Service users informed the inspector that they had a postal vote. 5 Environment (Standards 19-26) These standards were included in the last unannounced inspection report. 6 Staffing (Standards 27-30) Three standards were met; one was commendable. Staffing levels have been maintained as set by the previous regulator. An activities worker has been introduced. The level of qualification of staff at NVQ 2 and above exceeds the requirement. Records of recent recruitment complied with the standard and regulations. The arrangements for training appear well organised and the induction complies with the specification of The Training Organisation for the Personal Social Services. Records sampled detailed the provision of training in required areas.PenleePage 7 7 Management and Administration (Standards 31-38) Six standards were met; two were not met. Mrs Putterill has achieved the registered managers award and exceeds the experience requirement to run the home. The providers have introduced a number of systems for quality assurance. They have not yet made the results available to current and prospective service users and their representatives. There is an annual financial plan and the insurance certificate is displayed. The inspector examined the records of personal allowances and money held for safe keeping for service users. These were satisfactory. Records indicate that staff are receiving supervision as required by the standard. The homes records comply with the standard and regulations except that there is no record of visitors to the home. Recent reports by the Environmental Health Officer on health and safety and food hygiene required no action to be taken. Records sampled showed that required maintenance and safety checks are carried out.PenleePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)PenleePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 17(2) Schedule 4.17 OP37 The registered person must retain a record of visitors to the home. (Third notification) 31.03.05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 OP33 OP37 OP29 The results of quality assurance exercises should be made available to current and prospective service users, and their representatives. Staff should sign all records with a full signature. Application forms for employment should require a health declaration.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. Penlee Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO YES YES YES YES NO NO YES YES YES YES YES YES NO NO NO YES NO YES 8 2 0 NA NA YES YES 11 X 7/12/04 09:30 9.5PenleePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.PenleePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 260.00 To (£) 330.00Any charges for extrasNOIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? An up to date statement of purpose was provided following additions required at the last inspection. The service users guide consists of the statement of purpose, complaints procedure and individual terms and conditions. Service users confirmed that they had received information material. The certificate of registration is displayed in the entrance hall. The certificate reflected the current situation in the home. Evidence: inspection of statement of purpose and service users guide, and certificate of registration, discussion with registered persons.PenleePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The inspector examined copies of statements of terms and conditions provided to recently admitted service users. These complied with the standard. The service users discussed their contracts with the inspector and stated that they were satisfied with the arrangements. Evidence: inspection of statements of terms and conditions, discussion with service users. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector case tracked three service users. Two of these had been admitted recently. The records contained needs assessments, risk assessments, moving and handling assessments and nutritional screening. All records were appropriately completed and signed and dated. All service users have a care plan. The registered persons also complete an admission information record and a residents preferences record. Evidence: inspection of assessment records and care plans, discussion with registered persons. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The registered persons discussed their determination that the home should be able to meet the needs of all service users admitted. The care plans are detailed, with thorough evaluations, and provide guidance, information and direction to staff for meeting the assessed needs of service users. There is evidence that the providers actively reflect on their practice and the service provided. Assessments and care plans for service users with dementia (category DE) demonstrate the homes capacity to meet the service users needs. The staffs have a high level of qualification at NVQ 2 and NVQ 3. Service users made positive comments about the care and support that they receive and the kindness of the providers and staff. Evidence: inspection of records, discussion with registered persons, staff and service users.PenleePage 14 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The two service users who were admitted recently discussed with the inspector their visits to Penlee and to other care homes. Both service users felt that they had made a positive choice. Contacts with prospective service users are recorded on an enquiry form. All admissions are on a trial basis. Evidence: inspection of records, discussion with registered persons and service users. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Penlee does not provide this service.PenleePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The records case tracked by the inspector provided detailed care plans. These are drawn up for each service user as specific plans in each area of assessed need and risk. Each plan is dated and signed and details the area of care, the objectives and the intervention required, and records monthly evaluations. The plans and evaluations clearly detail the changing needs of the service user and specific occurrences, and the interventions made. For example, the plan for one service user provided care staff with detailed guidance on how to support the service user in her memory loss. Service users sign their care plans. Service users discussed their care plans and monthly review with the registered person with the inspector. Care plans include risk management strategies. Daily notes are recorded consistently and are factual and dated. Some staff are initialling these notes rather than providing a full signature. The registered person is aware of this and will raise the issue with staff again. Evidence: inspection of care plan records, discussion with registered persons and service users.PenleePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence Not inspected on this occasion. X X Standard met? 0Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Four service users are currently administering their own medication. A standard agreement is drawn up for this arrangement. Three service users take no medication. The home uses the Boots monitored dosage system and the medicine storage is a locked cupboard in the utility room. The inspector examined the storage facility and the medication administration records. The policy and procedure was revised after the last inspection. The registered persons retain patient information leaflets in a specific folder. The medication administration records were consistently signed. Amendments to dosages were noted, dated and referenced to the prescribing GP. The storage facility was well ordered with no accumulation of excess or out of date medicines. Eye drops were the only medicines currently requiring storage in the refrigerator. The home has limited amounts of controlled drugs at present. It would be good practice for these to be stored in a controlled drugs cabinet meeting the required standard. If the home were to store a wider range and greater amounts of controlled drugs, the registered persons would need to review this matter. A check on stocks of controlled drugs against the administration record proved accurate. Mrs Putterill takes the lead on training and supervision of the handling of medicines and is aware of the issues. All staff, except one currently in training, have completed the Boots course in the safe handling of medicines. The most recent visit from the pharmacist for advice was on 29.11.04. Evidence: inspection of medication administration records, self-administration agreements, storage facility, staff training records, discussion with registered persons.PenleePage 17 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Service users stated that staff respected their privacy and dignity. They felt that staff were competent and delivered care sensitively. Service users reported that staff knock on service users doors before entering the room. Care plans take note of service users preferences. A number of service users have their own telephone in their rooms. Service users can also use the telephone in the small conservatory, which is a quiet room. Staff address service users by their preferred names and there is a relaxed and informal atmosphere. Friends, relatives and advisors can visit at all reasonable times. Service users can see visitors in their own rooms or in the communal areas. The small conservatory is available if required for private discussions. One visitor reported that she was always well received and the staff assisted her to spend undisturbed time with her friend. All rooms are single. Evidence: discussion with registered persons, service users and visitors, observation, inspection of premises, care plans. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The home has a policy and procedure on the care of dying service users. There is evidence that service users wishes and preferences in respect of care and death are recorded. Mrs Putterill has recently completed a course in palliative care. The providers aim is for service users who are dying to be cared for in their own room, with support from other agencies such as the community nurses, and for family to be involved where this is the service users wish. The providers discussed care delivered recently where the community nurses provided support and necessary equipment, and the family were able to visit as they required. Evidence: inspection of documents, discussion with registered persons.PenleePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not inspected on this occasion.PenleePage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home provides three meals daily and a flexible supper drink and snack. The service users made consistently positive comments about the quality and content of the food and the standard of catering. The menu records a varied and wholesome diet. A range of choices is provided for breakfast, which is taken at the individuals preferred time. The main meal is served at midday. The inspector joined the service users in the dining room for lunch. The dining room is spacious and tables have clean linen tablecloths and napkins. The meal was well presented and appetising, and was enjoyed by the service users. The service users were unrushed and care staff provided appropriate individual attention. A choice of savoury dishes is served for tea. Some service users take this in the dining room, others prefer to eat in their own rooms. The registered providers complete nutritional screening assessments, and record preferences for all service users. Where appropriate, care plans include healthy eating plans. No service users currently require assistance with eating, although some find it helpful to have their food cut up. The home can meet individual dietary requirements. Evidence: inspection of menu, pre-inspection questionnaire, nutritional screening assessments and care plans, discussion with registered persons, cook and service users, observation, joining service users for lunch.PenleePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not inspected on this occasion. 0 0 0 0 0 0 X 0Standard met?PenleePage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The registered persons discussed the various arrangements that service users have in place for managing their financial affairs. Service users also discussed this issue with the inspector. A number of service users continue to manage their affairs; others have made arrangements for family to have power of attorney. The registered persons are aware of the issues in respect of capacity and advocacy. Service users informed the inspector that they have arranged postal votes. A service user who had been recently admitted stated that he had would use a postal vote. Evidence: discussion with registered persons and service users, inspection of records, preinspection questionnaire. Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Not inspected on this occasion. Standard met? YES 0 0PenleePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? The environmental standards were included in the last unannounced inspection report. Since that inspection, the lounge has been redecorated and the kitchen cabinets and work surfaces have been refurbished and replaced. The utility room/staff room has been refurbished, with some work remaining to be completed. New gas boilers for heating and hot water have been installed. There has been work to improve the outside rear guttering. The re-painting of the outside of the building is planned for next spring. The provider also intends to replace the call system and all the radiator control valves next year.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not inspected on this occasion.PenleePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.PenleePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence Not inspected on this occasion. YES NO NO X X X X Standard met? 0 X XX X X XPenleePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? Not inspected on this occasion.PenleePage 26 PenleePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 0 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 6 12 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 11 33 Key findings/Evidence Standard met? The residential forum model for calculating staffing levels does not apply as Penlee was registered at 31 March 2002. The roster shows that staffing has been maintained at levels set by the previous regulatory authority. The registered providers live on the premises. In addition to the providers, two care staff are on duty during the day. At night there is one waking staff and the registered persons are on call in the building. The roster also details the duties of the two cooks and the domestic assistant. The providers have introduced an activity worker for two afternoons a week. There were no staff currently under eighteen years of age and no vacancies. Evidence: inspection of staff roster, discussion with registered persons and staff. Penlee Page 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 8 80 4 Key findings/Evidence Standard met? One senior carer is training as an assessor for staff undertaking NVQ. Mrs Putterill is an NVQ assessor. The providers do not employ agency staff. One member of staff has recently completed induction based on the Training Organisation for the Personal Social Services standards and has moved on to training in NVQ level 2. Eight of the ten care staff are qualified at NVQ level 2 or above. Evidence: inspection of staff records, induction records, discussion with registered persons and staff, pre-inspection questionnaire. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home has an equal opportunities policy. The inspector examined the records for two recently recruited staff. These contained all the required documentation, including application forms and two references, and material for the confirmation of identity. CRB disclosures were on file for both workers. Staff confirmed that they had received the General Social Care Council Code of Practice for social care workers and employers. The provider issues staff with terms and conditions of employment, and copies of these were on file. Evidence: inspection of documents and records, discussion with registered persons and staff.PenleePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home provides induction training based on the Training Organisation for the Personal Social Services specification. The providers practice is to register staff for NVQ 2 promptly following induction. The staff here have a high level of NVQ qualification. There are arrangements in place for training in food hygiene, moving and handling and first aid. The records for a recently appointed member of staff showed that she had completed training in food hygiene and moving and handling as part of her induction. A member of staff discussed with the inspector a course on Parkinsons disease that she had recently attended. One of the senior carers is currently training to be an NVQ assessor. Training days are recorded on the staff roster. It is recommended that, where newly appointed care staff hold an NVQ at level 2 in care, the home evidences that they are working at this level through recorded assessment of care practice and recorded supervision. Evidence: inspection of training records, discussion with registered persons and staff, preinspection questionnaire.PenleePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Mrs Putterill has the NVQ 4 registered managers qualification and exceeds the experience requirement. During this year she has completed a course in palliative care, a course in communication run by Mount Edgecumbe Hospice, and attended a multi-disciplinary symposium on dementia. Mr Putterill is completing an NVQ level 3. There are clear lines of accountability within the home. Evidence: discussion with registered persons, inspection of records.PenleePage 31 Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The staff reported that, through living on the premises, the registered providers maintain regular contact with all staff and service users. The providers want to be kept informed about all relevant matters arising during the staffs work. Staff felt that the providers communicate direction and leadership, and set clear standards for the care and services provided. Staff reported that they had received the General Social Care Council Code of Practice. Service users have great confidence in the providers and made positive comments about the kindness and support they received from them. One service user discussed his individual private conversations with the registered person about his care plan. There is a programme of individual staff supervision, but, currently, not regular staff meetings. It is recommended that the providers review this. It is accepted that the registered persons living on the premises results in them having regular and close contact with all the staff and service users. Evidence: inspection of records, discussion with registered persons, staff and service users. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The providers are carrying out the following quality assurance and monitoring exercises: - a bi-monthly premises audit which generates an action plan for development and maintenance and refurbishment; - a regular recorded individual review with each service user of their views on the care and services provided; - an assessment form for visitors and relatives, - monthly care plan reviews with each service user. The poster for the inspection was conspicuously displayed. The providers have not yet made the results of their quality surveys available to current and prospective service users and their representatives. Evidence: inspection of records, discussion with registered persons and service users.PenleePage 32 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The registered persons draw up a financial plan for the home each year with planned expenditure under identified budget headings. Outcomes of actual expenditure against targets are monitored through the year. Mr Putterill completes the accounts for the home. There is evidence of continuing refurbishment, improvements and the purchase of replacement items. Recent examples include the installation of new gas boilers for hot water and heating, and the purchase of new freezers, washing machines and dryer. See also the details of work done and further work planned in standard 19. The insurance is with Norwich Union and expires on 4 March 2005. Evidence: inspection of records and premises, discussion with registered persons. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? A number of service users control their own money. Others have set up arrangements with their family or representatives. Mr Putterill acts as agent, for a number of service users and collects their pensions. This information was set out in the pre-inspection questionnaire. There is a facility for the safe keeping of service users money. The registered persons maintain a balance sheet for each service user which records the balance of money held for safe keeping, personal allowances, regular expenditure and cash taken by the service user. Transactions are signed. The balances are held as cash for each individual. Service users have savings accounts. The registered persons record inventories of belongings for each service user at admission. Evidence: inspection of records, discussion with registered persons and service users, preinspection questionnaire.PenleePage 33 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The inspector examined staff records which included records of two-monthly supervision sessions. These comply with the standard. The staff discussed the arrangements for their supervision with the inspector. There is a preference for individual supervision and handovers between care teams, rather than formal staff meetings. It is recommended that the registered providers review this. Evidence: inspection of records, discussion with registered persons and staff. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The records for service users comply with Schedule 3. The staff records generally comply with Schedule 2, although the employment application form lacks a declaration in respect of health. Records are up to date, in good order and well maintained. The inspector examined: - samples of inventories of belongings, - the statement of purpose, - the menu, - the accident record which complies with the Data Protection Act, - the records of safe keeping of service users money. The home lacks a record of visitors. Evidence: inspection of records, discussion with registered persons.PenleePage 34 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The pre-inspection questionnaire provided a list of required maintenance and safety records. The inspector checked a sample against the original and found these accurate. The Environmental Health Officer visited on 16 February 2004. The report for health and safety states that the standard was high and no action was required. The report for food hygiene sets no required action and states that hazard analysis was in place. Policies, procedures and guidance are posted in the kitchen. Refrigerator and freezer temperatures are recorded daily. There are individual risk assessments for service users as part of their care plans. Accidents are recorded in an appropriate format. Accidents to service users are addressed in risk assessment and care planning. First aiders are identified on the notice board. There is a policy and procedure in place for Legionella. The newly installed boilers provide hot water on demand which reduces the risk from stored hot water. Staff discussed the infection control systems. Liquid anti-septic soap is provided at staff hand washing points. The use of paper towels at these areas would improve infection control. There are adequate supplies of gloves and aprons. There is a system for the disposal of continence items. Staff clean the shower with anti-bacterial spray. The washing machine has required hot and disinfection cycles. The few commodes in use are disinfected daily. The home is kept clean and hygienic. Bathrooms, toilets and en-suite facilities are clean and hygienic. The homes fire risk assessment is satisfactory. The inspector examined the records of regular staff fire training, tests of the fire alarms and emergency lighting and the inspection of extinguishers. Evidence: inspection of records, Environmental Health Officer reports, pre-inspection questionnaire , discussion with registered persons and staff, inspection of premises.PenleePage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateR J Coates J McEachern 15 December 2004Signature Signature SignaturePenleePage 36 Public reports It should be noted that all CSCI inspection reports are public documents.PenleePage 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 7 and 9 December 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possiblePenleePage 38 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 14 January 2005 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here PenleePage 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I K Putterill / R Putterill of Penlee confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I K Putterill / R Putterill of Penlee am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.PenleePage 40 Penlee / 7th & 9th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000008917.V188091.R01© This report may only be used in its entirety. 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