Inspection on 04/07/07 for Penmeneth House

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Penmeneth House 27/06/08

Penmeneth House 06/07/06

Penmeneth House 20/10/05

Penmeneth House 19/05/05

Penmeneth House 07/10/04

Penmeneth House 15/04/04

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 Penmeneth House 16 Penpol Avenue Hayle Cornwall TR27 4NQ Lead Inspector Ian Wright Unannounced Inspection 10:00 4th July 2007 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 Penmeneth House DS0000009128.V342697.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. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penmeneth House Address 16 Penpol Avenue Hayle Cornwall TR27 4NQ 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) 01736 752359 Mr Philip John Richards Mrs Felicity Ann Richards Care Home 14 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (14) Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: Penmeneth is situated in Hayle, West Cornwall. The property provides care and support for up to 14 elderly people. The home offers residential care for up to fourteen elderly people, one of whom could have dementia and one a mental disorder. Accommodation is provided on two floors, the first floor can be accessed by a stair lift. There are three smoke free lounges, and there is a small-seated area adjacent to one of the corridors. There is a small garden to the front of the home and a courtyard at the back with bench seating. There is limited roadside car parking. Wheelchair accessibility is very limited. The registered providers Mr and Mrs Richards- live nearby, and are in control of the day-to-day running of the home. A copy of the inspection report is available from the registered providers, and it is suggested a copy is requested from management or obtained via the CSCI website if required. The range of fees at the time of the inspection is £310£359 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection took place over eight hours in one day. All of the Key Standards were inspected. The methodology used for this inspection was: • To case track four people who use the service. This included, where possible, interviewing the people who use the service about their experiences, and inspecting their records. • Interviewing two staff about their experiences working in the home. • Informal discussion with other people who use the service and staff. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: This inspection has resulted in eleven statutory requirements. These must be actioned by the registered provider within the timescales set: In summary: • Assessment procedures must be improved, so only people for whom the registered providers are legally registered to provide care for, are accommodated. • Care planning processes must be improved; for example everyone must have a care plan. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 6 • • • • • Medication practices must be improved. For example regarding the recording of medication. Staff training in this area also needs improvement. There must be a bathing facility on the first floor of the home. Staff recruitment practices must be improved, and documentation required by law in this area must be available for inspection. Staff induction and training must be improved, so staff receive the training they require by law Quality assurance procedures need improving so there are satisfactory processes to ensure continuous improvement and compliance with regulatory requirements. 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. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered provider has developed a contract / statement of terms and conditions of residency. These documents have been issued to people who use the service. The provision of suitable information ensures people who use the service are aware of the services the registered provider offers. This information also helps ensure people who use the service are made aware of their rights and responsibilities. The registered provider does not have a satisfactory assessment procedure. There is not suitable evidence that people who use the service have been assessed appropriately before admission is arranged. There is significant failure of the registered provider to adhere to the agreed registration categories. Subsequently people are being admitted to the home for whom the registered provider is not legally able to provide care for. Suitable assessment procedures ensure the registered provider only accommodates people for whom they are able to meet their needs. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 9 EVIDENCE: Files for people who live in the home were inspected. Each person has a copy of the home’s statement of terms and conditions of residency / contract, and/ or a copy of a contract issued by the Department of Adult Social Care (social services) where this is applicable. The registered provider said the people who use the service have a copy of this documentation. The inspector is concerned regarding the registered provider’s assessment processes. The assessment policy is not adequate in outlining how the assessment process should take place. Where pre admission assessments have been completed by the registered provider, these are often very basic and do not contain sufficient or accurate detail regarding the person’s needs. There appeared to be no assessment for at least one person who uses the service, who has been admitted to the home since the last inspection in June 2006. The registered provider has however, in many cases, obtained a copy of an assessment completed by Cornwall Adult Social Care (social services). At least five social services assessments stated that these people had a diagnosis of dementia. The registered provider is however only registered to provide accommodation and support to one person with dementia, and a second person that has mental disorder (mental health problems). Some of the people who use the service, who the inspector spoke to, remembered a senior member of staff completing an assessment before they moved to the home. Some people who use the service said they were able to visit the home before moving in, and others said a relative visited on their behalf. People who use the service said they were happy with the care provided, and they appeared to be well cared for. Most staff have received some basic training regarding dementia awareness. CSCI has written to the registered provider to state they must only admit people for whom they are registered to provide care for. CSCI has also written to the Department of Adult Social Care as they may wish to reassess some of the people who live in the home to check their needs are being fully met. The registered provider must provide to CSCI a list of the current people who use the service. This must outline what diagnosis they have, and briefly outline individuals’ needs. The service does not provide intermediate care. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning process is not satisfactory as not every person who uses the service has a care plan. Although acceptable, information in care plans could be more detailed. Suitable care plans help to ensure people who use the service receive all the care they need in a consistent manner. There is suitable evidence that staff ensure health care needs are met. Improvement is required to the medication system – for example regarding recording and administration of medication- so people who use the service can be assured their medication is managed to a satisfactory standard. People who use the service said they felt staff generally worked with them in a manner, which respected their privacy and dignity. However one matter regarding the conduct of a member of staff was referred to the registered provider to investigate. EVIDENCE: Care plans for some people who use the service were inspected. These are basic, could contain more detail but are acceptable. There were not care plans for some people who use the service i.e. the inspector could only find care Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 11 plans for eight people although there are currently fourteen people who live at the home. Care plans appear to be reviewed at least twice a year, and the review appears to be reasonably detailed i.e. outlining key issues which are of current relevance / concern. There is a manual handling assessment for each person who lives at the home. Care plans are accessible to staff. Although some people who use the service did not appear to be aware of their care plans, all service users said the care they received was appropriate and carried out in a manner according to their wishes and needs. Health care support appears to be satisfactory. People who use the service said they could see a doctor or other medical practitioner when this is necessary. The inspector spoke to a district nurse who said, in their view, care was satisfactory. The medication system was inspected. Medication is stored in locked cupboards and administered via a monitored dosage system. The operation of the system is only adequate. Several errors in the administration and recording of medication were noted during the inspection: • Dosages of medication administered to several people who use the service were not signed for, although they did appear to be administered. • Two dosages of medication had not been administered although had been signed for to state they had been administered. • One item of medication for one person who uses the service was not labelled • Medication for one person who uses the service had been put in a dosset. This must only be administered via a monitored dosage system or from original containers. Training records show some staff have received training regarding the administration of medication. However as this was last completed in 2003, staff should now receive an update. People who use the service spoke positively regarding the attitude of staff, and said staff respected their privacy and dignity. Staff appeared to work with people who use the service, in a positive manner. However one person said a member of staff, sometimes raised their voice to people, and could be intolerant. However the person would not name the member of staff. The matter was discussed with the registered provider who said they would investigate the matter. The inspector has requested a copy of the report of any investigation outlining any action, which is taken. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines are satisfactory so people who use the service can live a suitable lifestyle. Visiting arrangements are flexible. Arrangements to assist people who use the service with their finances are satisfactory. Meals are provided to a good standard, so people who use the service can receive a wholesome and nutritious diet. EVIDENCE: People who use the service said they could get up and go to bed when they wished. Most of people who use the service spend the majority of their time in one of the lounges. The registered provider said people who use the service could spend time in their bedrooms if they wish. There are also two other lounges, and a small quiet area where people can spend their time. There are some organised activities for example bingo and various board games. An organist also visits the home. Some people who use the service also attend a day centre. Currently the library does not visit the home. People who use the service said they could receive visitors when they wished. The inspectors spoke to several friends and relatives of people who live in the home, who said they felt the home offered a good service. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 13 The registered provider assists with the management of money for some people living in the home. Records kept are satisfactory. Otherwise people who live in the home either look after their own monies or these are managed by their relatives / legal representatives e.g. via power of attorney arrangements. People who live in the home said they were able to bring small items of furniture and their belongings when they moved in. People living in the home said they enjoyed the food provided. The main meal is provided at lunch time, and a choice of a hot and cold evening tea is offered. Suitable records of menus are maintained. Special diets (e.g. pureed meals) are provided as required. Although a choice of main meal is not provided, people who live in the home said staff were aware of preferences, and an alternative is provided where necessary. The inspector shared a meal with people who live in the home, and this was to a good standard. Support provided at the mealtime was good, and the meal was a sociable occasion. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 14 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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered providers have suitable procedures regarding complaints and adult protection. Subsequently people who use the service can be assured there are appropriate procedures, which should ensure concerns or bad practice, are dealt with appropriately. EVIDENCE: The registered provider has acceptable procedures regarding complaints and adult protection. Staff and people who use the service showed some awareness of the procedures, and were able to say whom they would approach if they had a complaint or were concerned about abuse. Most staff have attended adult protection training. Most staff and people who live in the home said they had not witnessed any abusive practices. However one person was concerned about the attitude of a member of staff, as outlined previously, and the owner said they would investigate this issue. All staff have Criminal Record Bureau check, and a Protection of Vulnerable Adults check (where applicable). Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 15 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): 19, 21, 26 Quality in this outcome area is generally good although improvement is required to the bathroom facilities. This judgement has been made using available evidence including a visit to this service. Penmeneth provides a pleasant, homely, clean and well-maintained environment for people to live and feel at home in. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. There is a small but pleasant garden, which people who live in the home can use. All communal rooms are homely and comfortable. There are three lounges, and a quiet alcove area in one of the corridors. People who live in the home have their meals in the lounge / dining area at the rear of the home. The middle lounge has a sign on the door stating it is a staff room. However apart from the storage of some files in one of the cupboards, the room is used by people who live in the home. Therefore the sign should be removed. The owner Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 16 said he would do this. The labels of people’s names on dining room chairs as these are unsightly and infantilise people. Bedrooms are individualised and comfortable. A stair lift is provided to assist people to go upstairs. All decorations are maintained to a very high standard, and are fresh, homely and pleasant. There is a ‘Parker’ bath facility on the ground floor, which offers a good facility particularly for those who are frail or have a mobility problem. However the upstairs bathroom has been converted to a sleep in bedroom for staff. The registered provider said this was done, as the bathing facility was not used. However this has resulted in there not being a bathroom on the first floor of the home. Staff and the registered providers do not feel this is a problem as people who live in the home tend to bathe in the evening before going to bed, rather than being put to the inconvenience of having to go downstairs first thing in the morning. However, there needs to be a facility on the first floor, for example if a service user is incontinent, the current facilities could result in inconvenience and difficulty. People who live in the home also should be given a choice where to bathe. It is suggested it would be useful to at least have a shower or ‘wet’ room on the first floor. All toilets are satisfactory, however one of the locks on one of the toilet doors is broken. The owner said he would fix this. Suitable kitchen and laundry facilities are provided. Cleaning staff are employed, and the home was clean and hygienic at the time of inspection. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear satisfactory so people living in the home can be assured they will receive satisfactory levels of staff support. Recruitment records still need improvement so people living in the home can be assured there are suitable recruitment procedures and checks in place. Staff training provision needs improvement so staff receive appropriate training as required by regulation. This will assure people living in the home, that staff have suitable skills and knowledge to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: On the day of the inspection rotas show two members of staff were on duty from 0800 to 1500, and two staff on duty from 1500 to 2200. There is one waking night staff on duty from 2200 to 0800, and one member of staff sleeping in. Both of the registered providers work in the home at least five days per week assist staff with providing care. A cleaner is also employed. People who live in the home spoke positively regarding the staff and registered providers. Comments included that they were ‘marvellous’, ‘really nice, very kind’. The registered providers have a suitable approach to providing National Vocational Qualifications for care staff. Staff training required by regulation needs some improvement. Since the last inspection staff have received first aid Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 18 training and moving and handling training. However there are gaps in the delivery of fire training, infection control training and food handling training. Staff who have received training regarding food handling and handling medication now need an update as both these training courses were last delivered in 2003. The requirement made in the inspection report dated 6th July 2006 is therefore renotified. Recruitment records were inspected. Most staff have been employed for some time. However one member of staff had been employed in May 2006, and this person’s records were only adequate. For example there was not a copy of an application form, no written references and no records of staff induction. The person had only received limited training for example regarding administration of medicines and first aid. A Criminal Records Bureau disclosure had however been received. The previous requirement made in the inspection report dated 6th July 2006 is therefore renotified. The registered provider’s approach to equal opportunities and anti discrimination is satisfactory. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered providers appear to be suitably experienced to manage the home. Quality assurance processes however need improvement so people who live in the home can be assured there are systems in place to ensure continuous improvement, and regulatory requirements are met. The registered providers approach to handling service users monies is satisfactory, so people who live in the home can be assured their financial interests are safeguarded, where the registered providers are involved in this area of their lives. The management of health and safety issues is good so people who live in the home can be assured they live in a safe environment EVIDENCE: The registered providers appear caring and approachable. The staff, the inspector spoke to, say the providers were good to work for, and provided Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 20 sufficient guidance and support to help them to do their jobs. The providers work day to day in the home and have a good knowledge of people who live in the home. People who live in the home and their relatives, who the inspector was able to speak to, were positive about the registered providers approach. Quality assurance processes however need improvement. For example their needs to be satisfactory systems in place to ensure regulatory requirements are met. A survey of stakeholder views was last completed in 2004, and this should be recompleted. Formal written notifications need to be provided to CSCI for example of deaths, or any events which affect the well-being of any person who lives in the home. (A full list of notifiable events is outlined in the regulation). The registered providers look after some monies on behalf of people who live in the home. Suitable records are maintained regarding these. The registered provider acts as agent for one person’s government financial benefits for which suitable records are kept. The registered provider has a health and safety policy. Records kept of checks required by regulation are satisfactory. For example there are suitable records of the testing of fire equipment, gas and electrical appliances and the electrical hardwire circuit. Accident records are suitably maintained. Health and safety risk assessments are satisfactory. There is a suitable risk assessment regarding the prevention of Legionella, and appropriate control measures are in place. There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 21 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 X 3 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 2 3 Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so: (a) the needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user. 2. OP1 OP3 OP4 4, 12, 14 The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. The registered person shall not provide accommodation to service users unless their needs have been assessed by a suitably qualified or suitably DS0000009128.V342697.R01.S.doc Timescale for action 01/08/07 04/07/07 Penmeneth House Version 5.2 Page 23 trained person. ( For example: (a) Accommodation and care must only be provided to the type and number of service users as outlined on the CSCI registration certificate. Immediate Requirement (b) The registered provider must provide to CSCI a list of the current service users outlining their needs and diagnoses at the time of admission to the home.) Please provide this information no later than 01/08/07 3. OP7 15. The registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. 01/09/07 4. OP9 13(2) Care plans need to: • Be prepared for every service user accommodated. • Be kept under review • Be available to the service user. • Aim to involve the service user and their representatives, by consulting them regarding the development of care plans and any revision. The registered person shall make 01/08/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of DS0000009128.V342697.R01.S.doc Version 5.2 Page 24 Penmeneth House medicines received into the care home. (For example: • Medication must always be signed for when administered. (Previous timescale of 01/08/06 not met) 2nd Notification • Must not be signed for if refused or not required. [Any reason for non administration should be for example be detailed on e.g. the back of the medication sheet.] Clearly labelled and only administered to the service user it is prescribed for. Only administered from containers received from e.g. the pharmacist. ) 01/09/07 • • 5. OP10 OP18 12(5)(b) The registered provider shall, in relation to the conduct of the care home— (a) maintain good personal and professional relationships with each other and with service users and staff; and encourage and assist staff to maintain good personal and professional relationships with service users. (For example the registered provider must investigate the allegation of the member of staff who had a poor attitude as outlined in the body of the report. The provider must write to the Commission with the outcome of the investigation, Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 25 (b) 6. OP21 23(2)(j) and outline what action, if any, is taken). 01/01/08 The registered person shall having regard to the number and needs of the service users ensure that there suitable numbers and types of baths and showers fitted ( For example the registered provider must provide a suitable bathing facility on the first floor.) Previous timescale of 01/07/07 not met 2nd Notification The registered provider shall not 01/08/07 employ a person to work at the care home unless: (a) The person is fit to work at the care home; (b) The registered provider has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2 (for example two references, the persons employment history, proof of identity and a statement by the person as to their mental and physical health.) Previous timescale of 01/08/06 not met. 2nd Notification The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. This must include suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (For example such training must include training as required by regulation such as infection DS0000009128.V342697.R01.S.doc 7. OP29 19(1) Schedule 2 8. OP29 18. 19 01/01/08 Penmeneth House Version 5.2 Page 26 9. OP29 18. 19 10. OP33 24(1) control, food hygiene, fire training, manual handling training and first aid. [Previous timescale of 01/12/06 not met] 2nd Notification The registered person shall ensure that the persons employed by the registered person to work at the care home receive suitable structured induction training. Suitable records must be maintained regarding this. [Previous timescale of 01/12/06 not met] 2nd Notification The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. 01/08/07 01/10/07 11. OP37 37 The registered person shall give 01/08/07 notice to the Commission without delay of the occurrence of matters required in this regulation. Any notification made in accordance with this regulation, which is given orally, shall be confirmed in writing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Penmeneth House DS0000009128.V342697.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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