Inspection on 19/10/05 for Penn House

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Penn House 02/12/09

Penn House 11/12/08

Penn House 19/12/07

Penn House 20/12/06

Penn House 11/01/06

Penn House 09/11/04

Penn House 01/03/04

Penn House 01/03/04

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

CARE HOME ADULTS 18-65 Penn House The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 ORJ Lead Inspector Barbara Mulligan Unannounced Inspection 11.00a 19 October 2005. th Penn House DS0000023006.V252419.R01.S.doc Version 5.0 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 Penn House DS0000023006.V252419.R01.S.doc Version 5.0 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 Adults 18-65. 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. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Penn House Address 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) The National Society For Epilepsy Chesham Lane Chalfont St Peter Gerrards Cross Bucks SL9 ORJ 01494 601435 The National Society for Epilepsy Mrs Kaye Bailey Care Home 22 Category(ies) of Physical disability (22) registration, with number of places Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Provision of respite care for service users. Date of last inspection 9th November 2004 Brief Description of the Service: The National Society for Epilepsy is an independent registered charity that is administered by a Board of Governors who oversee the running of the Chalfont Society. The centre is located on a large rural site on the edge of the village of Chalfont St Peter. It consists of residential houses, a supported living project, a number of workshops and sites for daytime activities, an assessment unit which is an NHS provision, and additional services including a chapel, a restaurant, central kitchens and laundry, a small shop run by service users, administrative buildings and staff accommodation. Penn House is one of the residential houses and provides twenty-four hour residential care for up to twenty-two adults. The home is divided into five ‘flats’ and is situated centrally on the site. Attractive, open, grassy areas surround the house. It has no private garden of its own but there is a small area at the front with benches and tubs of flowers. There is access to public transport and this is used by service users living in the home. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 19th October 2005 at 11.00am on a Wednesday morning. The visit consisted of discussions with the registered manager and deputy manager and a tour of the home. Records, policies and procedures were also examined. The inspection officer was Barbara Mulligan. What the service does well: What has improved since the last inspection? What they could do better: The registered manager has been on maternity leave and recently returned. The deputy manager has been on long-term sick leave and she has only just returned on part time hours. During the absence of the manager and the deputy manager, a manager from a neighbouring home has overseen the home. There has been a large turnover of staff, established good working practices have ceased and many records have not been reviewed and updated as necessary. The home needs a lot of input by the management team to improve working practices with in the home. Care plans looked at are lacking essential plans of care. One care plan had only two goals regarding holiday and a trip out. There is no plan of personal care, mobility, personal hygiene needs, health care needs, religious needs and social needs. It is a requirement of the report that all care plans are completed to include these areas. The majority of the staff team are new in post and do not Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 6 appear to understand the process and necessity of care plans. The staff team as a whole would benefit from care planning training. The staff team have not received formal supervision for an unacceptable length of time. The registered manager is aware of this and plans to implement staff supervision again in the near future. This is a requirement of the report. There are several environmental improvements that the home would benefit from. These are regarding the cleaning/replacement of some grubby carpets, and the replacement of kitchen doors/cupboards. 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. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. The care planning system is not clear and consistent and does not provide staff with the information they need to meet the service users needs. Service users make decisions about their lives, with assistance and communication support, that allows them to influence their lifestyle and how the home is run Service users are supported to take responsible risks within the context of the home’s risk assessments and risk management strategies that ensure service users can have independent lifestyles. Personal information is handled appropriately ensuring that personal confidences are respected. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 10 A random selection of care plans were looked at during the inspection. Care plans have been updated to incorporate a new format. Staff spoken to say that they felt the new care plan format is confusing and not user friendly. The staff team are relatively new and would benefit from care planning training. Care plans looked at are lacking essential plans of care regarding mobility, personal hygiene needs, health care needs, religious needs and social needs. It is a requirement of the report that all care plans are completed which include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. Service users have a choice of menu each day, and are supported to make individual choices. House meetings were a regular practice of the home but have not been carried out regularly. The manager has recently re-introduced these and the first house meeting was recently held. Minutes of this meeting are recorded. There are service users who are being supported by advocates. The majority of service users manage their own finances. Each individual is assessed regarding money management and staff offer informal training if required. The complaints procedure is available in picture format and is also available in the Statement of Purpose and the Service Users Guide. Service users are informally involved in decision-making regarding their flats and the home. There are notice boards in each flat which are used to display relevant information to service users. Key worker systems have had to be implemented again as this had ceased. A range of risk assessments are in place. The home has introduced their own format, which is detailed, and user friendly. Risk assessments were seen for the use of transportation, boiling a kettle and pouring boiling water into a cup, road awareness, service users who smoked, and fire awareness. There is an absence policy regarding unexplained absences by service users. All files were observed to be stored in lockable filing cabinets, in the office. Staff training in issues of confidentiality takes place during staff’s initial induction. Matters regarding confidentiality are included in the POVA Policy dated April 2004 and can be found in the Policy and Procedure Manual maintained in Penn House. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during the inspection. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has effective complaints procedures to ensure that service users or their representatives are listened to. EVIDENCE: The home has a complaints logbook where all complaints are recorded. This has been re-implemented as the previous complaints log is missing. The home does not appear to have received any complaints since the previous inspection. The homes complaints procedure is available in picture format. This gives a list of people whom service users can approach with their complaint and includes timescales for response. Copies of the complaints procedure are included in the Statement of Purpose and the Service Users guide. There is a separate complaints format used for service users to make a complaint regarding the food. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The standard of the environment within this home is adequate, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. The garden is regularly maintained to keep it safe and accessible for service users. EVIDENCE: Penn House is a two-storey building and access to the upper floor is by stairs. This is one of a number of residential houses on the site of the National Society for Epilepsy and provides twenty-four hour residential care for up to twentytwo adults. The home is divided into five ‘flats’ and is situated centrally on the site. Each flat has designated communal sitting areas and kitchenettes. Attractive, open, grassy areas surround the house. It has no private garden of its own but a small area at the front with benches and tubs of flowers. Generally the house provides a comfortable and homely environment for the service users. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 15 Each service users bedroom contains all the furniture and fittings as detailed in Standard 26. Bedrooms are bright, cheerful and decorated to reflect each individual’s personal tastes and lifestyles. Service users are encouraged to bring/purchase their own individual belongings to personalise their own rooms. Bedrooms are lockable, and service users have their own keys. There is a pay phone in the lobby of the home, however this does not provide service users with privacy. The manager stated that most service users have personal mobile phones. Each flat has shower rooms. There are six in total, which staff have decorated and provided with homely touches to remove the institutional appearance. Bluebell flat is decorated in a homely manner. The carpets in the lounge area are grubby and need to be either cleaned or replaced and this is a requirement of the report. The kitchen is small and the cupboards are worn. The kitchen would benefit from a new kitchen and this is a recommendation of the report. There is one bathroom available for service users on the ground floor and it is pleasing to see that the flooring has been replaced as required at the previous announced inspection. Following the previous announced inspection it was recommended that a new assisted bath has been fitted and this work has been completed. Service users are able to meet with visitors in the privacy of their own room if they wish to. Each flat has communal sitting rooms with a kitchen area, and each service user their own room for private use. In addition the home provides a large well appointed dining room and main kitchen. The kitchen cupboard doors are worn and broken in places. It is recommended that these be replaced. The upstairs flat communal space is small as noted. The home has a designated smoking room in one flat for smokers. An observation window has been fitted to this room as recommended at the last visit undertaken by the local fire authority. Smoking is not permitted in individual bedrooms. Moving and handling training is provided to staff and there is evidence of this. The home has a call system in place with accessible facilities and this is installed in all service users rooms. There is a separate sluice room and laundry provision for personal laundry where the service users do their own laundry. A red bag system is in use for soiled linen which is dealt with in the site laundry. The home is clean and free from offensive odours. COSHH information is obtained for products used and the inspector saw evidence of these. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 36. Staffing levels, although adequate do not offer consistency of care to the people using this service. The staff team are new and have not yet developed clarity of staff roles and responsibilities to ensure continuity of care. Staff have not received appropriate supervision during the absence of senior management. However, this is due to be implemented again and will provide staff with relevant support and guidance. Service users will then benefit from a consistent approach from the care staff. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 17 Staff are still learning about the homes /organisations values, policies and procedures through staff training and induction and reading policies and procedures. The home has just recently re-introduced a key-worker system. It is evident that with numerous new members of staff, the team is in an early stage of development. This is a large draw on the registered managers time and precludes her from her day-to-day role of managing the service. The home would benefit from extra support at this time. The home is fully staffed. However, a large percentage of the staff team are new in post and this does not provide a consistent approach. The unit has no volunteers at the time of the inspection. There are no staff members under the age of 18 yrs. Penn House uses regular relief staff, and this helps to keep the use of agency staff to a minimum. Staff sickness levels were observed to be low and this is monitored monthly. Physiotherapy and other specialist services are accessed on site. Staff meetings have not been carried out on a regular basis and the registered manager has had to re-introduce these. Formal staff supervision has not been carried out for a lengthy period of time and the registered manager and the deputy manager are aware that this needs to be implemented again. This is a requirement of the report. Each staff member should have an annual appraisal. However, there has been a large turnover of staff and many are still in the probationary period. There is a grievance and disciplinary procedure and all staff are given copies of these. Suitable protocols are in place for dealing with physical aggression towards staff and training is provided. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40 and 41. The home has not been adequately managed over the previous six months. However, the registered manager and the deputy manager have a good understanding of the areas in which the home need to improve to be able to satisfactorily meet service users needs. Policies and procedures are consistently implemented and monitored, thereby safeguarding the service users rights, health and best interests. EVIDENCE: Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 19 The manager has been in post as manager at Penn House for five years. Recently the manager has taken time off for maternity leave. The deputy manager has also been off on long term\sick leave. The registered manager is undertaking the Registered Managers Award. She has the overall responsibility for ensuring the homes written aims and objectives are achieved, the homes budget is properly managed, policies and procedures are implemented, certificate’ are displayed and that the home complies with the Care Standards Regulations. The manager says she communicates a clear sense of direction and leadership to the staff team by leading by example. The homes aims and objectives are included in the Service Users Guide. Service users and other stakeholders can voice their concerns via service users meetings, and by using the organisations complaints procedure. The inspector observed the organisations policy for Equal Opportunities and was told that the organisation has a commitment to ensuring equal opportunities. All policies and procedures are kept in the office, and are accessible to all staff working in the home. Staff are encouraged to read the homes/organisations policies. There is evidence to demonstrate that policies and procedures are being reviewed and updated. Staff and service users have limited involvement in developing or formulating policies and procedures. The complaints procedure is in a picture format however there were no other policies available in different formats for service users. Service users have access to their own records if they so wish. All records are constructed, maintained and used in accordance with the Data Protection Act 1998. The homes policies and procedures are comprehensive and cover a wide range of issues. The organisation is in the process of updating all policies and procedures. All confidential information was observed to be kept in secure areas of the home. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 X 3 X x 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Penn House Score X X X x Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 X x DS0000023006.V252419.R01.S.doc Version 5.0 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 6 Regulation 15 Requirement The registered manager is required to ensure that care plans are completed to include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. (Previous timescale 0f 30/04/2005 not met.) The registered manager is required to ensure that the carpets in the lounge of Bluebell Flat are to be cleaned or replaced. The registered manager is required to ensure that all staff receives formal supervision at least six times a year. Timescale for action 28/02/06 2 30 23 30/12/05 3 36 12 18 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Penn House DS0000023006.V252419.R01.S.doc Version 5.0 Page 22 No. 1 2 3 4 Refer to Standard 6 24 24 33 Good Practice Recommendations It is recommended that care staff undertake training in care planning. It is recommended that the kitchen in Bluebell flat be replaced. It is recommended that the cupboard doors in the main kitchen are replaced. It is recommended that the home receive extra staff support while there are numerous trainees undertaking their probationary period. 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