Inspection on 13/03/06 for Pennfields Court

This inspection was carried out on 13th March 2006.

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

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

Other inspections for this house

Pennfields Court 04/05/07

Pennfields Court 08/08/06

Pennfields Court 03/05/05

Pennfields Court 02/09/04

Pennfields Court 24/05/04

Pennfields Court 12/05/03

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

CARE HOMES FOR OLDER PEOPLE Pennfields Court Upper Zoar Street Pennfields Wolverhampton West Midlands WV3 OLA Lead Inspector Rosalind Dennis Unannounced Inspection 13th March 2006 11:00 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 Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 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. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pennfields Court Address Upper Zoar Street Pennfields Wolverhampton West Midlands WV3 OLA 01902 444069 01902 444070 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) Heantun Care Housing Association Limited Mr Tom Cullen Care Home 21 Category(ies) of Dementia (21), Mental disorder, excluding registration, with number learning disability or dementia (21) of places Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 21 beds for elderly mental illness Adults with dementia from age 55 years No number division between categories. Date of last inspection 3rd May 2005 Brief Description of the Service: Pennfields Court provides a continuing care service to 21 people with mental health problems over the age of 55 years.It is owned by Heantun Care Housing Association Ltd and is one of a group of care homes. It is a purpose built unit and is approximately 20 minutes from Wolverhampton City Centre.The accommodation comprises of single and double occupancy bedrooms. There are spacious lounge and dining areas, which are tastefully decorated to provide a homely atmosphere.There is a small-enclosed garden at the rear of the building with ample car parking at the front. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 11.00 and found the home functioning well. The inspection lasted for almost 5 hours and involved observing activity within the home, looking at residents care records and speaking with the manager and staff. Due to the nature of residents mental illness the inspector was unable to ascertain resident’s views of the service and care received. However observation confirmed that the residents appeared well cared for and staff attentive in meeting resident’s needs. One visitor that was spoken with during the inspection was positive regarding all aspects of the home. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls identified at this inspection are regarding care documentation, recruitment practices and health and safety practices regarding hot water temperature monitoring and bed rails. As identified at the last inspection, not all care plans and risk assessments are reviewed and updated on a monthly basis. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 6 The home has still not met the requirement made at the inspection in September 2004 to ensure that all information and documents in respect of persons working at the home is available for inspection. Staff that are involved in the fitting of bed rails are required to have appropriate training and hot water temperatures within the home must be monitored at least on a monthly basis. 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. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 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 Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this service The home has a satisfactory admissions procedure that provides for an effective needs assessment for each resident EVIDENCE: The current residents are unlikely to be able to contribute to the assessment and care planning process due to the nature of their illness. Senior staff undertake pre-admission assessments of prospective residents, which includes assessments of the individuals physical, social and mental health. The needs assessment is then used to formulate the individuals care plan. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10. Residents have care plans in place that identify their needs, however by not reviewing care plans and risk assessments in a timely way staff may not be provided with all the information they need to fully meet the residents needs. EVIDENCE: Individual care plans are available for each resident which include short term and long term care plans, formulated from the pre-admission assessments and on an ongoing basis. Of the three care files seen two contained care plans and risk assessments that were up to date, the other file had not been reviewed on a regular basis. The last inspection had also identified that not all care plans had been reviewed at least on a monthly basis. A discussion with the manager indicated that a new primary nurse is due to commence employment and that this will increase the amount of staff that are able to review residents care and the associated documentation. This will be assessed at a later inspection. Throughout the inspection staff were observed to deal competently and appropriately with fluctuating behaviour of residents and all staff were observed treating residents with dignity and respect. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The home provides meals that offer variety and cater for different nutritional needs. Staff at Pennfields Court assist residents to exercise choice as far as possible and according to their differing capabilities EVIDENCE: The home does not have a structured timetable for recreational activities. The organisation of individual activities is conducted as part of person-centred planning on a daily basis. Observation of daily records confirmed that residents are offered and are assisted to participate in activities such as reading newspapers, knitting, board games and visits to a local park. To ensure a full range of activities are offered the manager is advised to audit activities. Observation of menu plans show that a good variety of choices are available at each mealtime, which also meet the nutritional and cultural needs of residents. Staff establish likes and dislikes at the time of admission and on an ongoing basis and records are kept of all residents actual dietary and fluid intake, which is good practice. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 11 During the inspection care staff were observed to be attentive in assisting residents to eat. A discussion with one visitor to the home confirmed that staff are always helpful and respond appropriately to residents needs. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a complaints system that ensures that concerns are listened to and acted upon. EVIDENCE: A complaints procedure is available within the home. The manager maintains a record of any complaints received by the home and this record was observed to include action taken to address the complaint and the outcome. Since the last inspection, one event triggered the adult protection process, this was investigated robustly by the home and is now closed. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: The intended outcomes for Standards 19 and 26 were assessed at the previous inspection of this service and were not reviewed on this occasion. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. The home still does not meet the legislative requirement to keep all information and documents in respect of persons working in the home available for inspection, therefore CSCI cannot confirm that the home has a robust recruitment procedure. The home employs appropriately skilled staff to meet the needs of residents EVIDENCE: The last inspection identified that the home’s recruitment procedure does not meet legislative requirement. Observation of two staff files shows that the home now keeps a record of the employees identification documents, however the files were not complete, for example it was not possible to confirm that the references contained within one file corresponded to those given by the applicant on the application form. The registered person must audit staff files to ensure that they contain all required information. The home provides an induction programme that meets the required level and a staff member recently employed by the home spoke positively of her induction. The number of staff with NVQ Level 2 in care now exceeds the required ratio and some staff have also attained Level 3. Staff confirmed that good training opportunities are offered by the home. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Leadership in this home is good and staff demonstrate an awareness of their roles and responsibilities. The home is continually monitoring and reviewing processes to ensure that residents receive a good range of quality services. The home is well maintained however further consideration is required regarding the safe use of bed rails and the monitoring of hot water temperatures to ensure that the health, safety and welfare of residents is fully promoted. EVIDENCE: The manager is a registered mental nurse with a good range of supporting qualifications, skills and experience and is currently studying for the Registered Managers Award. Staff members that were spoken with confirmed that they Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 16 feel well supported by the manager and that good training opportunities exist within the home. A full range of servicing, maintenance and regular monitoring of services is undertaken and observation of documents showed all to be up to date apart from the monitoring of hot water temperatures within the home, which had not been completed for some time. Records of accidents are recorded accurately, audited by the manager and a comprehensive accident investigation is completed for accidents that result in injury or transfer to hospital. Observation of training records confirms that staff receive training in safe working practice topics. One staff member confirmed recent attendance at Health and Safety training that incorporated information on the safe use of bed rails, it was discussed with the manager that all staff involved in the fitting of bed rails must also receive appropriate training. Observation of records demonstrates that resident’s financial interests are safeguarded. The home operates a quality assurance system based on seeking the views of residents where capable and/or their representatives. Evidence was available to show that questionnaires have recently been distributed to relatives and the results have gone to head office for analysis. An action plan based on the responses is then formulated in order that any weak areas identified can be addressed. Senior management conduct comprehensive monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. Meetings for relatives are held at the home four times per year and copies of minutes are distributed to all relatives to ensure that everyone is kept informed. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 17 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 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 x X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 2 Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15 Requirement Service users plans must be reviewed and updated by care staff at least once per month Service user risk assessments must be kept under review Timescale for action 01/06/06 (Not consistently-previous timescale of 16/09/05 not met). 2. OP8 15 01/06/06 (Not consistently-previous timescale of 16/09/05 not met). 3. OP29 19 The registered person must ensure that all information and documents in respect of persons working at the home are complete and available for inspection. (Previous timescale of 30/11/04 and 30/09/05 not met) 01/06/06 4. OP29 19, Schedule 2 5. OP38 13(4)(c) The registered person must audit 01/06/06 all staff files to ensure that all elements as required by Schedule 2 of the Care Homes Regulations 2001 are present on each file. Staff who are responsible for 01/07/06 selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be incorporated in a planned maintenance schedule. DS0000017197.V275927.R01.S.doc Version 5.1 Page 19 Pennfields Court 6. OP38 13(4)(c) The home must ensure that hot water temperatures at outlets accessible to service users are monitored at least monthly to ensure that the temperature of the hot water is maintained as close to 43°C. 15/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The manager is advised to audit recreational activities to ensure that residents are offered a variety of suitable activities. Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pennfields Court DS0000017197.V275927.R01.S.doc Version 5.1 Page 21 - 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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