Inspection on 03/05/05 for Pennfields Court

This inspection was carried out on 3rd May 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

Pennfields Court 04/05/07

Pennfields Court 08/08/06

Pennfields Court 13/03/06

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 WV3 0LA Lead Inspector Rosalind Dennis Unannounced 3 May 2005 09.00 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 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 v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pennfields Court Address Upper Zoar Street, Pennfields, Wolverhampton, WV3 0LA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 444069 01902 444070 Heantun Care Housing Association Limited Tom Cullen Care Home with Nursing 21 Category(ies) of Dementia (21) registration, with number Mental Disorder (21) of places Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 21 beds for elderly mental illness. 2) Adults with dementia from age 55 years. 3) No number division between categories. Date of last inspection 02/09/2004 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 v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 3rd May 2005 and lasted for a period of 5 hours. The inspection included observing activity within the home, a tour of the premises, looking at residents care records, speaking with staff and observation of staff files. The manager and staff on duty were welcoming and offered their fullest co-operation throughout the inspection. Due to the nature of the resident’s mental illness the inspector was unable to ascertain residents views of the service and care received. However observation confirmed that the residents appeared well cared for, staff were attentive and responded competently to episodes of challenging behaviour shown by some of the residents. What the service does well: What has improved since the last inspection? Staff have attended further training in adult protection/abuse awareness. The home maintains records of resident’s dietary intake and their weight. An activity programme has been devised and the home is currently exploring activities outside of the home that would be suitable for residents to attend. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 6 What they could do better: 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 v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 standard(s) 4 Staff individually and collectively have the skills and experience to deliver the care required by the residents offers to provide. EVIDENCE: Through discussion with visitors and staff and by observing staff working with residents the home demonstrates that it meets the needs of the current residents. During the inspection staff were observed to deal competently and appropriately with challenging and fluctuating behaviour of residents. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 11 The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure resident’s medication needs are met. Resident’s have care plans and risk assessments in place which identify their needs and the safe ways to meet them, however by not consistently reviewing care plans and risk assessments staff may not be provided with all the information they need to fully meet resident’s needs. EVIDENCE: The current residents are unlikely to be able to contribute to the care planning process due to the nature of their illness. Individual care plans are available for each resident which include short term and long term care plans, formulated from the pre admission assessment and on an ongoing basis. Daily entries made by staff into residents care records describe the actual care given and in all files seen the care given corresponded to the care plan. Risk assessments are undertaken and these include assessments of trigger factors that might result in deterioration in a resident’s behaviour, moving and handling, falls risk and nutritional risk assessments. There were inconsistencies in the frequency of the review of care plans and risk assessments. A falls risk assessment that detailed a monthly review in the care plan had not been Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 10 reviewed for seven months and a care plan for a resident with diabetes had not been reviewed for six months although inspection of the daily record demonstrated that diabetic care had been undertaken in accordance with the care plan. Robust procedures exist to ensure the safe administration of medication. Medication is stored appropriately and at the correct temperature. Home has the met the previous requirement to establish and record resident’s wishes regarding terminal care and arrangements after death. The manager reported that obtaining this information had caused some distress to relatives/significant others and therefore the procedure for obtaining this information is likely to be reviewed. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 11 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 standard(s) EVIDENCE: The above standards were not inspected at this inspection. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 standard(s) 18 The arrangements for the protection of resident’s from abuse are satisfactory. EVIDENCE: The home has policies and procedures in place for responding to allegations and suspicions of abuse and neglect. The manager confirmed that all staff have now received training in adult protection/abuse awareness. This was confirmed during discussion with two members of staff who were aware of the procedure to follow should there be an allegation or suspicion of abuse or neglect. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 standard(s) 19, 20, 23, 24 and 26 The standard of the environment is good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home was clean and individual and communal rooms were decorated to a satisfactory standard. A sensory room provides a therapeutic environment for residents. The home offers thirteen single bedrooms and four double bedrooms, which have adequate screening to maintain privacy. On the day of inspection systems were observed to be in place to control the spread of infection and staff were observed utilising appropriate protective clothing. The home received an inspection by the local fire officer three days before this inspection and the manager is aware that he will need to meet any requirements that are identified in the fire officer’s report. Compliance will be assessed at the next inspection. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home has a stable staff group who work positively with residents to enhance their quality of life. The current recruitment process 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. EVIDENCE: The manager confirmed that staffing levels remain at 1 nurse and 4 carers in the morning, 1 nurse and 4 carers in the afternoon/evening and 1 nurse and 2 carers at night. The staffing levels at the time of inspection appeared sufficient to meet the needs of residents and staff were able to respond to the fluctuating behaviour of residents appropriately. The manager confirmed that all records pertaining to the recruitment process are held at the Human Resources department of the company. A selection of staff files inspected for their content did not contain all the required information such as confirmation of identification of the individual or recent photograph. This current practice means that CSCI is unable to confirm whether the recruitment procedure is robust. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The above standards were not inspected during this inspection. However the environment was observed during the inspection to be safe and secure. Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x x Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 7 8 19 Regulation 15 15 23(5) 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 The registered manager must ensure that the recommendations of the environmental health officers report are fully complied with.Compliance not assessed at this inspection ,previous timescale of 30/11/04 The registered person must ensure that all information and documents in respect of persons worknig at the home are complete and available for inspection.Previous timescale of 30/11/04 not met All care staff must receive formal recorded supervision at least six times per year.Compliance not assessed at this inspection, previous timescale of 30/11/04. The registered person must ensure all risk assessments for all safe practice topics are carried out and reviewed on a regular basis. Compliance not assessed at this inspection Timescale for action 16/9/05 16/9/05 The home states that this has been completed. 4. 29 19, 2 30/9/05 5. 36 18(2) 16/9/05 6. 38 12(1) The home states that this has been completed. Page 18 Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 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 Good Practice Recommendations Pennfields Court v224923 e56 000017197 pennfields court v224923 ui 030505 stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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. 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