Inspection on 04/05/07 for Pennfields Court

This inspection was carried out on 4th May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pennfields Court 08/08/06

Pennfields Court 13/03/06

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 0LA Lead Inspector Rosalind Dennis Key Unannounced Inspection 4th May 2007 10:00 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.V337948.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. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pennfields Court Address Upper Zoar Street Pennfields Wolverhampton West Midlands WV3 0LA 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.V337948.R01.S.doc Version 5.2 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 8th August 2006 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 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. Individuals are generally referred via a consultant, with fees paid via the Primary Care Trust. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first day of this inspection was unannounced and lasted for around 4 hours. A return visit to the home took place one week later for a discussion with the manager and to observe documentation, which was not readily accessible on the first day of the inspection. All ‘key’ standards were assessed during this time- that is those areas of service delivery that are considered essential to the running of a care home. On both days of the inspection the home was functioning well and all people living at the home appeared well cared for and staff attentive in meeting their needs. General observation, review of records, and discussions with staff show that the home continues to promote positive outcomes for people with complex, challenging, mental care needs. What the service does well: What has improved since the last inspection? Of particular concern at the last two inspections was regarding the home failing to ensure that the recruitment procedure provided adequate protection to people living at the home from the employment of inappropriate staff. At this inspection it is seen that the home has improved its recruitment procedure, this is now robust with all pre-employment checks undertaken. Three ‘key staff’ staff have now had training in the safe use of bed rails, although it was identified at this inspection that all other staff working at the care home need to be vigilant in monitoring bed rails to ensure that any faults in bed rails can be rectified promptly. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pennfields Court DS0000017197.V337948.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 Pennfields Court DS0000017197.V337948.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): 3. Standard 6 is not applicable in this home. Quality in this outcome area is good. The home has a satisfactory admissions procedure that provides for an effective needs assessment for each person. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of two care files for people living at the home shows that the home continues to assess people prior to and on admission to the home. Senior staff had undertaken assessments of the person’s physical, social and mental health needs and this information had then been used to formulate the person’s care plan. The two people who were case tracked were unable to give their views of the admission process but documentation showed that staff had been pro-active in finding out about the person’s likes, dislikes and preferences through discussion with the person’s significant others. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 9 The last inspection report described how the home was proposing to offer places to people on a short stay basis following a direct referral to the home from a “home treatment team”. The manager confirmed that admissions on this basis have been limited, although observation of documentation confirmed that the home has the necessary procedures in place to enable this to happen. Pennfields Court DS0000017197.V337948.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 and 10. Quality in this outcome area is good. There is clear and consistent care planning in place, which provides staff with the information they require to meet people’s needs. Evidence of regular review and good multi-disciplinary working ensures that the health and personal needs of people living at the home are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people living at the home at the time of this inspection were unable to give their views on the home and the care provided, so most of this inspection is based on observation. People appeared well-cared for, staff were attentive in attending promptly to people’s needs and the atmosphere within the home was calm. Staff working at the home show respect and ensure people are treated with dignity. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 11 Observation of care documentation for three people shows that care plans identify people’s preferences and provide detailed information on their short term and long term care needs. All care plans had been reviewed and updated on a regular basis and each file contained a range of appropriate risk assessments. Staff spoken with were able to give accounts of the varying needs of people living at the home and how they meet those needs. The home monitors and records people’s dietary and fluid intake but it was noted that monitoring of people’s weight had not been consistently carried out. It was established that the weighing scales are not suitable for weighing some people, and although staff were able to provide examples of observing whether clothing is too loose/too tight, this is not considered to be sufficient given the frailty of the people living at the home. Observation of three people’s medication administration records showed these to be completed accurately. Since the last inspection the home has purchased a new medication fridge and records show that the temperature is satisfactory. Records show that the temperature of the medication room is currently within the required limit. Medication administration is restricted to trained staff-the manager confirmed that a training session on ‘Management of Medicines’ is to be provided in the near future to provide trained staff with up to date information on medicine administration. Pennfields Court DS0000017197.V337948.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 and 15. Quality in this outcome area is good. The meals at the home are good, offering variety and catering for different nutritional needs. Staff at Pennfields Court assist people to exercise choice as far as possible and according to their differing capabilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Organisation of activities continues to be conducted on a daily basis by care staff and is individualised to meet the needs of the person. One person was seen having her hair attended to by a member of staff –this one to one activity promoted a positive response from the individual who then engaged in a discussion with staff. Observation of records showed that activities are provided which meet the cultural needs of people living at the home, for example an Asian Film and music had been shown recently. Records document the activity and any notable response from the person to indicate enjoyment or dislike of an activity, for example staff had recently enabled a Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 13 person to visit a local market and staff had noted that the person appeared to recognise the area. Staff discussed that changes with the physical dependency of people living at the home has created additional difficulties in the planning and provision of activities although staff confirmed that a meeting has been held recently to try and resolve this. The manager discussed how the home is looking at ways to enhance people’s sensory awareness both indoors and in the garden. Staff also recognised that not all activities are documented because they are viewed as part of daily care needs, for example a staff member was seen assisting a person to knit, and this resulted in a positive reaction from the person, but the activity was not documented. Meals in the home continue to offer choice and observation of meal plans show that the home offers a wide range of meals and provides many opportunities for people to eat throughout the day. A discussion with the cook demonstrated a good knowledge of nutritional requirements, special diets and confirmed that the home caters for people’s religious and cultural dietary needs. The manager and cook spoke of proposed changes to meal plans with the intention that this will increase people’s access to choice. Pennfields Court DS0000017197.V337948.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 and 18. Quality in this outcome area is good. Concerns or complaints are dealt with promptly and professionally and the arrangements for the protection of vulnerable adults are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is available within the service user guide and a person visiting the home confirmed his awareness of the procedure. Observation of the complaints file show that the home has received two complaints since the last inspection-these have been investigated and responded to appropriately by the manager. The manager has started recording ‘minor’ concerns and this process was seen to be robust. The manager has a good knowledge of adult protection processes and procedures and training records show that staff have attended adult protection training, including one senior member of staff who has recently completed a degree unit in this subject. . Pennfields Court DS0000017197.V337948.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 and 26. Quality in this outcome area is adequate. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random selection of bedrooms and communal areas were observed and these appeared clean and the décor satisfactory, if a little bland-although the planned programme of re-decoration, which was seen, should address this. The manager and staff discussed the home’s intention for the development of a sensory garden –which will be a positive development in providing sensory stimulation for people with dementia. Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 16 Furniture in use appeared appropriate and of good quality and the selection of moving and handling aids within the home provides staff with safe ways to move people. Staff were observed using protective clothing appropriately although it was brought to the attention of the manager that the disposal of protective clothing in an un-lidded bin in the lounge area did not fit with good infection control practice. Records show that most staff have received training in infection control with further dates planned for all staff to attend. Pennfields Court DS0000017197.V337948.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 and 30. Quality in this outcome area is good. Training opportunities within the home are good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. The home has improved its recruitment processes and this protects people living at the home from the employment of inappropriate staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection 13 people are living at the home and staffing numbers during the day have reduced to take account of the reduction in people living at Pennfields Court. However what was very apparent at this inspection is the change in the physical dependency of people living at the home, with most people requiring the use of hoist and/or two members of staff to transfer. A discussion with the manager confirmed awareness that staffing levels need to be calculated according to the dependency and needs of the people living at the home and that staffing levels will increase accordingly. Throughout the inspection staff were observed responding to people’s needs promptly and sensitively. The last inspection to the home in August 2006 identified that the home had not improved its recruitment processes. At this inspection files for two newly Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 18 appointed members of staff show that the home is now conducting the required pre-employment checks and all other staff files have been audited by the manager and administrator to ensure they contain required information. Observation of these files confirmed that the home provides a comprehensive induction programme for new staff Observation of the homes’ computerised training records show that staff are provided with all mandatory training with updates in practice provided when necessary. Staff are provided with a good range of training, senior staff have recently attended training in person-centred approaches to Dementia care and the Mental Capacity act and the manager confirmed that the outcomes of these sessions are to be cascaded to other staff. The home continues to support staff to attain NVQ Level 2 and the manager reported that all staff have now achieved level 2 with a proportion of staff achieving NVQ Level 3. Pennfields Court DS0000017197.V337948.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, 36 and 38. Quality in this outcome area is good. People living at the home benefit from management arrangements in place and the staff group are appropriately skilled which ensures that the health, safety and welfare of residents is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered mental nurse with a good range of supporting qualifications, skills and experience. The manager and staff group appear committed to achieving positive outcomes for the people living at the home and the company is effective in ensuring staff are equipped with the skills and training to meet people’s needs. Staff have access to regular supervision Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 20 sessions and those staff who are ‘supervisors’ have been provided with relevant training. Observation of staff appraisal documentation shows that training and development needs of each individual are identified during the annual appraisal process. The home has processes in place to monitor quality within the home. Questionnaires are distributed on a twice-yearly basis to people living at the home and/or their significant other and the responses are used to formulate an action plan for improvement as appropriate. Relatives meetings continue to be held on a regular basis and the minutes of these meetings are distributed to all relatives to ensure everyone is kept informed. A representative from the company also monitors quality assurance at regular intervals with monthly unannounced visits. A report is then formulated with the findings of the visit. The home operates a process where items needed for people living at the home can be purchased from a petty cash system and the person is then invoiced for this. Records seen show a robust process with two signatures being required and receipts kept. Maintenance and servicing records were not checked at this inspection. Observations confirmed a safe environment, apart from in one bed room where one bed rail was observed to be faulty. Although this fault would have been unlikely to have any detrimental effect on the part of the person in bed, it does highlight a need for increased staff vigilance-the faulty bed rail was removed and replaced promptly by the maintenance person. Training records show that three key people have received training in the ‘Safe Fitting of Bed Rails’ and regular checks of bed rails are undertaken. Pennfields Court DS0000017197.V337948.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N0 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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations A system should be implemented to monitor the weight of people who are unable to access the current weighing scales. This is to ensure that accurate measurements of a person’s weight can be taken which will enable the home to establish weight loss/gain, enabling appropriate action to be taken. The home is advised to consider changes with the interior of the home in accordance with current good practice guidance for dementia care. This may promote well-being and enhance sensory awareness for people living at the home (4/05/07-assessed as in progress). 2. OP19 Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Pennfields Court DS0000017197.V337948.R01.S.doc Version 5.2 Page 24 - 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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