Inspection on 08/08/06 for Pennfields Court

This inspection was carried out on 8th August 2006.

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 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 OLA Lead Inspector Rosalind Dennis Key Unannounced Inspection 8th August 2006 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.V297388.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.V297388.R01.S.doc Version 5.2 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.V297388.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 13th March 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 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. Individuals are generally referred via a consultant, with fees paid via the Primary Care Trust. Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 8th August and lasted for a period of 6 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. The people living at the home were unable to give their views of the service and care received, however three individuals that were visiting their relatives gave very positive feedback regarding all aspects of the home and the care provided. Observation confirmed that residents appeared well cared for and staff were seen to be attentive and responding competently to residents needs. The home continues to provide a service that is based on achieving good outcomes for service users. What the service does well: What has improved since the last inspection? The home has improved the process of reviewing residents care plans and risk assessments. Hot water temperatures are now checked on a monthly basis and the checking of bed rails is incorporated into a maintenance schedule. Pennfields Court DS0000017197.V297388.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. Pennfields Court DS0000017197.V297388.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.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit 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, however observations of documentation, discussions with staff and visitors identified that staff have developed systems to identify residents’ likes, dislikes and immediate needs. A visitor whose relative had been admitted to the home fairly recently spoke of their satisfaction with the admission process and that the staff were welcoming and reassuring. 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.V297388.R01.S.doc Version 5.2 Page 9 A discussion with the manager confirmed that, following consultation with the PCT, the home is intending to decrease the number of long stay places and increase the number of places available for individuals requiring a shorter stay at the home, these individuals may have been referred direct to the home via a “home treatment team”. The proposed changes were discussed with the manager and it was agreed that the current proposals do not necessitate a change to the home’s current registration, however the manager is aware that the changes will need to be kept under review. Additional assessment documentation is to be introduced which will provide further information in respect of an individuals mental health needs. Pennfields Court DS0000017197.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is clear and consistent care planning in place, which provides staff with the information they require to meet residents’ needs. Evidence of regular review and good multidisciplinary working ensures that the health and personal needs of residents are met. The administration of medication is generally good, however the storage of medication is not satisfactory and could place service users at risk. EVIDENCE: Observation of three residents care files showed that 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. It is pleasing to note that all the care plans that were seen had been reviewed and updated on a regular basis and each care file contained a range of appropriate risk assessments. Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 11 It is difficult to establish from residents their own views of the care provided, however residents appeared well cared for and were observed being treated with great respect and individuality by all members of staff. Relatives visiting the home at the time of inspection felt that the level of care provided was good. Observation of individual residents medication administration records (MAR) sheets showed these to be completed accurately. The medication room appeared well organised, however the temperature of the room was recorded at 28°C and records show that it has occasionally exceeded 30 degrees. It was discussed with the manager that systems to cool the temperature must be introduced if the temperature consistently exceeds 25 degrees. The home records a daily temperature of the drugs storage fridge, records show that the temperature has at times been below the required minimum level, however it has been identified that a new fridge is required and the manager confirmed that a new drugs fridge has been ordered. Pennfields Court DS0000017197.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 activities is conducted on a daily basis by care staff, activities appear individualised and based on resident’s capabilities. Records that were seen had been completed by care staff and describe how staff had accompanied and enabled individuals to visit the local market, city centre shops for a “cup of coffee and cake”, day trip to Stourport. Another entry described how a resident had been assisted to make choices at mealtimes, by being provided with samples of different foods. Staff appear eager to establish likes and dislikes and this is done at the time of admission and on an ongoing basis. Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 13 The meal served during the inspection looked and smelled appetising and staff were observed to respond sensitively to those residents that required assistance with their eating. Records are kept of resident’s weights and their actual dietary and fluid intake, which is good practice. The manager discussed that he is looking at different systems that can be introduced to assist the home in ensuring that each resident receives a diet that meets their varying nutritional needs. Pennfields Court DS0000017197.V297388.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system that ensures that residents and/or their representatives concerns are listened to and acted upon. The arrangements for the protection of residents from abuse is satisfactory. EVIDENCE: The complaints procedure is available within the home. The manager informed that there had not been any recent complaints and CSCI have also not received any complaints in respect of the home. It was discussed with the manager that is good practice to record any “minor concerns” that are raised. Visitors to the home that were spoken with, commented that they felt comfortable to raise concerns with the manager or other staff should the need arise. The manager has demonstrated that he has good knowledge of adult protection processes and procedures and evidence was available to demonstrate that staff have attended adult protection training. Pennfields Court DS0000017197.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides residents with an attractive and clean place to live, although further attention to the environment will enhance the appearance of the home and may assist with residents orientation in the home. EVIDENCE: A full tour of the home was not undertaken, however a random selection of individual rooms were observed to be clean and decorated to a satisfactory standard. The home is looking into ways to enhance the environment so that residents may be orientated to their own bedrooms such as by the provision of reminiscence aids near to or on individual bedroom doors, which are otherwise rather bland. The manager discussed that although there had been some delay in completing this project, it is anticipated that it will be completed soon. Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 16 On the day of inspection systems were observed to be in place to control the spread of infection and staff were observed using appropriate protective clothing. Pennfields Court DS0000017197.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment practices are not robust and this could potentially result in the recruitment of inappropriate staff. The home has a stable staff group who work positively with residents to enhance their quality of life. EVIDENCE: Observation of staffing rotas and discussion with the manager confirms 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 manager is supernumerary to the staffing levels, thus enabling managerial duties to be attended to and further develop the home. Discussion with relatives, two members of staff and observations made during the inspection confirmed that staffing levels appear sufficient to meet the needs of the current residents. Depending on the needs of the individuals accommodated, the proposed changes to increase the number of short stay places may impact on the staffing levels, and for this reason staffing levels will need to be kept under review. The home provides an induction programme that meets the required level and staff are supported to attain NVQ Level 2 in care. The number of staff with NVQ Level 2 in care exceeds the required ratio and some staff have also attained Level 3. Observation of the company “Core Training Resource” guide Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 18 demonstrates that a good range of training is available for staff. Recent training undertaken by some members of staff includes dementia care, care planning and supervision. Computerised records are kept to confirm staff attendance at training, and a selection of these were observed. The manager discussed his intention to collate this information into a training matrix, it is considered that this will assist with the planning and review of training. Recent inspections identified that the home had not meet the legislative requirement to keep all information and documents in respect of persons working in the home available for inspection. Observation of a random selection of staff files shows that the manager is in the process of auditing files to ensure that they contain all the information and documents required for people working at the home. However it is disappointing that an individual recently employed by the home had been appointed prior to receipt of a CRB Disclosure, a POVA First check had also not been made. The registered person must take prompt action to ensure that all pre-employment checks are consistently undertaken. Pennfields Court DS0000017197.V297388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the skills and knowledge to lead the staff team and manage the home. The home is well maintained and the staff group appropriately skilled to ensure that the health, safety and welfare of residents is promoted. EVIDENCE: The manager is a registered mental nurse with a good range of supporting qualifications, skills and experience and since the last inspection has completed the Registered Managers Award. A discussion with the manager confirmed that he has some good ideas to enhance care practice and appears enthusiastic to improve services within the home. Throughout the inspection staff were observed to be accessible, good communicators and interacted appropriately with the residents. A student Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 20 mental nurse on duty gave positive feedback regarding the home commenting that the staff group were helpful and supportive and that the home is “a good placement to gain experience”. A full range of servicing, maintenance and regular monitoring of services is undertaken and observation of documents showed all to be up to date. The home has recommenced the monitoring of hot water temperatures and it was discussed with the manager that it is good practice for staff to also record the action taken to address any deficits. It was also discussed that staff should be routinely checking the temperature of all baths prior to assisting a resident to bathe. The home has robust systems in place to safeguard resident’s financial interests and regular audits are undertaken of financial records to confirm accuracy. The home operates a quality assurance system based on seeking the views of residents where capable and/or their representatives, and examples of these questionnaires were seen at the last inspection. Senior management continue to conduct 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. Observations during the inspection confirmed a safe environment; bed rails that were observed in use were fitted correctly and moving and handling equipment appeared well maintained. The company has devised a system for monitoring bed rails to ensure that they are fitted correctly, the home has not yet achieved the requirement for staff to receive training in the safe fitting of bed rails however recent discussions with the assistant director have identified that the home is currently looking for an appropriate person to deliver this training. Pennfields Court DS0000017197.V297388.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 2 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 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Timescale for action 01/12/06 2 OP29 19, Schedule 2 The registered person must introduce systems to reduce the temperature of the treatment room within the home to below 25°C. The registered person must audit 01/11/06 all staff files to ensure that all elements as required by Schedule 2 of the Care Homes Regulations 2001 are present on each file. (Previous timescale of 1/06/06 not met, identified as in progress at this inspection). 3 OP29 19 Schedule 2 5. OP29 19 The home must ensure that a POVA First check is made for staff that commence employment prior to receipt of the full CRB Disclosure, the employee must be closely supervised until the full CRB Disclosure is obtained. 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, 30/09/05 and 1/06/06 not met- 01/11/06 01/11/06 Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 23 identified as in progress at this inspection. 6. OP38 13(4)(c) Staff who are responsible for selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be incorporated in a planned maintenance schedule. Previous timescale of 01/07/06 partially met-training still to be provided. 01/11/06 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. 2 3 Refer to Standard OP16 OP19 OP30 Good Practice Recommendations The manager is advised to maintain a record of “minor” concerns that are raised, including the action taken in response to the concerns. The home is advised to enhance the environment and décor through the provision of reminiscence aids. To produce a matrix to monitor the provision of training Pennfields Court DS0000017197.V297388.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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.V297388.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!