CARE HOME ADULTS 18-65
Pennings View Porton Road Amesbury Wiltshire SP4 7LL Lead Inspector
Elaine Barber Key Unannounced Inspection 22nd January 2007 10:35 Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 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 Pennings View DS0000060337.V310642.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Pennings View Address Porton Road Amesbury Wiltshire SP4 7LL 01980 624370 01672 569477 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) Cornerstones (UK) Ltd Teresa Guthrie Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Any placement for short-term care or for emergency placement must be agreed with the Commission before the placement commences. For the purpose of this condition, short-term is defined as a placement that is expected to last not longer than 3 months. An emergency admission is defined as an admission whereby someone is likely to be placed at short notice without an up-to-date assessment of needs having been carried out and the person has not had the opportunity to visit the home prior to placement. 2nd December 2005 Date of last inspection Brief Description of the Service: Pennings View is a privately operated home. It provides care and accommodation for 7 young adults with a learning disability. The owners, Cornerstones UK Ltd., have a number of similar establishments across the county of Wiltshire. Pennings View is on the outskirts of Amesbury. Residents are able to access a range of local amenities. The property is a two storey domestic dwelling. There are bedrooms on both floors. Each person who lives in the home has a single room. One of these has an en-suite bathroom. There is a large garden at the rear of the house. The fees range between £3,350.60 and £3,914.40 for four weeks. . Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home on 22nd January 2007 and a planned visit on 23rd January 2007. During the visits information was gathered using: • • • • • Observation Discussion with seven people who lived in the home Discussion with three staff Discussion with the manager Reading records including care records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • The manager provided information prior to the inspection about the running of the home. Five comment cards were received from relatives. A Random inspection took place 28th February 2006 to follow up the requirements at the previous main inspection. All the requirements had been addressed. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the three inspection visits. What the service does well:
People’s individual needs were assessed so that their needs could be met. Each person who lived in the home had their needs assessed by staff at Pennings View. They also had assessments by social workers. Detailed care plans had been developed and there was evidence that these were reviewed. The plans included all aspects of personal, health and social care. People had their abilities, needs and goals reflected in their individual plans. There was evidence that people could make choices. People were supported to manage their money. Any restrictions were recorded and seen to be in the person’s best interests. People made decisions about their lives with assistance as needed. There were detailed risk assessments with actions to be taken to reduce risks. People were supported to take risks and given opportunities for independence. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 6 People were provided with a range of activities and opportunities, offering access to their local community. Each person had a day time activity of their choice. The used the community facilities such as the shops, cafes and church. People had access to the community on a daily basis. People were able to maintain and develop appropriate relationships with family and friends. They had regular visits to friends and relatives and friends and relatives were also welcome in the home at any time. Routines were flexible and fitted in with people’s activities. People participated in the household chores. Each person had their own room and chose to spend time in the privacy of their room or in company in the communal areas. People’s rights were respected and their responsibilities were recognised in their daily lives. There was a varied menu which reflected people’s choice of meals. Special diets were catered for. People had opportunities to go food shopping. People were offered a healthy diet and enjoyed their meals. There was information about people’s individual needs and preferences in their assessments and care plans. People’s preferred routines were recorded in their personal notes so that people received support in ways they preferred and required. People’s healthcare needs were included in their personal plans. Each person was registered with a GP and they saw a range of health professionals including a physiotherapist, community nurse, occupational therapist, psychiatrist, dentist, optician and chiropodist. People’s physical and emotional health needs were met. Staff supported people to take their medication. There were appropriate arrangements for the storage, administration and recording of medication and people were protected by the home’s policies and practices. There was a complaints procedure and the people who lived in the home and their relatives knew how to make a complaint. People’s views were listened to and acted upon. There were policies and procedures about protection from abuse and physical intervention. Staff had received relevant training. People were generally protected from abuse, neglect and self harm. There was a large lounge with a dining area and a large kitchen with a seating area. People lived in a comfortable, clean and safe environment, suitable to their needs. The shared spaces complemented people’s rooms. Each person had a single bedroom in excess of twelve square meters. Each room was individually decorated and furnished and was lockable. People’s Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 7 bedrooms suited their needs and lifestyles. There were sufficient toilet and bathroom facilities to ensure privacy and meet people’s needs. There were infection control guidelines and the laundry facilities met the needs of the people who lived in Pennings View. The home was clean and hygienic. There were six support workers, the manager and a deputy. There was a range of training to ensure that staff could meet people’s diverse needs. More than 50 of the staff had a National Vocational Qualification or equivalent. People were supported by an effective staff team, who were appropriately trained and competent to meet their needs. There had been no new staff since the last main inspection when it was noted that all the appropriate recruitment checks were completed before staff started work. People were protected by the home’s recruitment practices. The registered manager was suitably qualified, competent and experienced, so that people benefited from a well run home. A quality assurance survey had been conducted and views of people who lived in the home and relevant professionals had been collected. People’s views underpinned all selfmonitoring, review and development by the home although the report about these views needs to be published. There was a range of health and safety measures and staff had received appropriate training. People’s health and safety were protected by the majority of the systems in place. What has improved since the last inspection?
Several requirements and recommendations were made at the last main inspection. Most of these had been addressed. Improvements had been made to the system of care planning. This would ensure that people’s personal, social and health care needs were met. A recommendation was made that there should be more detailed information in individual records about support to people who have limited access to formal education and occupation. This had been addressed through the introduction of monthly and quarterly evaluation sheets. These clearly showed the support that was provided to people and the opportunities offered and opportunities turned down. Some people required support with managing their behaviour. Following a requirement there was clearer evidence of suitable current guidance about this as part of the overall improvements in care planning. This would help to ensure that people’s behaviour was managed more safely. Rotas had been adjusted to ensure greater staff cover in the evenings and weekends, when more people were usually at home, to ensure they had support with activities.
Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 8 Risk assessments for lone working had been updated in December 2005, and all staff had signed to indicate their awareness of these. This would ensure that people who lived in the home and the staff were kept safe. A system of more direct managerial oversight of the fire safety precautions had been implemented to ensure double checking and that necessary tasks had been completed. All checks and instructions relating to fire safety were recorded as being carried out and up to date. Necessary repairs identified at the December 2005 visit had been completed. This would ensure that people were protected from the risk of fire. 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. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s individual needs were assessed so that their needs could be met. EVIDENCE: The care records of three people were seen. Each person had an in-house assessment of their needs. One person also had a social work assessment. A second person had a social work assessment and care plan. The third had a multi-professional care plan. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. People had their abilities, needs and goals reflected in their individual plans. People made decisions about their lives with assistance as needed. People were supported to take risks and given opportunities for independence. EVIDENCE: At the random inspection the format in use for service user plans had been reviewed and condensed, to provide a more accessible working document for all staff. Individual personal plans had been updated to reflect new needs assessments. This process has involved the people who lived at Pennings View, and input from the whole staff team. Plans included information about each person’s strengths, needs, likes and dislikes. Care issues were defined, with goals and objectives set for addressing these. Support was described
Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 12 under a range of headings. Plans were cross-referenced to other relevant documents, such as risk assessments. They had been signed by the people concerned and staff, and copies provided to care managers. At this inspection the care plans of three people were read. Each person had a detailed care plan covering all aspects of their personal, social and health care needs. Each plan was signed by the person and the staff. The plans had been reviewed and dates of reviews were recorded. Any restrictions were recorded in the care plans. All four relatives who completed comment cards said that they were satisfied with the care provided. One relative said, in answer to this question said ‘Very much so’. At the random inspection it was noted that risk assessments for lone working had been updated in December 2005, and all staff had signed to indicate their awareness of these. The key risks that people presented were linked either to distressed behaviour, or to epileptic activity. All staff were trained in supporting these needs. No new staff were left alone in the home until they had completed their induction, or if there was evidence of a risk situation developing. At all times, including overnight, advice and support was available via the on-call system. Outside the home, all the people who lived in the home required staff support. Risk assessments made it clear which individuals are not safe to travel together. Staff working away from Pennings View carried mobile phones, so that they could obtain support if necessary. At this inspection each of the three people, whose records were seen, had a series of risk assessments. Some were general for each person for example going out in the community or locking the fridge. Others related to the particular needs of the person. During the inspection people were observed making choices, for example, whether or not to go out, what drinks to have and where in the house to spend their time. They were observed involved in household tasks including cleaning the living room. Staff said that people were involved in choosing the menus and shopping for food. During the inspection a balance was observed between activities and household routines. Any restrictions were recorded in the care plans and there were detailed behavioural plans to manage behaviour. Staff supported people to manage their own money. The manager was appointee for one person. Financial records were kept. Any restrictions were recorded in the care plans and there were detailed behavioural plans to manage behaviour. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. People were provided with a range of activities and opportunities, offering access to their local community. People were able to maintain and develop appropriate relationships with family and friends. People’s rights were respected and their responsibilities were recognised in their daily lives. People were offered a healthy diet and enjoyed their meals. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 14 EVIDENCE: All the people who lived at Pennings View were spoken to. One person was at home all day on both days of the inspection. They said that they preferred not to go out on a regular basis. They had been to the organisation’s day service the previous Friday to play bingo and had enjoyed that. On the second day of the inspection four people went out to the organisation’s day service. They all said that they enjoyed going there. Some people also attended a day centre and one person went to college. People had access to community facilities. Several people went to the shops at various times during the inspection. People had monthly evaluation sheets and quarterly evaluation sheets in their personal records. Three people’s records were seen. These showed that they had a range of activities. These included going to church, arts and crafts, going for a drive, going shopping for food and for personal items, beauty sessions, going to a pantomime, discos, clubs and holidays. One person said that they had been to Butlins. People also went for walks, fed the swans and had meals out. At home they watched television and DVD’s and participated in the household chores. A recommendation was made at the previous inspection that there should be more detailed information in individual records about support to people who have limited access to formal education and occupation. This had been addressed through the monthly and quarterly evaluation sheets. These showed the support provided and opportunities offered and declined. People said that they visited their family and friends. One person said that they regularly saw their boyfriend and they used to visit their mother but chose not to visit at present. Another said that they phoned their father and stepmother weekly and they visited them. A third person said that they visited their mother regularly and they were going to see their mother the following Friday. There were records of contact with family in the personal notes. A relative visited one person during the inspection. They said that they could visit at any time. The four relatives who completed comment cards said that they were welcome in the home any time and they could visit their relative in private. Routines were flexible and fitted in with people’s activities. People had their own individual bedrooms and they had unrestricted access to the shared areas. People could see their visitors in the privacy of their rooms. The staff were observed to interact with the people who lived in the home and not just with each other. People could choose to have privacy in their rooms or be with others in the communal areas. People were observed participating in the household chores. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 15 There was a varied menu. A staff member said that the staff planned the menus fortnightly based on knowledge of people’s likes and dislikes and any special dietary needs. People had opportunities to go shopping for food. On the first day of the inspection people who were at home had a choice of sandwiches and yoghurt for lunch. There was vegetable lasagne for the evening meal. On the second day people were taking packed lunches to their say service. Two had chosen sandwiches and one had chosen salad. For the evening meal they were having chicken and cous cous. All the people spoken to said that they enjoyed the food. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People received support in ways they preferred and required. People’s physical and emotional health needs were met. People were protected by the home’s policies and practices about medication. EVIDENCE: People’s health care needs were recorded in the support plans. The ways in which they liked to be supported were also recorded in their plans. People were registered with the GP. The manger and deputy said that people also saw the optician, dentist and chiropodist. On one of the days of inspection one person became unwell and staff took them promptly to see the GP. Five people had seen the chiropodist the previous evening. Each person had health care records. Three of these were seen. They showed that people saw the GP, physiotherapist, occupational therapist, psychiatrist, community nurse, optician and chiropodist. Some people also had hospital visits.
Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 17 There were comprehensive medication policies including administration, storage, self-medication and leaving the home with medication. People’s consent to take medication was recorded in their personal plans. They also had a list of medication taken. Medication was stored appropriately in a locked cabinet. Records were kept of medication received into the home, administered and returned to the pharmacist. The medication administration records were appropriately recorded. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is generally good. This judgement has been made using available evidence including the visits to this service. People’s views were listened to and acted upon. People were generally protected from abuse, neglect and self harm. However, there should be further clarity about when it is appropriate to use physical intervention. EVIDENCE: There was information in the service user guide about how to make a complaint. There was also information in the personal records about staff explaining the complaints procedure to people so that they would understand the process. One person who had recently moved into the home had a pictorial complaints procedure in their file. The people who were spoken to knew who to talk to if they had a complaint. Four relatives who completed comment cards were aware of the complaints procedure. There had been no complaints. There were guidelines about protection from abuse and a procedure for reporting allegations of abuse. There was information in the personal records which showed that the procedures had been used appropriately in the past. There had been no recent allegations of abuse. There were also policies about whistleblowing, harassment and bullying. All the staff had received training about prevention of abuse in May 2006.
Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 19 Some people required support with managing their behaviour. Following a requirement at the last main inspection there was clearer evidence of suitable current guidance about this as part of the overall improvements in care planning. Target behaviours are defined, along with information on how to minimise the likelihood of these occurring. Strategies had been developed with input from the whole staff team, and other relevant professionals. Any agreed restrictions were set out, along with the reasons for them. There is space on support plans for everyone to sign up to the agreed approach. Physical interventions were practised on occasions for some people. Recording is in place for whenever this occurs, and is generally of good quality, with clear and informative detail. Incidents were reported to the CSCI as required. There was evidence that staff have received relevant training on the techniques used. At the random inspection it was identified that the range of physical interventions approved for use in the service were well defined, with clear and objective descriptions of the 13 separate holds which staff are trained in. A recommendation was made that the guidance should include more detail about the techniques, which are appropriate to each person. The number of holds had been reduced to four and all four could be used for each person. There should be more clarity about when it is appropriate to use these holds with each person. Once holds are being applied, there should also be clarity about how long it may be necessary or appropriate to continue to do so, and guidance on how to disengage. There were some possible ambiguities in one person’s records. For instance, one instruction stated that staff are never to intervene physically with less than two people. However, some of the approved holds only required one person to carry them out. The guidance appeared to relate to the number of staff present, rather than those directly involved in the physical intervention. This should be made clearer. People were supported to manage their money and to withdraw money from their bank accounts when applicable. The manager was appointee for one person. Appropriate records of all transactions were kept. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to this service. People lived in a comfortable, clean and safe environment, suitable to their needs. People’s bedrooms suited their needs and lifestyles. There were sufficient toilet and bathroom facilities to ensure privacy and meet people’s needs. The shared spaces complemented people’s rooms. The home was clean and hygienic. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 21 EVIDENCE: There was information on room sizes in the home’s Statement of Purpose which indicates that all bedrooms exceed 10 square meters. Each person a single room which was decorated and furnished to reflect their individual personality. All the rooms were lockable. The bedrooms varied considerably in size and layout. Two were on the first floor and these had areas of sloping ceiling, and dormer windows. Some ground floor bedrooms had French doors. One bedroom had an en-suite bathroom. The rest of the household had two other baths, both with showers. There were also three toilets. Communal space consisted of a large lounge; an entrance hall with some seating; and a large kitchen with a small seating area around a table. The manager said that they planned to repaint the lounge. There was a staff sleep-in room on the first floor, which was also used as an office. There was a large well maintained garden which was used in the summer. There was a laundry area next to the kitchen, with a washing machine and tumble drier. The tumble drier had broken at the time of the inspection and the manager was arranging for it to be repaired. During the inspection some of the people who lived in the home were observed cleaning the lounge. There were infection control guidelines. The home was clean throughout. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by an effective staff team, who were appropriately trained and competent to meet their needs. People were protected by the home’s recruitment practices. EVIDENCE: The staff rota showed that there were three staff on duty during the day and evening with one member of staff sleeping in. Usually two staff went to the day service with people and one member of staff stayed in the home with the person who chose not to go to day service. There were three staff in the evenings to support people with their activities. Following the last main inspection rotas had been adjusted to ensure greater cover in the evenings and weekends, when more service users are usually at home. The staff team consisted of the manager, deputy manager, and six support workers. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 23 Staff records were available for inspection at the random inspection. Sampled files showed that all required employment checks had been completed at the appropriate stage. The home’s newest employee did not commence working until a satisfactory result was received from a POVA First check. There had been no new staff since the last inspection. One member of staff had transferred from another home within the organisation and their recruitment checks had been completed in that home. Staff received a range of training including first aid, food hygiene, manual handling, health and safety, physical intervention, medication, prevention of abuse, autistic spectrum disorder and mental health needs. The manager had National Vocational Qualification (NVQ) level 4 in care and the deputy had NVQ level 3. Two other staff had NVQ 3, one had NVQ 2 and one was working towards NVQ 2. Another staff member had a degree in psychology. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to this service. The registered manager was suitably qualified, competent and experienced, so that people benefited from a well run home. People’s views underpinned all self-monitoring, review and development by the home although the report about these views needs to be published. People’s health and safety were protected by the systems in place although some tests of appliances were due to be carried out. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager had National Vocational Qualification (NVQ) Level four in care and the deputy had NVQ Level three. The manager also had the appropriate level of experience to manage the home. She kept her training up to date. Quality assurance was being developed. Questionnaires had been sent to care managers, doctors, community nurses and other professionals. The views of the people who lived in the home had been sought. The information had been collated at head office and some recommendations about improvements in communication with professionals had been made. However a report of the findings and an improvement plan had not yet been produced. There was a health and safety policy. There was information about health and safety, Control of Substances Hazardous to Health (COSHH), food safety and manual handling. Staff received training about health and safety, first aid, food hygiene, and manual handling. There was a quarterly check of all areas of the house to ensure they were maintained safely. Radiators were covered and the hot water temperature was regulated by thermostatic valves to reduce the risk of burns and scalding. A member of staff said that these were installed two years ago and they had not yet been serviced. These should be regularly serviced to ensure they maintain the temperature of the water at the correct level and water temperatures should be regularly checked. Portable appliances were tested annually. The PAT test was due in December 2006 and a member of staff said that they were following it up but there was a delay because the tester had been on holiday. The boiler was serviced annually. There were general and individual risk assessments. It was noted at the random inspection that a requirement about risk assessments had been addressed. Risk assessments for lone working had been updated in December 2005, and all staff had signed to indicate their awareness of these. This would ensure that people who lived in the home and the staff were kept safe. There was also a detailed fire risk assessment for all areas of the building and fire safety checks took place and were recorded. There were regular fire drills and staff received fire instruction. The environmental health officer visited in June 2006 and made a requirement. The manager had addressed this by buying a new fridge. Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x Pennings View DS0000060337.V310642.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement The registered person must produce a report of the findings from the quality assurance survey, supply to the Commission a copy of the report and make a copy of the report available to people who use the service. Timescale for action 31/03/07 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 YA23 Good Practice Recommendations The guidance about the application of physical interventions to individual people should be developed further, to include more detail about the techniques that are appropriate with each person, how long it is appropriate to use the techniques and when and how to disengage. The thermostatic valves on taps should be regularly serviced and water temperatures should be checked regularly to ensure that the valves maintain the water at the correct temperature and reduce the risk of scalding.
DS0000060337.V310642.R01.S.doc Version 5.2 Page 28 2. YA42 Pennings View Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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