Inspection on 25/05/05 for Pennings View

This inspection was carried out on 25th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pennings View 08/01/08

Pennings View 22/01/07

Pennings View 02/12/05

Pennings View 12/01/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pennings View Porton Road Amesbury Wiltshire SP4 7LL Lead Inspector Tim Goadby Unannounced 25 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pennings View Address Porton Road Amesbury Wiltshire SP4 7LL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cornerstones (UK) Ltd 01672 569477 Vacant Care Home 7 Category(ies) of 7 Learning Disabilities registration, with number of places Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The company must employ one or more administrators working for a period of not less than 5 hours per week in this home. This person must provide the home with administrative support in the maintenance of goods records, including financial records, and any documentation and relevant paperwork necessary for running a care home. The administrator must be in place by 1 October 2004. 2. Cornerstones (UK) Ltd must ensure that a quality assurance audit is carried out at least annually as to the way the home is performing. This audit must also specify any corrective measures that need to be put in place with suggested timescales for action. Any such audit must be carried out by a reputable and competent person or company with experience of quality assurance systems and processess. A copy of the audit must be provided to the Commission within 6 weeks of its production. The first audit must be provided by 4 July 2005. 3. 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 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. Date of last inspection 12th January 2005 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. 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. All residents have single rooms. One of these has an en-suite bathroom. There is a large garden at the rear of the house. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced with a visit in May 2005. The inspector then returned in early June, with the aim of meeting the acting manager. But, due to a rota change, she was not available on this second occasion either. So a final visit took place, by appointment, to conclude the inspection process, and give initial feedback. A total of 8.5 hours were spent in the home. A meeting between the registered provider and the CSCI was held on 1st July 2005, and relevant information from that session has also been incorporated into this report. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; discussions with service users, staff and management; survey of professionals; tour of the premises. What the service does well: What has improved since the last inspection? Improvements had been demonstrated in a number of areas of recording. The requirement to allocate at least 5 hours per week specifically for administrative work was being met, and this appeared to have helped with this. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 6 The home was responding to any incidents which occurred, or complaints that arose. This included notification of the CSCI and other agencies, with such reports usually containing a good level of information. Local adult protection procedures had been activated when it was appropriate to do so. A management consultant had been engaged to assist the organisation with working towards various longstanding requirements. This included the production of a first quality audit report, by the deadline set in registration conditions. Arrangements for fire safety had improved overall. The necessary checks and other measures were being carried out and recorded more reliably. Some outstanding works previously required by the fire safety officer had now been completed. The organisation had allocated a part time co-ordinator to oversee training. Records at the home were clearly ordered, and provided evidence that a range of relevant courses had been undertaken recently. All staff had had access to these. The home has been without a registered manager for some time. The acting manager has now submitted an application to the CSCI, and this will be processed over the coming months. What they could do better: Some requirements remain unmet from previous inspections. Continued failure to address these issues by the appropriate timescales will lead to further enforcement action. Strategies for the management of complex and challenging behavioural needs must be clearly defined. They have to be kept under regular review, and ensure that the input of other relevant agencies is incorporated appropriately. Use of physical interventions is applied within a suitable framework, but needs some further attention, to show that they are properly tailored to any individual service user concerned. Medication records do not provide precise information about the time of administration. Attention is also needed to ensure that amendments to records are checked by 2 staff, and that guidance for individual service users is updated. Records remain deficient in some areas, particularly for staff. Recruitment records must provide evidence that all required checks are completed, at the appropriate times. Job descriptions must be available for all posts. Service user records could also be strengthened in some aspects. The input of individuals to their own care should be shown wherever possible, especially Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 7 where any restrictions or control measures have been assessed as being necessary. Goal setting needs to ensure that overall aims have been broken down into a series of measurable actions, to aid meaningful review. And for those service users who have a more restricted weekly programme, because of their preferences, records need to show clearly why this is, and what is being done to try and address it. Information about fire safety arrangements needs to be reviewed and clarified. The risk assessment and associated procedures do not address relevant factors, such as likely evacuation routes, and the individual levels of awareness and co-operation of service users. Too much is left to the discretion of staff, with no appropriate guidance to assist them in reaching safe decisions if an emergency arose. Continuing work at organisational level needs to address some general areas. Monthly visits and reports on the conduct of the home need to continue, and ensure that all relevant issues are addressed. This should include regular updates about progress on any outstanding requirements. 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 D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 9 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 standard(s) 3 Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs met by the care provided. EVIDENCE: The home has not had any new admissions since the previous inspection. Pennings View supports people with a variety of needs. The majority have lived at the home for a number of years. In addition to their learning disability, service users may have a range of health issues. The home has access to input from other relevant professionals. Systems are in place for ongoing monitoring and review of individual placements. At this inspection, examples were seen of progress made by some service users. For instance, one was pleased to have successfully lost weight, and was generally more chatty and outgoing. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 10 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 standard(s) 6, 7 & 9 Service users’ needs are reflected in their individual care plans. Goal setting and review systems need some attention, to ensure that they are clearly measurable. This will assist service users in making progress on their identified aims. The home fails to show the input of service users to decisions about their own care. Suitable risk assessment and management systems are in place. But the home fails to define some of the control measures used, leading to concern about whether service users’ welfare is properly upheld. EVIDENCE: The home has an extensive care plan format. Evidence was seen in sampled records that areas of the plans are being reviewed and evaluated at suitable intervals, and in response to changing needs. Goals are set. But in some cases they need to be broken down into sets of actions, so that progress can be measured when they are reviewed. This is Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 11 particularly true when the overall goal is a long term one, or covers a number of issues. If any limitations are to be imposed, these are specified in individual plans. There is space to show the input of various people, including the person concerned, or their representative. But in most examples seen, it was only staff of the home who had signed relevant documents. Staff support service users with management of their personal money. Appropriate records are kept, including the retention of relevant receipts. There are usually 2 signatures each time any money is paid in or taken out. Risk assessments and management guidelines are in place. These have been completed for a range of topics. A scoring system is in use. There is information about how this operates. Staff sign completed documents to indicate that they are aware of the set approach, and will work in accordance with it. Examples seen at this inspection showed that risk assessments are kept under review, and that new ones are devised when necessary. In some cases, control measures have been felt to be needed. In the sampled files, these were not always fully defined. The home must show exactly what steps are being taken, and how these interventions are devised, monitored, and reviewed. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15, 16 & 17 Service users are enabled to take part in appropriate education, occupation and leisure activities. There is insufficient evidence about how service users’ needs are met when they choose not to engage in the usual programme offered. Service users regularly participate as members of their local community. Service users are supported to maintain appropriate relationships with family and friends. Service users rights are upheld, and reasons for any restrictions imposed are made clear. Service users receive a balanced choice of meals, and are supported with healthy diet choices, in line with individual wishes EVIDENCE: Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 13 Most service users attend various forms of education, employment, and occupation. This differs between individuals. Changes can occur, in line with someone’s choice. For instance, one person had recently opted out of a sheltered employment scheme, and was intending to increase their sessions at college instead. Some service users are escorted to outside placements by staff of the home. Some people have proved more difficult to engage in such opportunities. For those individuals who do not currently access formal daytime provision, the home offers a range of alternative support. Various new ideas were also being considered, and it was hoped to try these out in the near future. Records should be more explicit in showing how the needs of the service users concerned are being supported. They also need to give evidence of the reasons why people may opt out of certain opportunities. A range of activities are undertaken outside the home. This includes some sessions specifically tailored for people with learning disability. There is also regular use of community amenities, alongside non-disabled people. Records are kept of activities undertaken, and also of those missed for any reason. People go out either individually, or in groups. They are always escorted and supported by staff when doing so. The home has 2 vehicles which assist with getting to activities. Service users are free to undertake their preferred leisure activities. This applies both at Pennings View, and elsewhere. Everyone has home entertainment items in their individual rooms. There is various sports equipment in the garden. People are involved in various things outside the home. This includes physical recreation, such as swimming or going to the gym. Service users also have social outings. For instance, trips to the pub, restaurants, or the cinema. Records are kept of all activities undertaken. A record is also kept of when something has been offered, but the person has declined it. People are offered the opportunity to go on holiday at least annually. They go singly, or 2 at a time, escorted by staff. A variety of destinations have been visited. This has included some overseas trips. The length of holidays varies. Some people benefit more from a number of short breaks. Individuals may also go on holiday with their families, in some cases. 2 service users were away for a week during the course of this inspection. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 14 Most service users enjoy regular family contact. Relatives are welcome to visit at any time. In turn, several residents often visit their family home. This has included travelling overseas, in one case. Sometimes it is difficult for families to arrange transport. So Pennings View will help out by providing this. Some people also keep in touch with their families by telephone. Records demonstrated that relatives are invited to attend review meetings, and other relevant consultations with professionals involved in the care of their family member. Where relatives had raised concerns about aspects of care, appropriate steps were being taken to respond to these. The usual routines for each individual are set out in their care plans. Some restrictions are in place within the home, based on assessed needs and risks. Menus are drawn up over a 5 week cycle. There is some flexibility within this, as service users may be doing different things on certain days. Sample menus showed a variety of food on offer. An alternative option was available for each main evening meal, whilst breakfast and lunch both offered service users their own choice. Some service users were being supported with their own desire to lose weight. Input and advice had been obtained from a dietitian, and some relevant guidelines drawn up. Individual weights were being monitored for these people. One had recently achieved her goal, and was clearly very pleased about this. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 15 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 standard(s) 18, 19 & 20 Service users receive appropriate personal and health care support, ensuring their needs and preferences are met. Arrangements for the control of medication in the home need attention, to ensure the protection of all service users. EVIDENCE: Guidelines on the personal care needs of each service user form part of their individual plans. The aim is to promote independence in this area, where possible. The home’s policy is to promote same gender care. This is especially so for female residents. Male staff will carry out only a limited amount of care tasks for them. Therefore, it is usual to have female staff available most of the time. Health and personal support needs of the user group are generally well understood. A range of advice and treatment is accessed, as appropriate. Records show that a range of issues are addressed for each individual. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 16 The current service users are not self-medicating. So staff have to assume the responsibility for all aspects of this task. Arrangements for storage, recording and administration of medication were seen during this unannounced inspection. These were generally satisfactory. One continuing requirement was identified. The home draws up its own medication charts. Times of administration are not specified on these. Instead, abbreviations such as ‘M’ for morning, and ‘T’ for teatime, are used. This is not sufficiently precise, as times could vary widely between individuals, and from one day to another. The medication record must show the actual time of administration for a drug. This could be entered into daily notes. But the simplest way would be to note the time on the administration record chart. There are also some recommendations in this area. As previously suggested, 2 staff should check and sign medication administration records, especially where changes have to be made to these. But there was no evidence of this being done. Guidelines for the administration of ‘as required’ medication to one service user need to be reviewed and clarified. The home had contacted the relevant consultant for advice, and a reply had been received at the end of March 2005. But the information had not yet been incorporated into the individual guidelines. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 17 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 standard(s) 22 & 23 Service users are protected by appropriate procedures for responding to complaints and concerns. Service users with complex and challenging needs are placed at some risk by the home’s failure to sufficiently define the steps being taken to manage these. EVIDENCE: The service reviewed and expanded its complaints procedure in 2004. Advice was sought from the CSCI regarding this. Various suggestions made by the Commission were incorporated into the final version. Over the period since the previous inspection, the home has kept the CSCI notified, as required, of any significant events occurring. This has included any complaints received. Other relevant agencies have also been informed, where appropriate. Local multi-agency adult protection meetings have been held on some issues, helping to ensure the welfare of service users. Most of the concerns raised had been resolved. One complaint was ongoing at the time of this inspection. Pennings View supports service users with a range of behavioural needs. Clearer and more objective definition is needed, in some cases, of particular behaviours. This information should form part of individual plans, to enable effective monitoring and intervention. Some examples seen gave imprecise headings for behaviours. In other cases, more than one issue was being recorded under the same heading. This increases the risk of inconsistency. It means the information gathered is likely not to be as accurate as it needs to. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 18 Sampled records also failed to show up to date information on the input received from other agencies. Relevant professionals who spoke with the CSCI around the time of this inspection expressed concern that their advice is not always applied effectively. The failure to transfer such guidance into the home’s own service user records must contribute to the deficits in implementing agreed strategies. Physical interventions are practised on occasions for some service users. Recording is in place for whenever this occurs, and is generally of good quality, with clear and informative detail. Evidence was also seen that staff have received relevant training on the techniques used. This was most recently updated in March 2005. General policy information includes a description of the interventions that might be used within the home. Guidelines for individual service users who might require physical interventions have also been drawn up. But these do not always fully define when to apply them, or make clear which type of techniques are felt to be suitable for each individual. Cross-referencing to other sources of information is not effective. It is important to describe exactly which interventions might be used with each service user, as this can vary, depending on their individual characteristics and physical health. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 19 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 standard(s) 24, 25, 26, 27, 28 & 30 Service users live in a pleasant, comfortable, homely environment, that is clean and well maintained. Individual and communal space meets the needs of service users. EVIDENCE: Pennings View has a high degree of wear and tear. But effort and investment have been put into keeping up its appearance. The nature of the home means that this has to be ongoing. Various repairs were being carried out during this inspection. Service users are involved in choosing colour schemes when areas are redecorated. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 20 Information on room sizes is contained within the Statement of Purpose. This gives dimensions in feet. The home’s measurements have not been verified. Calculations converted from them indicate that all rooms exceed 10 square meters. Each resident has a single room. They are decorated and furnished to reflect the individual personalities of their occupants. Many of the items are people’s own possessions. All are lockable. Bedrooms vary considerably in size and layout. 2 are on the first floor. These have areas of sloping ceiling, and dormer windows. Some ground floor bedrooms have French doors. One bedroom has an en-suite bathroom. The rest of the household has 2 other baths, both with showers. There are also 3 toilets. Communal space consists of a large lounge; an entrance hall with some seating; and the kitchen. The latter also has a small seating area around a table. Staff sleep-in facilities are situated in a first floor room. It also serves as an office. The garden provides another useful amenity. It is well maintained. Various sports equipment has been provided. The home was clean and hygienic in all areas seen during the unannounced inspection. No specific cleaning staff are employed. Care staff carry out the necessary tasks, in addition to their other duties. Service users may also participate, in line with their abilities. A cleaning schedule, which covers all areas of the home, is displayed on the kitchen noticeboard. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 & 35 The role and responsibilities of a staff member are not clarified, meaning that aspects of support to service users remain unclear. Service users are supported by staff in suitable numbers to meet their daily needs. Evidence is not available to provide reassurance that service users are protected by recruitment and selection practices. Staff receive relevant training to assist them in meeting service users’ needs effectively. EVIDENCE: The home has recently employed a staff member who is aged under 18. Standards require that such an employee must not be involved in providing intimate personal care for service users. Verbal accounts were given of the duties of the worker concerned. But there was no written job description available for this new post. So it was not possible to conclude whether or not the person was being deployed appropriately. Job descriptions were seen for all other posts in the home. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 22 At the time of this inspection Pennings View had an acting manager, who had commenced the process of applying to the CSCI for registration. There was a new deputy manager, who had transferred from another Cornerstones home. The organisation’s responsible individual was working mainly at this service, to support it during its period without a registered manager. There were 4 other care workers, plus the junior staff member mentioned previously. Relief cover was available from other employees of the organisation. One such person was working at Pennings View regularly, and was due to be allocated there full-time to cover a colleague’s period of maternity leave. The relief worker was previously employed at this home, so knew the service user group well. The home runs on a minimum of 2 staff per shift, during daytime hours. The aim is to increase this to 3 or more people, whenever possible. On the various visits involved during this inspection, 2 or 3 staff were on duty on each occasion. The number actually on site varies, as it is common for staff to be away from the home, escorting people on various activities. When they do this, they are contactable via mobile phone. Overnight cover is provided by a person sleeping on site. They can respond to any situations that need support. They also have access to an on-call manager, if necessary. Staff also act as keyworkers for up to 2 service users. This role covers administrative aspects. These include arranging review meetings, organising appointments with healthcare professionals, and booking holidays. It also covers practical tasks, such as shopping with people for necessities like clothes and toiletries. Recruitment records for the home’s newest employee were lacking in some respects. Evidence could not be produced that all the required checks had been carried out. In particular, it could not be shown that a check of the national list of people deemed unsuitable to work with vulnerable adults had been completed before the person started working. This information was reported to be elsewhere. 3 staff working in the home at the time of this inspection had achieved NVQ Level 3 awards in care. Some relief workers used by the home were also NVQ qualified. Calculations suggested that the home was just above the 50 target required, although this was open to some fluctuation. 2 other staff were due to begin working towards NVQ awards at the next opportunity. This will help the home to more comfortably meet the relevant standard. Cornerstones has a designated staff member who spends 16 hours each week acting as the organisation’s training co-ordinator. A folder contained details of the various courses undertaken by each employee at Pennings View. This included copies of any certificates gained. There was evidence of recent Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 23 training on several topics, including health and safety, medication, epilepsy, and autism. New staff have an induction pack to work through. They were also following national guidance on standards for people working in the learning disability field. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41 & 42 Recent developments in the organisation’s operation of its registered services need to continue, to ensure that service users benefit from progress on the targets identified. General improvements in record keeping need to be strengthened by maintenance of all required staff records. This will provide evidence that service users’ best interests are being safeguarded. Fire safety procedures need reviewing, to demonstrate effective protection of service users. EVIDENCE: Cornerstones has been working on producing an initial quality audit report, to comply with one of its conditions of registration. The first report was provided to the Commission by the required deadline of 4th July 2004. The organisation engaged the services of a management consultant to assist with this. They Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 25 envisage retaining him to continue working on the overall quality assurance exercise, and also to help with making progress on targets identified. A key element of this will be to ensure that service user views are accessed as meaningfully as possible, using a range of relevant approaches. The home was maintaining statutorily required records to a higher standard than at the previous inspection. For instance, menus and rotas were readily available, and comprehensible. Service user records were being updated as needed, and the terminology used in examples seen was appropriate. Daily notes contained a good level of detail, and were clearly cross-referenced to other documentation, if necessary. The monthly visits and reports that the organisation is required to carry out on the home, and copy to the CSCI, are being completed. Further guidance was given during the meeting of 1st July 2005 about how to meet all criteria for these. In particular, it was recommended that the visits should include follow up on any outstanding requirements of inspection reports. A sampled staff employment record showed insufficient evidence of effective recruitment checks. Other required information that was not available included the employee’s start date, and information about their job role. Arrangements for fire safety were much improved from the previous inspection. Records in the log book indicated that required checks, drills and instruction were being carried out at the prescribed frequencies, with some minor oversights. Defects noted about 2 fire doors had subsequently been repaired, but the book had not been updated to reflect this. The home had a fire risk assessment, fire procedure, and evacuation procedure. But these were in need of review, to ensure that all relevant issues were covered. There was no consideration in the existing documents of possible factors that might affect evacuation routes. This needs to address both premises issues, and also the likely levels of awareness and co-operation of individual service users. The guidance for staff when working alone was particularly poorly defined. They were simply instructed to use their own judgement, with no qualifying advice about how to apply this, other than to ensure their own safety. The possibility of different responses in different situations, or at different times of the day or night, was not set out. A condition of registration for Cornerstones requires evidence that at least 5 hours per week are allocated for administrative work. As presently worded, the condition requires the appointment of one or more administrators. The company has undertaken to meet the desired outcome, by ensuring that service managers are shown to give the prescribed amount of time to such duties. At Pennings View, the relevant hours were shown on the rota. General improvements in addressing requirements associated with recording and administration suggested that this arrangement was working. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 26 Steps should be taken to ensure that systems for demonstrating staff awareness of key policies and guidelines work effectively. There are spaces on key documents, such as care plans, for staff to sign. But sampled records still found that this is not happening in all cases. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 27 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x N/A 3 N/A x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 1 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pennings View Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score N/A x 3 x 2 2 x D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2); 17(1)(a), Schedule 3(3)(i) Requirement Records for the administration of medication to service users must contain the time at which drugs were given. (Timescale from 12/01/05 not met) COMMENT: The letter codes used by the home are not sufficiently precise about the time of administration. Where needed within individual plans, there must be clear and objective definition of behavioural needs, to enable effective monitoring and intervention. (Timescale from 12/01/05 not met) COMMENT: Sampled files continue to show examples of lack of clear definitions. The homes use of physical interventions must be supported by clearly defined individual guidelines for any service user affected, including descriptions of techniques applied. The persons registered must ensure that all staff have clearly defined job descriptions. Timescale for action From 20/06/05. 2. YA23 15; 17(1)(a), Schedule 3(1)(a) From 20/06/05. 3. YA23 4. YA31 12(1); 13(6), (7) & (8); 17(1)(a), Schedule 3(3)(p) & (q) 12(5); 17(2) & (3), Guidelines to be reviewed not later than 30/09/05. Not later than 31/08/05. Page 29 Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 5. YA34 Schedule 4(6)(e); 18(1)(a) 17(2), Schedule 4(6); 19, Schedule 2 The persons registered must maintain all required records relating to staff employment checks. (Timescale from 03/06/04 not met) COMMENT: Evidence of compliance was not fully available. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. Staff records required by regulation to be kept in the care home must be available for inspection at all times. (Timescale from 12/01/05 not met) COMMENT: Some records were available at this inspection, but not all required documents could be produced. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. The persons registered must ensure the home has an appropriate fire risk assessment and evacuation procedure, addressing all relevant factors. All records to be available at the home from 31/07/05. 6. YA41 17(2) & (3), Schedule 4(6) All records to be available at the home from 31/07/05. 7. YA42 23(4)(a), (b) & (c) Not later than 31/08/05. 8. 9. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 30 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. YA6 YA7 YA9 YA12 YA20 YA20 YA32 YA41 YA42 YA42 YA43 Service user plans should define the actions to be taken towards achieving longer term goals. There should be evidence of the input of service users into decisions about their own care, especially where any restrictions are to be imposed. When risk assessments identify the need for control measures to be in place, those measures should be defined as clearly as possible. There should be more detailed information in individual records about support to service users who have limited access to formal education or occupation. Two staff should check and sign medication administration records, especially where changes have to be made to these. Updated information from a consultant about use of medication for a service user should be incorporated into that individuals guidelines. More care staff should commence studying for NVQ awards as soon as possible. Monthly visits and reports on the service should include updates on any outstanding requirements from CSCI inspections. Fire safety records should show the actions taken when defects have been identified. All fire safety checks should be carried out and recorded at the prescribed frequencies. Steps should be taken to ensure that systems for demonstrating staff awareness of key policies and guidelines work effectively. COMMENT: It is expected that staff sign to demonstrate that they have read and understood guidelines. But this is not happening in all cases. Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 31 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Pennings View D51_S60337_PENNINGSVIEW_v241611_250505stage4.doc Version 1.30 Page 32 - 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. 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