Inspection on 12/01/06 for Pennwood Lodge Nursing Home

This inspection was carried out on 12th January 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

Pennwood Lodge Nursing Home 16/10/08

Pennwood Lodge Nursing Home 25/10/06

Pennwood Lodge Nursing Home 25/05/05

Pennwood Lodge Nursing Home 01/02/05

Pennwood Lodge Nursing Home 04/10/04

Pennwood Lodge Nursing Home 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Pennwood Lodge Nursing Home Wotton Road Kingswood Wotton-under-edge Glos GL12 8RA Lead Inspector Sharon Hayward-Wright Announced Inspection 12th January 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 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 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. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pennwood Lodge Nursing Home Address Wotton Road Kingswood Wotton-under-edge Glos GL12 8RA 01453 521522 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) pennwoodlodge@highfield-care.com Southern Cross Care Centres Limited Mrs Elizabeth Taylor Care Home 70 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (70) of places Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of five (5) service users from the age of 55 with dementia (Cat DE) can be accommodated. Date of last inspection Brief Description of the Service: Pennwood Lodge is a purpose built care home situated within grounds that are shared by a sister home. It is within the village of Kingswood, near WottonUnder-Edge in the South of the county, approximately midway between Bristol and Gloucester. The two-storey building is split into four separate units. Three of the units specialise in the care of elderly people with dementia and one has 14 beds contracted to Frenchay Healthcare Trust and provides care for elderly people with enduring mental health care needs. The Home offers predominantly single accommodation, although there are some shared bedrooms. Most rooms have ensuite facilities. Each unit has its own communal areas consisting of lounge/diner rooms and smaller, quiet lounges. There are other seating areas within the units. Each unit is accessed via a keypad system. The first floor units can be reached via a staircase or shaft lift. The central body of the building contains offices, kitchen and conservatory, which over looks the front lawns. An uninterrupted, level pathway is provided to the main entrance of the home leading from the car park, which is located in front of the building. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection by three inspectors, took place over 12 hours on two days in January 2006. Service users where able were spoken with to gain their views on the home; the care of service users was examined in detail and staff members were also spoken to, as well as the Manager and Operations Manager. One letter from a relative was received on the second day of the inspection. This letter highly complimented all aspects of the home. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendations made at the last inspection were followed up and records relating to the homes’ Statement of Purpose, Service Users Guide, service users care, medication, duty rotas, staff training, complaints, activities, food, personnel files, and servicing of equipment were examined and a tour of the home took place with a number of service users rooms inspected. Since the last inspection a new Manager has started at the home and she is in the process of applying to the Commission for Social Care Inspection to be considered for registration. What the service does well: The home is a purpose built unit allowing service users the freedom to wander in a secure environment. The meals in this home are good offering both choice and variety, and catering for service users special dietary needs. The home has comprehensive quality assurance systems in place that include the views of service users (where able), relatives and staff. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: On two occasions one inspector went on to Hawthorn Unit and found only one member of the care staff present. This situation could potentially put service Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 7 users at risk and can compromise their safety as several service users on this unit have unpredictable behaviour and a number wander. The inspectors were also concerned about the number of staff on night duty as two units share a carer, whilst the qualified nurse on each of these units also has to cover the unit above them if the care staff have any problems. The Manager said they are aware of this and are looking to review the staffing levels on nights as service users on one of the unit are becoming frailer. The inspector will monitor this situation. A number of rooms had strong odours; whilst the home is aware of these and is looking to address this problem it is unpleasant for the service users, staff and visitors to the home. Two units still require refurbishment and this will then address the ongoing maintenance issues identified at previous inspections. 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. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 8 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 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 9 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): 1,3 & 5 The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. However discrepancies have been found in some of the statements made in the Statement of Purpose. Arrangements are in place to ensure prospective service users and their family/representatives can feel confident that the needs of the service user will be met on admission to the home. EVIDENCE: The home’s Statement of Purpose and Service Users Guide has been reviewed following the merger with Southern Cross. Both documents contain detailed information about the services provided by the home. There are several statements in the Statement of Purpose that the inspectors did not see any evidence that they are taking place or are incorrect. These are: Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 10 • • • • • • To remove any reference to the Deputy Manager as the home does not have one and replace this with details about the House Managers. It states the minutes to the meeting are displayed by the conservatory, however they are displayed on the notice board by the Manager’s office. The terms ‘Matron’ and ‘Manager’ are used, this could be confusing to people reading this and clarity is needed on which term of address is to be used. The section about smoking needs to be clearer to explain where service users can smoke if they wish. Nursing care needs to be added to their registration category. That within six weeks a placement review takes place for new service users, and if the service user has a Care Manager they are invited. Otherwise the named nurse will organise a multi-disciplinary review and then 6 monthly thereafter. No evidence was seen to suggest this is happening, however a review was seen but this was undertaken by the House Manager and a member of care staff and was not a multidisciplinary review. One pre-admission assessment was seen and this contained comprehensive information about the service user. A copy of the letter sent to the relatives explaining the home is able to meet their needs was seen. This also included information about the relative visiting the home. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 11 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 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Arrangements are in place for service users to access health services. Safe systems for the management of medicines are in place and generally followed. The report illustrates some issues where more attention to detail would help to improve. EVIDENCE: Six-service users care was examined in detail. Laburnum unit care plans were not examined at this inspection. From the care plans examined the standard has improved since the last inspection with more detailed individual information about each service user and care plans addressing both physical and mental health needs. Staff spoken with demonstrated excellent awareness of the needs of these service users. Daily records are also maintained. The home is still in the process of changing from Highfield Care, care-planning format to Southern Cross. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 12 Risk assessments were in place for pressure sores, moving and handling, dependency, nutrition, continence and falls. Evidence was seen of ongoing reviews. Individual risk assessments were seen for example one service user had removed a window restrictor and the use of fixed height beds. A physical and social assessment was seen in care plans but one had not been signed or dated. A list of health professional visits are maintained as evidence of their involvement in the care of the service users, the inspectors did not see any evidence that service users are part of a Care Programme Approach. The home should find out if service users are subject to these and obtain copies of the necessary records. All medicine storage areas are clean and tidy and generally there is good record keeping for medication. The door on the medicine trolley on Hawthorn was buckled and could easily be opened without the key. This was repaired during the inspection. An additional trolley has been provided but all medicine trolleys are showing signs of wear and are due to be replaced. Written plans are being compiled to describe the use of some medicines prescribed ‘as required’. These are best kept with the current Medication Administration Record (MAR) charts. There are some more plans to complete. There are other examples of information of more complex medication use in the care plans. Dose directions on prescriptions must reflect the actual use of the medicines. There are examples of medicines given ‘as required’ where the directions indicate regular use. A check of prescriptions before they are sent to the pharmacy could assist with this and enable changes to be made before they are dispensed. This was a good practice recommendation at the previous inspection and is contained in the company medication policy. It would be opportune to introduce this with the planned change of pharmacy. There was evidence that a verbal medication change from a doctor had not been recorded or implemented for a few days. (Subject to a separate complaint investigation report). The recording of use of prescribed medicines for external use is not consistent. Alternative ways to record these were discussed. Medicines for two residents only needed occasionally were in stock but not included on the current MAR chart. The continued need for these to be reviewed with the doctor. Two packs of homely remedy medicines were out of date. The record book for these medicines did not reflect the stock in the cupboard. There was one oxygen cylinder past the printed expiry date. There was evidence of a small amount of one resident’s medication being used for another during August 2005. This is not a legal practice so good stock control must ensure medicines for each person are always available. Some tablet crushers were seen on some trolleys. Advice must always be obtained (and documented) from the pharmacist to ensure this is safe practice Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 13 for the particular medicine. The company has a policy about this, which must always be followed. Liquid medicines are prescribed if there are swallowing difficulties. The fixings on some cupboards in the clinic room need checking to ensure they can be securely locked. (The clinic room is locked.) Controlled drugs no longer needed must be returned via the licensed waste contractor using a denaturing kit, as is generally done in this home. There has been recent clarification that medicines must not be returned to dispensing surgeries. Lancing devices used by staff to obtain blood samples from individual residents need to comply with Medical Device Alert MDA/2005/063 – further information was provided. There is a comprehensive company medicine policy. Some revision is necessary to reflect new procedures for the return of medicines in accordance with the Special Waste Regulations 1996 and to reflect the change of company. Other sections needed are a procedure for handling verbal medicine changes from a doctor and a sheet of local information relevant to this home. The Operations Manager uses a quality audit tool for monitoring the management of medicines (good practice). This could usefully include audit counts of medicines to help demonstrate they are being given to residents correctly. First aid boxes are available on all units with checklists. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 14 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 & 15 There are activities offered in all of the units by the coordinator during the week. Activities are provided both individually and in a group to meet with service users needs. However during her absence and at weekends there is no evidence that activities are taking place. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Activities are now being provided to all service users by a new activities coordinator. A rough timetable is in place, which is changeable to meet with individual needs. Group work is provided generally in the morning, which includes exercises using a balloon, art/crafts based on seasonal subjects and outside trips to garden centres etc. Music and movement is offered every 2 weeks by an outside entertainer. Individual therapies are also offered, which include hand massage, reading, health and beauty. The co-ordinator is working towards providing a reminiscence and snoozelem room for service users to access. However it was evident that another staff member is required to assist with this work to ensure that all service users especially those who are not so able Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 15 and need one to one attention are provided with a form of activity and stimulation. Records are maintained by the co-ordinator for each service user, which states the activities provided. The need to provide some training to all staff who work within the home on recreational activities for service users with dementia was also evident. This would enable them to carry out some form of activities at weekends when the activities co-ordinator does not work. Lunchtime was observed on all units over the 2-day inspection. Service users were offered a choice of meal and staff assisted them in a sensitive and unhurried manner. Hot and cold drinks were also offered to service users. The chef was spoken to and he has recently had an Environmental Health visit when 2 requirements were made. These were to change a fridge and update their health and safety posters. The chef said these have been done. He is also to be awarded a certificate from Environmental Health acknowledging his high standards. The Chef operates a 4-cycle menu depending on the season. From the menus seen the home offers service users a balance nutritious diet with the Chef making the vast majority of the food from fresh ingredients. Food records are discussed in Standard 37. The inspectors sampled the food and found it to be delicious again a choice was offered. Staff confirmed the food provided is very good but one member of staff said the quality depended on who was cooking the food. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 16 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 & 18 There is a complaints system in place with evidence that views expressed by service users relatives/representatives are listened to and acted upon. Arrangements are in place for protecting service users from the possible risk of harm and abuse. EVIDENCE: The home has received 10 complaints in the last 12 months. The Commission for Social Care Inspection has received 1 complaint that is being investigated at the time of the inspection. At the last inspection the home was not able to find evidence that complaints were being dealt within the agreed 28-day timescale. At this inspection the home has found evidence that they were dealt with within the timescale. Records relating to all the complaints were examined. In some of these the relatives were asked if they were happy with the response and their comments are also documented. A copy of the home’s complaint procedure is displayed in the main entrance hall. One relative has written to the inspector saying that when they had expressed any concerns the staff and/or the Manager have dealt them with. The home has provided adult protection training to a large percentage of their staff but there are still some that require this training. A number of staff were asked questions about adult protection issues and they were able to provide the appropriate answers. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 17 The Manager is aware of the procedures to follow as a result of recent incident in the home. The Manager and Southern Cross acted promptly and appropriately dealing with this matter and the outcomes ensured the safety of the service users was paramount. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 18 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): 19,20,21,22,23,24,25,26 The environment is still in the progress of being refurbished and redecorated. Two of the units have now been completed and provide an attractive and homely place for service users to live. The other two units require further work to be undertaken to meet with the standards required. EVIDENCE: Southern Cross have now completely refurbished Sycamore and Willow units, which provide a homely environment for service users to live in. New lighting in the corridor areas of the home has also enhanced the surroundings and assist service users when walking around the units. Hawthorn and Laburnum are still in the process of being refurbished and the need to complete this work is now critical and the inspectors expressed this view at the time of the inspection. It was noted that curtains need replacing throughout the home, which would further enhance communal and service users rooms. Door handles were also Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 19 noted to be very tarnished and had paint on them as well as being loose and not easy to use. The majority of rooms in both Hawthorn and Laburnum units required redecoration and maintenance. Walls were very marked and stained. Door surrounds and general woodwork was damaged, chipped, marked and stained. Rooms 7. 9 and 13 in Hawthorn unit requires immediate attention due to prevailing odour. The flooring in these rooms was also very sticky. A headboard was broken in Room 12 and a hole in the wall was noted in Room 13. In Laburnum unit furniture required attention in Rooms 33 and 40 and the door did not shut in Room 42A. Sluice rooms were very odorous throughout the home. It was pleasing to note that some new beds had been purchased which meet with the service users needs. Six more have been ordered and are due to be delivered soon. The Manager stated that a programme was in place for one new bed to be purchased each month. It was evident that further pressure relieving equipment is required in the home to ensure that service users are provided with the appropriate mattress on their beds to meet their needs. Staff must also be aware of other pressure relieving appliances and obtain them when required. All of the bathrooms have now been fitted with either a Parker bath or an assisted bath and hoist except for Bathroom 13, which still requires further work to be carried out. Staff indicated that they found that the new baths and hoists were not appropriate to meet with the service users needs. The Manager was aware of these issues, which would be followed up. The Laundry was inspected and it was noted that the safety bar on the iron was broken and two switches on one of the dryers had fallen off and need replacing. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 20 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, & 30 After a period of instability in staffing, there is a good match of staff offering consistency of care within the home. Training opportunities have been provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. Since the last inspection the standard of vetting and recruitment practices has improved, however not all appropriate checks are being carried out, potentially leaving service users at risk. EVIDENCE: Off duty rotas were examined with the Manager and the Operations Manager. The home has not used agency staff since December. Staff expressed concerns about the night staffing situation, as Hawthorn and Sycamore share a member of care staff and both have a trained nurse, which also covers the unit above them. The Manager said this has been brought to their attention and as the service users on Sycamore are becoming frailer the home is looking to increase the number of care staff on duty. The inspector will follow this up. Staff said that they have been through a period of instability since the last inspection with staff leaving and being moved between units but they feel things are now settled. The inspector on two different occasions went on to Hawthorn Unit and found only one member of care staff to care for the service users. On this unit there Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 21 are several service users with unpredictable behaviour and service users that wander. Due to this the home must ensure that a minimum of two staff are present on the unit at all times to ensure the safety of the service users. Comments received about the staff from relatives were positive and included the way the staff interacts with their relative and themselves. Fifteen staff have left the home since the last inspection and seventeen have started. The home has five staff with NVQ 2 training and 1 member of staff has NVQ 3 and is an assessor. Personnel files of five recently appointed staff were inspected. Three files contained the required information by the Care Homes Regulations, however two files for overseas staff did not contain the required application form therefore the home is not able to explore any or check on employment history, and no recommended interview records. Training records were examined and the home has detailed records of training provided in both mandatory and other training. The home has made vast efforts at providing training for the staff, however not all staff have undertaken the training needed for the tasks they undertake. A number of staff are due to start a dementia training course. An induction booklet was seen and the supervisors name is written on the front of the booklet. Southern Cross has devised this training to meet the specifications of the National Training Organisation. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 22 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, 33, 36, 37 & 38 The Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives. The home regularly reviews aspects of it performance through a good programme of self-review and consultations which include seeking the views of relatives and staff. Systems are now in place to ensure staff receive appropriate supervision. The standard of record keeping has improved since the last inspection. So far as is reasonably practicable the health, safety and welfare of service users, staff and visitors are promoted and protected. EVIDENCE: Since the last inspection the home has a new Manager. She is a Registered Mental Nurse who has been qualified since 1981. The Manager is in the Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 23 process of applying to the Commission for Social Care Inspection to be considered for registration. Staff felt the new Manager has worked hard in improving the home and the all had positive comments to make about her. Evidence was seen of monthly relative meetings and one relative has commented on how useful these meetings are. Minutes of different staff meetings were also seen. Client surveys were seen and the results are displayed on the relatives’ notice board. The Manager has a weekly surgery for relatives and staff to attend if they wish to see her and she said she also has an ‘open door’ policy. Monitoring systems used by the home include pressure sore evaluation, auditing of service users accidents on a monthly basis and monthly auditing of moving and handling equipment. The home also undertakes monthly audits, one month it is completed by the Manager and the next month by the Operations Manager. Action plans are put in to place following these to rectify any issues identified. Other quality assurance procedures are documented in their Statement of Purpose. A supervision matrix was seen with dates and times when staff are to receive supervision and the date of any appraisal. All staff are to receive supervision six times a year. The home must maintain detailed records of all food provided to include any changes to the menu, service users that receive a special diet and the fillings used in the sandwiches and types of vegetable used. Maintenance records were seen as evidence of monitoring of equipment, this includes window restrictors, hot water taps, fire equipment testing and door guards. Records were seen of how the home is reducing the risks of Legionella. The pre inspection questionnaire provided details of servicing of equipment, however the date for when the home last had the electrical wiring test is missing. The home must provide evidence that this test has been undertaken to ensure service users and staff are not put at risk. Servicing of pressure relieving equipment by a suitably qualified person has started with six mattresses completed to date. Risk assessments for the environment have been undertaken. Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 24 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 2 x 4 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 2 3 2 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 4 x x 3 2 2 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 25 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 OP1 Regulation 4&6 Requirement The Registered Person must add to their Statement of Purpose that nursing care is provided and review the statements listed in this standard to ensure they are taking place in the home. The medicine policy and procedures to be revised to include the items included in this report. The Registered Person must provide suitable training for staff to ensure activities can be provided when the activities coordinator is absent. The Registered Person must continue with the refurbishment of the home to address the maintenance issues identified at previous inspections. Timescale of the 31/1/05 and 01/07/05 was not met. The Registered Person must ensure the areas identified in this report with odours are addressed. The Registered Person must ensure that at least two members of staff is present on DS0000038291.V266417.R01.S.doc Timescale for action 01/04/06 2 OP9 13 30/04/06 3 OP12 18 1(a) & c(i) 01/05/06 4 OP19 23(2a-c & j) 01/08/06 5 OP26 16(k) 20/02/06 6 OP27 18,1(a) 10/02/06 Pennwood Lodge Nursing Home Version 5.0 Page 26 7 OP29 7,9,19 & Schedule 2 8 OP37 17 & Schedule 4 (13) 9 OP38 23 2(c) Hawthorn Unit at all times due to the needs and safety of the service users. Since the introduction of the POVA scheme, and the amendments to the Care Home Regulations on the 26/7/04 for pre-employment checks on staff, the home must obtain the following for all staff recruited since this date: 1) Full employment history with satisfactory written explanation of reasons for gaps in employment. Timescale of the 30/3/05 and 01/07/05 was not met. The Registered Person must keep records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The Registered Person must repair the following in the laundry: • The safety bar on the iron as it was broken • Two switches on one of the dryers had fallen off and need replacing. 01/07/05 25/02/06 20/02/06 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 27 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 4 5 6 7 Refer to Standard OP7 OP8 OP8 OP9 OP9 Good Practice Recommendations The home should ensure that the member of staff completing assessments signs and dates them and ensures they are completed in full. The home should find out if any service users are subject to a Care Programme Approach and if they are, obtain a copy of the plan. The home should record in service users moving and handling assessments what equipment and slings are needed. FP10 prescriptions to be seen in the home before being sent to the pharmacy. Regular audits counts of medicines to be documented to help demonstrate that they are being given to residents correctly. The home should replace all the curtains in service users room and communal areas as they are worn. The home should maintain records of all prospective staff interviews. OP19 OP29 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Pennwood Lodge Nursing Home DS0000038291.V266417.R01.S.doc Version 5.0 Page 29 - 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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