Inspection on 25/05/05 for Pennwood Lodge Nursing Home

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 Poor. 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 12/01/06

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 Gloucestershire, GL12 8RA Lead Inspector Sharon Hayward-Wright Unannounced 25 May 2005 09:50 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 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 D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pennwood Lodge Nursing Home Address Wotton Road Kingswood Wotton-under-Edge Glos, GL12 8RA 01453 521522 01453 521551 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) Highfield Care Centres Ltd Mrs Elizabeth Taylor Care Home with Nursing 70 Category(ies) of Dementia - over 65 (70) registration, with number Dementia (5) of places Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A maximum of five (5) service users from the age of 55 with dementia (Cat DE) can be accommodated. Date of last inspection 1 February 2005 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 D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.45 hours on one day in May 2005 and two inspectors undertook this inspection. Twenty service users and 6 relatives were spoken with to gain their views on the home and the care provided. Six staff members, the Deputy Manager and Registered Manager were also spoken with. Staff were observed going about their duties and interacting with each other and service users. A tour of the premises took place and lunchtime was observed on two of the units. Care records, duty rotas, service users’ monies, supervision records and personnel files of new staff were inspected. A small number of requirements issued at previous inspections remain outstanding and must now be addressed and several requirements were not checked, as the time limit for completion has not expired. A recent merger between Highfield Care and Southern Cross has resulted in changes to the management structure of the company that manages Pennwood Lodge. What the service does well: The home has a core group of staff that provide continuity of care for service users. The meals in this home are good offering both choice and variety and catering for service users special dietary needs. As the home is a purpose built; service users can wander freely within their secure units. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Arrangements are in place to ensure service users are not admitted to the home without first having their needs assessed and the opportunity for the service users representatives to visit the home. EVIDENCE: A requirement issued at previous inspections for the home to send evidence to the Commission for Social Care Inspection that they are meeting Regulation 5 of the Care Homes Regulations in respect of RNCC payments (Registered Nurse Care Contributions) has not been met. However as Highfield Care has recently merged with Southern Cross the company has had to revise all its paper work. Following a meeting with Southern Cross the company has nearly completed this requirement and the information will be sent shortly to the Commission for Social Care Inspection. Pre admission assessments of two recently admitted service users to the home were examined. Both contained assessments of their needs and from this the care plans for their care have been devised. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 9 A relative of a recently admitted service user said she was able to view the home prior to admission and from this and discussions with the staff in the home felt confident the needs of her relative would be met. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10 The home now has a clear and consistent care planning system in place to adequately provide service users with a plan of care to meet their needs. However care plans must be individualised for specific service users needs. Service users have the opportunity to access outside health professionals for their assessed needs. Personal support in the home is offered in such away as to promote and protect service users’ privacy and dignity. EVIDENCE: The care of five service users’ was examined in detail. A marked improvement had been noticed in the care plans on two of the units. Assessments were in place for pressure sores, nutrition, continence, moving and handling and falls. In several care plans risk assessments were in place for the use of fixed height beds and the removal of the call bell from the service users’ room. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 11 One recently admitted service user’s pre-admission assessment was not dated or signed by the person completing it and the moving and handling assessment was not completed in full. Written plans of care were in place for all service users whose care was examined in detail, however more information is needed on certain care plans to ensure the care is individualised for the service user. For example the care plans for personal care state “assistance of one carer is needed”, but it does not state what assistance is needed. Another care plan stated a service user needed “prompting with continence” but again does not describe the prompting needed. Social care plans and care plans for mental health needs are starting to be devised for each service user. All care plans inspected had evidence of monthly reviews. A service user’s relative has signed one care plan and they were aware of the care needs of the service user. Daily records are maintained and records of health professionals visits were seen. There was no evidence seen in service users’ moving and handling assessments of the type of equipment needed. There was also no information seen in service users’ care plans that any service user is subject to Care Programme arrangements. If service users’ are subject to this arrangement a copy of the plan should be obtained. Medication was not inspected in full only the administration procedure was observed on one unit. The Qualified nurse followed an unsafe procedure that could potential put service users at risk. Staff were observed undertaking their duties and interacting with service users. The staff were seen to maintain service users’ privacy and dignity at all times. The communal corridors do not have any curtains or blinds at the windows leaving service users and staff exposed to people looking in. Due to the medical condition of the service users, and some tend to wander; the home is not maintaining service users’ privacy or dignity. The Registered Manager said there are plans to put up screening at the windows and it is on order, however no date for completion was given. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 &15 Social activities are now organised, creative and provide stimulation and interest for service users living in the home. Service users are able to maintain contact with their relatives, friends and representatives. Meals are nutritious and balanced and offer a healthy and varied diet for service users. EVIDENCE: The home has two staff with designated responsibility to provide activities for service users. One of these staff members has recently attended a one-day seminar about activities for service users with dementia. Activities are provided for service users in groups and on a 1:1 basis. The home now has a shop where service users are able to purchase toiletries etc. As mentioned in standard 7 the home is starting to devise social care plans for service users listing activities that they enjoy so activities can be tailored to meet their needs. On the day of the inspection the hairdresser was visiting the home and several service users from one unit were going out for a drive in the mini bus. From discussions with staff members some said they provide activities for service users in their units and these include singing along to the piano and playing games. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 13 Visitors to the home confirmed they are able to visit when it is convenient for them and they can see their relative in the communal areas or in the service users own room. Service users personal effects were seen in their rooms during the tour of the home. Lunch was observed being served in two units. Staff were seen assisting service users discreetly and allowing them time to finish their meal. On Laburnum Unit meals were observed left on the side uncovered to get cold whilst the staff assisted other service users with eating their meal. This issue about meals left to get cold on the side has been mentioned in previous inspection reports, however the staff assisting service users with eating their meals ensured that each service user received their meal in full and they had a drink. Whilst on this unit it was noticed that not all staff assisted service users in eating their meals but were undertaking other duties like completing the off duty. Service users, staff and service users relatives commented on the standard of food provided in the home saying choices are offered and the standard of the food provided is very good. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints process in the home is poor. Although complaint information is available for service users and their relatives/representatives, there is no evidence that these concerns are acted upon. EVIDENCE: The homes complaints and whistle blowing policy is displayed on the notice board in the home and the complaints policy meets the requirements of the Care Homes Regulations. The home has received three complaints and from the information in the home these had been forwarded on to the Operations Manager. However there was no further information to say how either the home or the company dealt with these complaints. The company have now updated all adult protection policies. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24 & 26 The standard of the environment is in the process of being refurbished and redecorated to make the home more attractive and homely place for service users to live. EVIDENCE: The home is in the process of being redecorated and some of the bathrooms are being refurbished. The areas that have been completed have improved the environment for the service users. As part of the redecoration the home is looking to assist service users in recognising certain rooms with the use of colour coding for example all frames around the toilet doors are being painted a different colour to other doors in the home. The remaining maintenance issues require action. Willow Room 43 - hole in back of bedroom door panel and front door panel en-suite. Room 58 - slight odour of incontinence. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 16 Hawthorn Room 1 hole in walls and wardrobe corner damaged. Coat hook loose on door. En-suite door panel damaged. Broken tiles in the en-suite. Room 3 - shared room. Wall light broken. Light switch broken above this bed. Could not activate pull cord above this bed. Dimmer switch damaged, had exposed peg. The knob was missing. Room 4 - Crude piece of wood screwed on back of door presumably for a coat hook, which was missing. Room 8 - remove Minor wall damage at bed head. Minor damage to easy chair. Pull cord broken in en-suite. Room 9 -. Main light not working. Room 10 - Coat hook missing from rear of bedroom door. There are holes where one use to be. Room 11 - marks on wall next to en-suite. Holes where clothes hook use to be. Room 12 - shared room. Clothes hook loose. Room 13 - Door Guard not operating correctly on impervious floor covering. Room 14 - bedroom door sticking on carpet, not closing correctly. (no Door guard fitted). Room 15 - wall light not functioning at bed head. Laburnum Room 30 - hole in wall at wardrobe side of room. Room 42 - hole in en-suite door. Damage on wall surface near T.V. also two holes in wall near T.V. Lounge. Two holes in corridor wall at doorway to lounge. Room 38 - Door Guard not operating correctly on floor covering Bathroom 13. Used as storeroom. Room 32 - Pull cord too high in en-suite. Visitors’ toilet. Hole in corridor wall next to this toilet. Room 30 - hole in wall next to wardrobe. Each unit has it owns communal areas and these include a sitting area near the main entrance doors and 2 lounges/dining rooms. The home is in the process of refurbishing several of the bathrooms. The home provides equipment to assist staff in caring for service users; these include hoists, height adjustable beds and assisted baths. Evidence of servicing of hoists was seen. A number of service users have electric alternating pressure relieving mattresses. The home was not able to provide evidence that this equipment is being serviced by a suitably qualified person and the Registered Manager said the maintenance people have not received training in how to service the equipment only visual inspections. If the maintenance people are to service this equipment they must receive adequate training to equip them with the necessary skills. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 17 During the tour of the home service users personal possessions were seen in their rooms and some families have brought in photographs to assist the home in making the rooms more personal for each service user. Several visitors commented on the cleanliness of the home saying they have never smelt any odours and that it is always clean and tidy. Staff were seen wearing protective clothing when necessary. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Since the last inspection improvements have been made to the standard of vetting and recruitment practices to ensure service users are protected. EVIDENCE: A warning letter was sent to the company following a visit to the home and the evidence given by the staff that one of the units had worked with one carer less that the agreed limit between the Commission for Social Care Inspection and the company. The company conducted a full investigation and found that their procedures were not being followed and an actions have been put in place to address this. Copies of the homes off duty were provided as evidence the home is staffed to agreed levels. The staff spoken with demonstrated a good understanding of the needs of the service users and this was evident from the positive relationships, which have formed and were seen between the staff and service users. Visitors spoken with all said the staff in the home were always willing to assist service users and were friendly and helpful. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 19 The home has 305 care hour vacancies and they are in the process of recruiting staff. To fill these vacancies the home uses agency staff or the home staff work extra hours. The home has a core group of staff that provide consistency for service users. The standard of recruitment practices has improved since the last inspection, however improvement is still needed to meet the Care Homes Regulations. From personnel files inspected of recently appointed staff not all had a full employment history or medical information. Criminal Records Bureau checks must be completed on all staff prior to appointed even if they have come from another country and they must be received back into the home prior to the new staff member starting work. There was no evidence that interview records are kept and that the home has devised a risk assessment that should be used if a Criminal Records Bureau check is returned with convictions or cautions listed. There was no evidence in staff files that induction programmes were taking place, however the Registered Manager said all new staff keep their induction book with them and they are returned to the Registered Manager once completed. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 & 36 Procedures are in place to ensure staff are appropriately supervised and service users’ financial interests are safeguarded to protect and promote service users’ health, welfare and safety. EVIDENCE: From discussions with staff and visitors to the home they all said they could approach the Registered Manager or any member of staff if they had any concerns. Three relatives said they are always kept up to date with the condition of their relative and always informed if they have had an accident. The home manages a number of service users personal allowances. All monies are stored separately and computerised records are maintained and receipts kept. Some receipts are signed but it is recommended that all be signed. One service user’s money was found to be £1 short, the administrator was addressing the issue during the inspection; however the home must ensure that all service users records and monies tally. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 21 Records are in place detailing service users subject to the Power of Attorney processes. Staff supervision is now underway with the Registered Manager keeping a timetable of when each member of staff supervision is due. Records are maintained. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 2 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x x 3 x x 2 2 x x Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 23 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 2 Regulation 5 Requirement Timescale for action 1/9/05 2. 7 15 3. 9 13(2) 4. 10 12 The Registered Person must send evidence to the inspector that they are meeting Regulation 5 in respect of RNCC payments and information given to the service user or their relative/representative. Timescales of the 10/1/05 and 1/4/05 were not met. However Highfield Care has recently merged with Southern Cross therefore the company has had to revise their paper work. Following a recent meeting with Southern Cross this information will be sent to the inspector shortly. The Registered Person must 10/9/05 ensure that service users care plans are individualised to meet their needs. The Registered Person must 25/5/05 ensure that medication is stored securely during the adminstration process and that the Medication Adminstration Records are used as part of the this process. The Registered Person must 10/9/05 ensure that screening is provided communal corridors to protect Version 1.30 Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Page 24 5. 15 16(2i) 6. 7. 16 16 22 22(8) 8. 19 23(2a-c & j) 9. 22 23(i) 10. 22 181(c) & 23 (2c) 11. 29 7, 9, 19 & Schedule 2 service users privacy and dignity. The Registered Person must ensure that service users meals are not left to get cold whilst waiting for a member of staff to assist them with eating. The Registered Person must respond to complaints within the 28 day time limit. The Registered Person must send to the Commisision a statement detailing a summary of complaints received in last 12 months and the action taken in response. The Registered Person must address the maintenance issues listed in standard 19. Timescale of the 31/1/05 was not met. This requirement was not assessed in full as the time limit had not lapsed. The Registered Person must ensure that the home has adequate storage areas. Timescale of the 31/5/05 was not met. This requirement was not assessed as the time limit had not lapsed. The Registered Person must ensure that a suitabley trained person services the homes pressure relieving equipment and maintains records as evidence this has been addressed. 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) Criminal Records Bureau disclosure (including where a POVA check where applicable). 26/5/05 26/5/05 1/9/05 1/7/05 1/7/05 1/9/05 1/7/05 Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 25 12. 35 16(l) 13. 5(1) 1 2) Full employment history with satisfactory written explanation of reasons for gaps in employment. 3) Evidence of physical and mental fitness for the purpose of the work. Timescale of the 30/3/05 was not met. The Registered Person must ensure that the records and monies held for service users are the same. The Registered Person must add to their Service Users Guide the following informaiton: A copy of the homes terms and conditions and contract The address and telephone number of the Commission for Social Care Inspection A copy of the last inspection report or reference to where this can be found. Timescale of the 10/1/05 was not met. The company has requested an extension on the time limit to complete this requirement due to the recent merger of the two companies. 23/6/05 1/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 7 7 8 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 being more specific in care plans and not use the words regular and frequently. The home should include in service users moving and handling assessments what equipment and sling if required is documented. D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 26 Pennwood Lodge Nursing Home 4. 5. 6. 7. 15 29 29 29 8. 9. 10. 35 36 7 The home should ensure that all staff assist where practicable with service users meals to prevent service users meals being left on the side to get cold. The home should maintain records of all prospective staff interviews. The home should devise a risk assessment to be used in case a Criminal Records Bureau disclosure reveals convictions or cautions. The home should, following the amendments to the Data Protection Act last year, store Criminal Record Bureau disclosures separate from staff personnel file. They must also be stored securely. The home should ensure that all receipts that relate to service users monies are signed. The home should discuss at staff supervision sessions the importance of prioritising service users needs before other duties. The home should find out if any service users are subject to the Care Programme Arrangements and if they are, obtain a copy of the plan. Pennwood Lodge Nursing Home D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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 D51_D03_S38291_Pennwood Lodge_v229526_250505_Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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