Inspection on 25/10/06 for Pennwood Lodge Nursing Home

This inspection was carried out on 25th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pennwood Lodge Nursing Home 16/10/08

Pennwood Lodge Nursing Home 12/01/06

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 Key Unannounced Inspection 25th October 2006 13:30 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.V310566.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 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 pennwoodlodge@highfield-care.com 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) Southern Cross Care Centres Limited Mrs Patricia Anne Sheppard 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.V310566.R01.S.doc Version 5.2 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. 12th January 2006 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. All four units specialise in the care of elderly people with dementia. The Home offers predominantly single accommodation, although there are some shared bedrooms. Most rooms have en-suite 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 as well as one of the main entrance doors to the home. 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 overlook 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. Fee ranges are from £494.30 to £650 and do not include extras for example chiropody and hairdressing. This information was given to the inspector prior to the inspection. If a service user is privately funded and is in receipt of the Registered Nurse Care contribution Scheme (RNCC), this is added on to the fees. Copies of the homes Statement of Purpose and Service Users Guide is available in the main reception area. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over 3 days in October 2006. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was available during the inspection as were other members of the home team. A total of 27 standards were inspected. Service users were observed and where able spoken with to ascertain their views on the care and services provided. A number of surveys were left for staff and visitors to the home. Of these, six visitors returned theirs. All had positive comments to make about the home, one said ‘they feel confident in the knowledge that they are included in the care of their relative and they appear happy and comfortable in the home’. Another comment said the staff ‘are very kind and caring, with clean and cheerful surroundings’. The comments received from staff during the inspection all indicated they are very happy working at the home. From observations made of the service users they all appeared to be relaxed in their environment. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feed back on the inspection findings were given on completion of the site visit and were received in a constructive and positive way by the Registered Manager. All requirements issued at the last inspection have been addressed. What the service does well: The home has a secure environment so that service users are able to wander freely within their units. The meals in this home are good offering both choice and variety and catering for special dietary needs. The kitchen staff have been awarded 4 stars following a recent Environmental Health visit. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 6 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Arrangements are in place to ensure the home assesses all prospective service users to ensure their needs can be met. The homes complaints procedure is accessible to service users, staff and visitors to the home and they ensure their views are listened to and acted upon. 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 DS0000038291.V310566.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The homes Statement of Purpose and Service Users Guide are excellent providing service users relatives/representatives with details of the services the home provides enabling an informed decision about moving into the home. Arrangements are in place to ensure service users are not admitted to the home without first having their needs assessed and assurance that the home can meet their needs. EVIDENCE: At the last inspection the home needed to review their Statement of Purpose and Service Users Guide, this has been completed. A copy of the homes Statement of Purpose and Service Users Guide is on display in the main entrance to the home. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 9 Pre admission assessments were seen on several recently admitted service users. All had a comprehensive assessment completed prior to admission. Several service users had come from a hospital and discharge information from them was available. One service user had copies of their assessment completed by a Social Worker and another had information from a Doctor. A copy of the letter sent by the home to the service user’s family confirming they can meet their needs was seen in one service users file. During the inspection a group of relatives arrived at the home unannounced as they were looking for a placement for their relative. The Registered Manager gave them a tour of the home and spent time with them answering any questions. It is not always possible for prospective service users to visit the home prior to moving in, however the Registered Manager encourages their relatives/representatives to visit the home unannounced at a time convenient to them. Pennwood Lodge does not provide intermediate care. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. 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, however improvements with the standard of record management will ensure service users are not put at risk. Personal support provided by staff in this home ensures that service users privacy and dignity are protected. EVIDENCE: The care of eight service users was examined in detail and three of these were recent admissions to the home. The three recent admissions all had an up to date assessments of needs, whereas the remaining five had an assessment of need carried out in either September 2005 or in one case June 2004. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 11 The home must consider ways of ensuring service users have an ongoing assessment of needs. Care plans were detailed and personalised to each service user. Two of the recent admissions took place during the inspection and the staff had started to write their care plans. Reviews were seen of care plans. Assessments were in place for continence, bowels, pressure sores, moving and handling, nutrition and dependency. All had been reviewed on a monthly basis. Risk assessments were in place for service users to include falls, bed rails and any other risks identified. Again reviews were seen of these. The home had also started to complete assessments and risk assessments on the newly admitted service users. Daily records are maintained as well as relatives’ communication, clients’ weekly progress and if required fluid and diet and turning charts were all seen. In a small number of cases assessments and daily records were not signed and dated by the member of staff completing them. Reviews of service users care were seen and these included if applicable social workers and health professionals. Relatives are also invited to attend these reviews. Staff spoken with demonstrated good awareness of the needs of the service users in their care. Evidence was seen of health professional visits in each service users care file examined. The Chiropodist was visiting the home during one day of the inspection. A member of staff was also contacting the local GP for advice about one service user. Registered Nurse Care Contributions (RNCC) assessments were seen in some service users care records. Weight charts were also seen in several service users records and the frequency of this depends on their assessment. Influenza vaccine consent forms were evident in a number of service users care records. Medication was examined in each unit. A medication round was observed in each unit and the nurse wore a red tabard, as this requests that the staff member is not disturbed whilst undertaking administration of medication. Each member of staff used the medication trolley and took it to the lounge/dining room where service users were having their meal. When leaving the room the trolley was locked. Each unit has received a new medication trolley since the last inspection. The Medication Administration Records (MAR) were used as part of the process for administration. All MAR sheets were examined. Evidence was seen of medication received into the units and administered, with the exception of one new service user who did not have the quantity of medications recorded when they were received by the home. On the whole handwritten entries were signed and checked by another person. Again in the majority of cases care plans were in place for service users who receive ‘prn’ or ‘as and when’ medication. Three discrepancies were found on the MAR sheets in Sycamore unit and the nurse in charge was informed. On Hawthorn one service user was receiving an extra tablet to what was prescribed on the MAR sheet, the nurse Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 12 on this unit said the prescription had been altered but this was not transferred on to the MAR. Two other MAR sheets had gaps in from the night shift so there was no record to prove if this medication had been given or not. Dates of opening were seen on the majority of liquid medication but not on creams in one unit. Dates of opening were found on certain stock medication. A specimen signature and initials list was in place as well as an up to date drug reference book. A copy of the homes policy and procedure is also included with the MAR sheets. All service users medication records have a front sheet, which includes a photograph, allergies and room number. A homely remedy list had been signed by the GP. In one unit records were maintained of the reason why a medication was omitted. The ordering of medication was discussed with one nurse. The medication room was inspected and room temperatures are maintained along with the medication fridge. Stock medication was not examined in detail. Records were seen of medication to be disposed of and the home has a contract in place for their collection and disposal. Controlled medication was checked; all was correct except for one-service users Temzepam where the number of tablets did not correspond to the records. It appears that the home had received more medication but the amount of the new medication was not recorded in the Controlled medication register. The home did have a receipt from the chemist to confirm delivery. Auditing of the medication systems used in the home takes place monthly and the Registered Manager and records confirmed that the qualified staff have received training in relation to medication. Following the last inspection the home has a procedure in place to follow when taking verbal messages to change medication. Southern Cross has also reviewed their policy regarding disposal of medications. Staff were observed treating service users with respect and dignity. Staff also maintained service users privacy when attending to their personal care. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home provides a range of activities to meet service users choices, abilities and needs. Contact with family/friends and the local community are encouraged and maintained. Staff support and encourage service users to exercise choice and control over their lives. 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: The home has an activities coordinator who manages her time between each unit. The other part of her job is to encourage and support the staff to provide activities in her absence. During the three day inspection the coordinator was undertaking a variety of activities with service users and staff were also assisting service users in activities, however this is dependent on the needs and ability of each service user, which varies on each unit. The home plays music on each unit, which has helped to provide a calm environment. One service user commented that they enjoyed the music. The activities coordinator provides group and one-to-one activities and maintains records for Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 14 each service user. Other activities provided by the home include on a monthly basis music and movement and a church service. PAT dog also visits the home. Art classes take place every two weeks and the home has a part-time minibus driver to take service users on outings. Harvest festival celebrations had taken place recently. Posters are displayed in the main reception area. Where able the home encourages contact with the local community. In the summer the home had a joint fete with Kingswood Care Centre and they had plans to hold a bonfire on the weekend following the inspection. Each unit had built their own ‘guys’ for the bonfire and these were going to be judged by a relative. Due to the service users medical needs they are not able to go alone, however during the inspection several visitors to the home took their relatives out for a short walk. From observations, discussions with staff and from reading care records service users are able to make choices about their daily lives where able. This ability varies for each service user. The home has notice boards for visitors in the main reception area, which contains information about the home and other services outside of the home. Mealtimes in each unit were observed and found to be unhurried with staff offering assistance and support in a sensitive unhurried manner. The homes menus are on a four-week cycle, which include two choices. Choices were seen being offered to service users. The inspector tasted the meals on two of the days of the inspection and found them to be of a very high standard and very tasty. The Chef was spoken with and he confirmed that he ensures the service users receive a balanced and nutritious diet with fresh produce. The home has had a recent visit from Environmental Health and they awarded the kitchen 4-stars. Records were seen relating to the food provided to service users and health and safety checks. Staff on each of the units was seen providing hot and cold drinks to service users throughout the day. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The complaints process in this home is good with complaints information available to service users/relatives/visitors and had evidence that their views are listened to and acted upon. The home has arrangements in place for protecting service users from the possible risk of harm or abuse. EVIDENCE: A copy of the homes complaints procedure is displayed in the main entrance to the home. Records relating to complaints were examined. These included the complaint, response and any actions taken by the home to rectify the situation. One service user had complained to the Registered Manager and the records relating to this were also examined. From observations during the inspection the Registered Manager operates an ‘open door’ policy and a number of relatives were observed speaking to her. Staff spoken with all confirmed that they could approach the Registered Manager if they had any concerns or complaints. Due to the medical condition of the service users only a small number would be able to complain if they had any concerns. A comment card received from a relative following the inspection said that they could approach any member of staff if they had any concerns and these would be dealt with, therefore they said they have never needed to make a complaint. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 16 From discussions with staff and the Registered Manager and from reading the training matrix, the majority of staff have received training about abuse. Due to the high numbers of staff working at the home this is ongoing and recently appointed staff have not received this training, but plans are in place to provide it. Southern Cross has polices and procedures in place for the protection of vulnerable adults. These are available in the home. The home has not had to make any referrals to POVA. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 17 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, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Recent and the planned continued investment has and will significantly improve the appearance of this home creating a comfortable and safe environment for those living there and visiting. EVIDENCE: A tour of the home took place with a number of service users rooms seen. The main entrance to the home has been redecorated since the last inspection and a visitor has donated a large fish tank. A keypad system has been added to one of the front doors to assist with security and to prevent service users leaving the home unattended. Each unit also had a keypad entry system. At the entrance to each unit a seating area is provided and the staff on each unit have decorated them with a theme of their choice. One unit has created an outside seating area with a small water feature. The conservatory next to the main entrance has also been redecorated and new furniture provided. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 18 The redecoration of the home continues with both communal areas and service users rooms being redecorated. The areas that have been redecorated have greatly improved the environment for the service users. Several of the service users rooms seen have been redecorated and new curtains provided, again improving the environment for service users. Several rooms had been personalised with pictures and photographs. The family of a new service user were moving in their furniture and personal belongings during the inspection. Screening was seen in the shared rooms. The Registered Manager said they have plans in place to decorate service users doors in the colour of their front door when they were living in their own home. Some rooms have been started. Plans are in place to replace the door furniture as in places it is tarnished. The home still has fixed height beds in some service users rooms but plans are in place to replace these beds. Risk assessments were seen for service users who used these beds. Notice boards were seen on all units and one unit had photographs on their walls. Another unit has mobiles hanging from the ceiling in one of the communal rooms. On Sycamore unit one bathroom cannot be used as it has been condemned. The Registered Manager said quotes have gone in to replace this one as the service users like this style of bath. Only one room had an odour and the Registered Manager said the home is working hard to combat this and has plans in place to review the flooring. The home was clean and no issues were identified. Staff were seen wearing protective clothing as required. The laundry was inspected and there was a backlog due to the difficulties they were experiencing with a tumble dryer. The company were trying to repair it and replaced it however they could not get the new one to work. The Registered Manager had a plan in place to provide a short-term solution until the company could fix the dryer. Otherwise the laundry was organised and the assistant was seen delivering service users clothing to their rooms. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Since the last inspection the standard of vetting and recruitment practices has improved with the appropriate checks being carried out to reduce any risks to service users. Training opportunities are provided for staff to ensure they have the skills and knowledge to care for the service users in their care. EVIDENCE: Since the last inspection the Registered Manager has increased the staffing levels on Sycamore unit as the service users are becoming frailer and due to two admissions. The Registered Manager said the night staffing levels would increase as the number of service users increase. The staffing levels to the other units have not changed. The home is confident that the needs of the service users are being met. Agency staff are used if the home is unable to cover a shift with their own staff. One member of staff had been working a lot of hours; the Registered Manager said that this only happens in extreme circumstances due to shortages of staff and that she is monitoring the situation. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 20 From discussions with staff all said they felt the home has improved and that they all enjoy coming to work. Staff also demonstrated a good awareness of the needs of service users and all worked well with the service users in a relaxed manner. The home has six staff with NVQ 2 training, nine undertaking the course and they are waiting for verification for their overseas staff to their qualification and the NVQ 2. The personnel files of four recently appointed staff were examined. All had the required recruitment checks in place, to include a PIN check for a qualified nurse. Three had a POVA first check prior to starting work and but for the other member of staff the home had completed the full Criminal Records Bureau Disclosure, (CRB) prior to them starting, however the home does not get see a copy of these as they are held at their regional office. The home does receive notification from their regional office detailing if the CRB is clear or not but on this occasion it does not identify if a POVA check has been carried out. The Registered Manager said that a POVA is requested for all staff. All new staff receive an induction booklet that they keep with them. Qualified nurses receive different booklets to care staff. No changes have been made to the format since the last inspection. The new staff members mentor’s name is written on the front. One new member of staffs’ induction booklet was seen and this had been partly completed. New staff are supernumerary for a number of shifts and are supervised. The Registered Manager said that all qualified nurses are going to undertake the induction programme for a refresher course. The home has devised a training matrix that details when training has been undertaken and when it is next due. The Registered Manager monitors this to ensure staff attend training. Records were seen of mandatory training for staff to include fire, moving and handling and first aid. Posters were seen around the home advertising training for staff. Training is provided for qualified nurses to help maintain their PIN numbers and recent courses include CPR and care of the unconscious person. Staff spoken with confirmed that training is provided and several listed the courses they have attended or due to attend. One member of staff has attended a ‘trainers’ course to help train the staff about dementia and the Registered Manager said she has plans to also undertake this course. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The Registered Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives and she is able to discharge her responsibilities fully. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of relatives and staff. The home has safe systems in place to manage service users monies. The home needs to ensure the systems they have in place for staff to receive appropriate supervision are undertaken. So far as is reasonably practicable the health, safety and welfare of service users, staff and visitors are promoted and protected. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection the Manager has been registered with the Commission. She is undertaking the Registered Managers award. She is aware of the importance of keeping herself updated and is due to undertake a two-day course on health and safety. All requirements issued at the last inspection have been addressed. From discussions with staff all said they could approach the Registered Manager if they have any concerns and she would listen to their views and take action if required. Staff also said that they could approach her at anytime due to her ‘open door’ policy. A comment card received after the inspection from a relative said they value the close communication they have with all staff in the home. The home uses Southern Cross quality assurance systems audits to include monthly audits of the home, medication, accidents, pressure sores, moving and handling equipment and care plans. The Registered Manager one month and then the Operations Manager the next undertake the monthly audits of the home. Relatives meetings are held and minutes of these are displayed in the home. Minutes of staff meetings were also seen. The home has a notice board especially for visitors and relatives, which contains information about the home etc and their newsletter. The Registered Manager is going to send out quality assurance questionnaires to relatives and visitors to the home. The home manages personal allowances for a number of service users. They have a secure facility. The appropriate records and receipts were seen. The home can store valuables for service users but encourage families to take them home with them. The Registered Manager said staff supervision is taking place but they are not meeting the recommended six times per year. Qualified staff supervise senior carers and they then supervise carers. The Registered Manager supervises qualified staff and ancillary staff. She plans to provide training for staff that undertake supervision sessions and is going to put a plan in place to meet the recommendation. Maintenance records were checked and these include monthly checks on equipment. These checks include fire equipment (fire alarm tests are weekly), Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 23 bedrails, water temperatures, showerhead cleaning, window restrictors, wheelchairs, visual checks on pressure reliving equipment and the call bell system. Evidence was seen of a Legionella test. Other information about servicing of equipment was included in the pre-inspection questionnaire. The home has had their heating system checked but is awaiting proof from the company. The home has their fire risk assessment in place. Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 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 3 X 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 14(2) (a & b) Requirement The Registered person shall ensure that the assessment of the service users needs is kept under review; and at any time when it is necessary to do so having regard to any change in circumstance. The Registered Person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medications received into the home. (This relates to recording of medication on the Medication Administration Records and in the Controlled Medication Register) Timescale for action 30/01/07 2. OP9 13(2) 31/01/07 Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The home should ensure that the member of staff completing assessments and daily records signs and dates them when they are completed. The home should ensure that the notification from their regional office regarding Criminal Records Bureau Disclosure indicates; that if a POVA first check has not been undertaken a POVA check has been done and the outcome of this. The home should ensure that care staff receive six supervisions sessions per year. 2. OP29 3. OP36 Pennwood Lodge Nursing Home DS0000038291.V310566.R01.S.doc Version 5.2 Page 27 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.V310566.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!