Inspection on 15/01/08 for Penny Pot Care

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Penny Pot Care 8/16 Alton Road Clacton on Sea Essex CO15 1LB Lead Inspector Pauline Dean Unannounced Inspection 15th January 2008 09:25 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 Penny Pot Care DS0000070527.V358127.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. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penny Pot Care Address 8/16 Alton Road Clacton on Sea Essex CO15 1LB 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) 01255 424077 01255 473096 Integrity Care Services Ltd Mrs Lori Chaslot Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38) of places Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home - PC to service users of the following gender: Both whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP Dementia - code DE The maximum number of service users who can be accommodated is 38 New Service 2. Date of last inspection Brief Description of the Service: Penny Pot Care provides care for up to 38 OP with DE category. The accommodation is provided in a property refurbished from five adjoining houses. There is a range of communal areas on the ground floor. Bedroom accommodation is on the ground and first floor and there are staircases and a passenger lift. The accommodation comprises of one double and thirty-six single rooms. The one double room has en-suite facilities of bath, wash hand basin and toilet and six of the single rooms have en-suite facilities of a toilet and a wash hand basin. Within the home there is five bathrooms, which are located on the ground and first floor. Catering and laundry services are in-house. The home is located close to the sea front with local shops; GP surgeries, churches and a hospital close by. The property has gardens to the front and rear of the property, with some car parking on a forecourt. The current range of fees, as at the site visit were said to be £387.50 per week to £505.38 per week. Toiletries, newspapers magazines, hairdressing and chiropody are an extra cost. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection of the Penny Pot Care took place on 15th January 2008 over a nine-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since Integrity Care Services Ltd. became the new service providers in September 2007 and looking at records and documents at the care home. We were able to speak with the Interim Manager of the home (referred to as manager in this report), care staff, catering staff and the people living at Penny Pot Care. The Registered Manager of the home was on long- term sick leave. The Responsible Individual of the company came into the home during the inspection. The Annual Quality Assurance Assessment (AQAA) completed in November 2007 was considered as part of the inspection process and a tour of the premises was completed at the visit to the care home. Surveys were sent to the home for distribution to all of the people living at Penny Pot Care and three surveys were completed and returned to us by the people using the service, four by relatives/friends and one by a staff member. During the inspection visit three people who live at the care home, two care staff and a catering staff member were spoken with. All of the people living at the home were pleased with the service they received. What the service does well: Penny Pot Care has admission processes, which were found to be comprehensive and detailed, giving sufficient information for the development of a care plan. Staff were found to be friendly and relaxed and during our visit to the home and they were seen to chat and joke with the people living in the home as they assisted and supported them with their care. People living at Penny Pot Care said that they enjoyed the food served at the home. Individual choices are catered for and the residents appreciated this. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Penny Pot Care DS0000070527.V358127.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 Penny Pot Care DS0000070527.V358127.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who come to live at the home can be confident that their needs will be fully assessed and these will be met. EVIDENCE: The admission paperwork of three people who had entered Penny Pot Care was sampled and inspected at the site visit. Two of these were admissions made in January 2008. Detailed records and a photograph of the individual were found on each file. A care placement assessment had been completed by the home with both a hospital placement assessment and Social Services assessments held on file. Risk assessments and a resident’s handling assessment had been completed in both instances. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 9 The manager said that they had conducted these assessments visiting each person in hospital prior to their admission to the home. During the visit we were able to speak with one of these most recent admissions to the care home and they were able to confirm that they were visited in hospital before they were admitted to Penny Pot Care. They confirmed that they had also been able to visit the care home before moving in. They said that staff and the manager had been very kind and had supported them as they had entered the home and they had been able to bring in their own television, music centre, some items of furniture, books, photographs, ornaments and pictures. No intermediate care is offered at Penny Pot Care. Penny Pot Care DS0000070527.V358127.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, people who live at the home can expect to have their needs, including their health identified within an individual plan of care and these needs will be met. Care practices in the home ensure that the people who live at the home are treated with sensitivity and respect. EVIDENCE: Three care plans were sampled and inspected at the inspection. The care plans of the two most recent admissions were inspected and whilst it is recognised that they had only entered the home in that week a good basic care plan had been developed. The manager said that they expected to add to this document as needed and gradually over the next few days and weeks expand this document to a full comprehensive document. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 11 The manager said that they are currently reviewing and revising the care plans of the remaining twelve residents. A person-centred approached is being adopted and an example of this revised document was seen. Care planning needs such as personal care; physical well-being, physiological well-being and nutritional needs were detailed in this format. Recommendations were made as to the presentation and separation of the different personal care needs in this document e.g. bathing, washing and dressing. It was agreed that a detailed plan of action is required to ensure that the independence of the person living at the home is not compromised and the carer is fully aware of their duties. This was not clear in the care plans sampled. In addition there is a need for the development of the care plan needs to cover all aspects of health, personal and social care needs, for whilst some account had been taken of personal and health care needs, little consideration was given to social care needs. Records relating to health care needs were seen within the care plan and in separate record sheets e.g. nutritional needs, medication assessments and Waterlow Pressure Area assessments. Record keeping in these areas was detailed and comprehensive and a clear picture of each person’s care needs was found. Little information around health and personal care needs was provided in the completed Annual Quality Assurance Assessment (AQAA). It was stated that the new providers had taken the home over in September 2007 and that they had only had the opportunity to speak with the residents who said that their needs were met. The new providers said that they anticipated conducting a through review of this aspect of care to ensure that residents’ needs are met. Many of the people living at Penny Pot Care had been able to stay with the GP they had had prior to coming into the care home and one person said that they found this very reassuring, as they knew them well. A question relating to medical support was asked in the survey work conducted by the Commission for Social Care Inspection (CSCI). Three people living at the care home who had completed these surveys said that they always received the medical support they needed. At the site visit medication administration, storage and record keeping was sampled and inspected. A senior carer assisted with this aspect of the inspection. They had a good understanding of the processes and procedures involved in medication administration and were confident and competent in dispensing medication. The dispensing of medication was observed at lunchtime. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 12 Records were seen of medication coming into the home and leaving the home and we were informed that the home conducts both a weekly and a monthly audit of medication procedures in the home. Records in place supported this. Overall medication records were seen to be in good order. An exception was found in the Medication Administration Records (MAR) sheets of one person who had recently been admitted to Penny Pot Care. Medication – Minocvol and Senna were noted on their MAR sheet, but it was unclear from the coding used as to whether these medication had been given or whether it was available in the home to be given. Both the senior staff member and the manager said that they would look into this matter, clarifying with care staff the correct entry required on the MAR sheet. The list of staff signatures and initials of those staff giving medication required updating, for it was noted that two carers had left. The senior carer said that this would be actioned immediately. Medication storage is in two medication trolleys, which are secured and locked in the dining room. The home has a controlled drugs cabinet, but at the time of the site visit was not holding or administering any controlled drugs. During the visit to the home we observed staff being both supportive and sensitive to residents needs. Words of encouragement were given as a resident was supported to walk to the dining room and assistance offered as required with feeding. Within the survey work conducted by the Commission a relative said that the care home gave both ‘care and kindness’ and three people who live at Penny Pot Care who had completed a survey said that staff listen and acted on what they say. Penny Pot Care DS0000070527.V358127.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home should expect to be given choices about how they spend their time, visiting arrangements and meals. EVIDENCE: People spoken to during the visit to the home were generally happy and contented. Observation, discussion and records seen detailed some activities, which people had enjoyed. Photographs of some activities such as the Christmas party and entertainment were on display and A4 pictorial posters were seen on display on an Activity Board located in the hallway close to the dining room. The manager said that this board is used to offer and encourage activities to residents. However this was not evident during our site visit. Survey work completed by the Commission had three responses from three people who live in the home. One said that there were never any activities arranged that they could take part in; one said that there were sometimes activities arranged that they could take part in, but they ‘would like to go out Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 14 more’ and the third person said that there was sometimes activities arranged by the home that they could take part in but with failing eyesight they had problems playing games, but they did ‘like listening to music.’ Two relatives had also commented in their completed surveys that they felt the home should provide more stimulation and activities for the residents. On our site visit it was noticeable that some people lack stimulation, for the majority of the day they sat in the lounge watching television. It was evident from observation and from speaking to the people living at the home that they entertained themselves by talking and watching television. Occasionally staff would interact with the residents and a good example of interaction was seen when a staff member who had brought in photographs of the resident who they had worked with shared these with them. The Annual Quality Assurance Assessment (AQAA) stated that they will consult with the people living at Penny Pot Care and activities will be offered on a one to one and in groups. It was acknowledged that staff require training to offer suitable activities and stimulation and record keeping within care plans. From speaking to two people who live at the home and the manager we understand that visitors are welcomed. As the new manager of the home, they said that they are endeavouring to make themselves known to visitors and relatives as they visit the home. Within the Commission for Social Care Inspection (CSCI) survey work completed by relatives, four relatives had completed and returned their survey. Two had not answered the question – ‘Does the care home or agency help your friend or relative to keep in touch with you?’ One person has said that they usually did and the fourth said ‘has never been given the time or help to phone or write to relatives.’ The manager acknowledged that as a new manager and a new registered provider this is something the home needs to develop. The manager said that residents are encouraged to handle their own financial affairs for as long as they are able. They told us how families and solicitors assist with this and one person spoken to on the inspection had a clear understanding of how their money was managed and arranged with family assistance. The financial arrangements for the two most recent admissions still had to be arranged, but we were able to see the record keeping and auditing relating to personal expenditure for two people. Both the record keeping and the money was in good order. A comment was made in a relative’s survey. They said that they felt the home was ‘Beginning to manage personal money spending better.’ Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 15 In survey work conducted by the Commission two people had said that usually like the meals served at the home and one said they always liked the meals served. The home’s chef said they try to offer a varied and wholesome menu. At least two to three choices are offered for lunch each day and if these are not acceptable salads, jacket potatoes and soup are on offer. They said that at least two desserts are available each day, with once again alternatives such as Jelly and fruit. The home’s chef said that they are in charge of ordering food supplies and whilst there have been some changes since the new providers took over the home, systems are developed and established. Frozen, fresh and dried food supplies were seen in the home and with planned shopping these would seem to be sufficient for the current resident group. Record keeping relating to menu planning and recording was managed well generally. Some recommendations were made with regard to more detail in the breakfast record keeping and one chest freezer did not have records of regular temperature checks. The home’s chef agreed to develop the breakfast records to evidence that the people living at Penny Pot Care have a balanced and varied diet. The shortfall regarding keeping a record of a freezer temperature is to be completed by the home’s chef. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect their concerns to be taken seriously by the care home. EVIDENCE: Integrity Care Services Ltd. have developed a complaints procedure for Penny Pot Care. It is to be found in the Service Users’ Guide of the care home. Within this document it is agreed that an acknowledgement is to be made within 24 hours and the complainant should expect a response within 7 days. Details of the Commission for Social Care Inspection (CSCI) are to be found in this document. The manager said that the care home has a Complaints Record Form and an example of this form was seen. Since taking over the home, Integrity Care Services Ltd. has dealt with a complaint forwarded by the Commission to the home. This concerned problems with the home’s heating system and lack of food over a weekend. Integrity Care Services Ltd. had looked into these matters and advised the Commission for Social Care Inspection (CSCI) of the problems they had experienced and how this had been overcome. Their response had been submitted within the required timescale. Whilst the home and manager were aware of this complaint, no central log is in place for it’s recording. Within the Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 17 AQAA it was said that any complaints received should be regularly reviewed to ensure that the care home is addressing any shortfalls in their service. Without a central logging system this would be difficult. Two people spoken to at the inspection said that if they had a complaint they would raise it with senior staff or the manager. Survey work completed by three people using the care service said that they would talk to staff should they have any complaints, but all three said they were unsure what to do should they need to make an official complaint. Three of the four returned survey forms from relatives had answered the question – ‘Do you know how to make a complaint about the care provided by the home or agency if you need to?’ Two said that they did know how to make a complaint; one said that they couldn’t remember how to complain and one had not answered this question. From this survey work and observation it would seem pertinent to review and promote the home’s complaints procedure with both residents and their families. Penny Pot Care has Safeguarding Adults policies and procedures. These documents detailed the different types of abuse and outline the procedure of what to do should a staff member witness abuse. Whilst these documents were detailed and comprehensive, little information was given as to contact details for the Essex Social Care Direct Safeguarding Adults team. Contact details were given to the manager and the care home might benefit from producing written documents that sets out a step-by-step guide for staff to refer to in the event of the manager being absent from the home. For whilst two care staff spoken to had some understanding of the need to raise concerns with the manager, they did not have an understanding of Safeguarding Adults referral procedure and neither had received adult protection training in the past year. The format for the Policies and Procedures of the care home are such that they are to be found in a large file and rather than being separated, each policy runs on from the previous. Both an index and separation of each policy would make each policy easier to find. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall Penny Pot Care provides a safe environment that is accessible to residents. However, people’s lifestyle would be greatly improved with an investment in the home’s communal areas and toilet and bathrooms. EVIDENCE: Penny Pot Care is undergoing decoration and refurbishment. Both the library and the main lounge have been re-decorated and new carpets have been fitted here and in the corridors. Both of these rooms looked fresh and clean. On the day of the inspection, the home’s handyman was in the process of decorating the first floor corridor and landings and the smaller quiet lounge at one of the end of the home has been cleared and prepared for decoration. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 19 The manager said that as new residents come into Penny Pot Care, bedrooms are decorated. This was seen in three bedrooms, which had been decorated. New carpets had been fitted and new bedcovers and curtains added. One of the people in one of these rooms said that they were really pleased with their room and they said they had been able to choose their room and gradually they were adding pieces of their own furniture. It was recognised by the new providers that the home was looking tired and in need of attention. Within the AQAA it was stated that since taking over the home in September 2007, the new providers had commenced a programme of improvements. They said that they realised that ‘the home was in a very tired state’ and they said that they would ‘endeavour to refurbish as much as we can as the homes occupancy levels increase’. Within a relative’s survey it was commented on that ‘They are also starting to face lift Penny Pot and doing so slowly but well.’ Whilst it was noted as we toured the home that there were sufficent bathing facilities for the current number of residents i.e. two walk-in baths and one bath with a bath chair, the need to review bathing facilities throughout the home is being considered. The current bathrooms look old and worn and the manager said that other bathing facilities not currently in use will be reviewed to ensure that Penny Pot Care has sufficient and suitable toilet, washing and bathing facilities to meet the needs of the people living at the care home. The laundry sited in an outbuilding at the rear of the property has been decorated, new work surfaces and new flooring fitted. Within the laundry there are two industrial dryers, three washers – one professional and two domestic. The laundry person told us that one of washers was out of action at the time of the inspection. The manager said that they would look into getting it repaired. The laundry person said that they worked three hours each weekday and with the current level of occupancy they said that they were able to complete the laundry daily. Overall, residents spoken to said that their laundry was completed well and in a short time span. It was acknowledged that occasionally items of clothing go missing, but normally they are found and returned. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect to be supported by staff, but not be confident that staff will have sufficient skills and knowledge to meet all of their needs. EVIDENCE: Staff rotas were seen and inspected at the inspection. The manager said that staffing levels are calculated on the needs of the people living at Penny Pot Care. They said that additional staff are on duty at mealtimes and this was seen on the rotas. They did recognise however, that in determining staffing levels they should consider the dependency needs of each individual resident. At the site visit staffing levels were found to be sufficient to meet the needs of the people living at the home and two people living at the home said that they receive assistance, as they required it. The manager said that there are currently eleven members of staff of which five carers have a National Vocational Qualification (NVQ) Level 2 in care or above. Two staff spoken to at the inspection said that they were keen to undertake further training. Prior to the new providers taking over Penny Pot there had been no training in 2007. Within the AQAA the new providers Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 21 acknowledged that they needed to develop a training programme, for it was recognised that refresher training in basic training topics such as moving and handling, food hygiene, infection control, first aid and adult protection require updating. During the inspection the Responsible Individual visited the home and said that Integrity Care Services Ltd. have employed a training co-ordinator and training courses in Moving and Handling and First Aid were planned in January. A maximum of six staff will be able to attend these courses and a second course will be planned later in the year. They said that they are looking to develop a training and development programme for each staff member and both staff members spoken with confirmed that training issues had been considered in recent supervision sessions. One staff survey completed and returned to the Commission said that they felt that they received training relevant to their role. The majority of care staff have received training in dementia care and one carer said that they had missed this training, but they were hoping to complete this in the near future. The manager said that no new staff have been employed since the new providers took over the home in September 2007. Three staff files were sampled and inspected at the inspection. It is acknowledged that there have been changes to the paperwork used in recruitment and the manager said that further changes are planned. Within this sample, a shortfall was found; one carer only had an applicant’s copy of a Criminal Record Bureau (CRB) Enhanced Disclosure from their previous employer. The manager acknowledged this shortfall and said that they would discuss with the new provider the need to review all Criminal Record Bureau (CRB) disclosures held by current staff. Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured of a good management structure, although there is a need to develop a quality monitoring and quality assurance system and health and safety systems to ensure that the people living in the home are protected. EVIDENCE: The registered manager of Penny Pot Care is on long-term sick leave having been off since September 2007. An Interim Manager was brought into the home in December 2007. Their role is to manage the home in the absence of the registered manager and to promote and advertise Penny Pot Care, which is Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 23 now registered for people with dementia. The manager spoke of ways in which they intended to do this and they said they already have links with leading dementia care bodies. The majority of care staff have had some dementia care training, but it is recognised that there is always a need to update and refresh this training. The Responsible Individual said that initially they had been in day to day charge of the home when the Registered Manager went off sick, but with the current arrangements of an Interim Manager in post they will complete Regulation 26 visits and reports to oversee the management of the home at this time. Notifications as required under the Care Homes Regulations 2001 – Regulation 37 were discussed and considered at the inspection. Whilst these have been completed and sent to the Commission some important information and detail had been omitted. The manager agreed to update the Commission with this information. At the time of writing this report this is still required. The need to develop a quality assurance and a quality monitoring system was discussed with the manager. They said that they had given this some thought and were looking towards calling regular residents/relative meetings every four weeks, with a view to developing a quality assurance process. The manager said that the home currently holds money and valuables for ten residents. From sampling the records and money of two people living at the care home, these accounts and money was found to be in good order. Currently the home does not provide staff with appropriate levels of Health and Safety training. As stated previously in this report this matter was considered at the inspection and the need to develop individual training programmes was recognised. Safety certifications were sampled and inspected at the inspection. Current safety certificates were seen for Electrical Installation, current until March 2009; Periodic Inspection Report for an Electrical Installation, current until February 2009 and certificates of inspection were seen for Fire Alarms and Emergency Lights completed in December 2007, with both Fire Extinguisher inspections planned in May 2008 and Periodic Appliance Testing (PAT) testing in April 2008. Penny Pot Care DS0000070527.V358127.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 X X 3 X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 15 Schedule 3 (i)(b) 18(1)(c) Requirement Timescale for action 11/03/08 2. OP30 OP38 3. OP33 24(1)(a)( b), (2)(3) People living in the home must be assured that all of their care needs will be met. This is with particular regard to social care needs. People living in the home must 11/03/08 be assured that staff are competent and skilled through the development of an individual staff training and development programme, which must include health and safety training and refresher training. People living in the home must 11/03/08 be assured that their views will be heard and listened to through the development of a quality assurance and quality monitoring system. Penny Pot Care DS0000070527.V358127.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 OP9 Good Practice Recommendations People living in the home should be assured that care staff will use the correct coding on Medication Administration Records (MAR) sheets to ensure they receive medication as they require. People living in the home should have access to a range of social and recreational activities that will provide stimulation and improve their lifestyle. The home should ensure that care staff have clear safeguarding adults information to make a referral as needed. The home’s environment should be improved to ensure that people live in a homely and comfortable place. The home should continue to redecorate and re-carpet bedrooms, communal spaces, hallways and toilets and bathrooms. 2. 3. 4. OP12 OP18 OP19 Penny Pot Care DS0000070527.V358127.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Penny Pot Care DS0000070527.V358127.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. 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