CARE HOME ADULTS 18-65
Penrith Drive 55 Penrith Drive Wellingborough Northants NN8 3XL Lead Inspector
Mrs Helen Wilson Unannounced Inspection 10th November 2005 15.00 Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 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 Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Penrith Drive Address 55 Penrith Drive Wellingborough Northants NN8 3XL 01933 678681 01536 711761 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) Royal Mencap Society Mrs Elizabeth Anne Grout Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home may only admit service users aged 35-65 The total number of service users must not exceed six Date of last inspection Brief Description of the Service: 55 Penrith Drive is a care home providing personal care and accommodation for 6 Service Users aged 18 - 65 years. The premises are rented by the organisation MENCAP from a local housing association, North British Housing. Located in a suburb of Wellingborough, the home is easily accessible by public transport, close to local shops and the town centre amenities. The home was opened in 1998 and consists of a detached, two storey house offering single bedrooms for all residents. The communal areas consist of 2 dining rooms, lounge and kitchen. There is a garden area and car parking spaces. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is on the outcomes for service users, and on their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 2 residents and tracking the care they receive through review of specific records, observations of them and care practices, and discussions with the care staff, The inspection took place during a late afternoon and early evening over a period of 3 hours and was carried out on an unannounced basis. Communal areas and some bedrooms were visited. A selection of care records and essential records of the home were reviewed and discussions took place with the Deputy Manager and staff on duty. Most of the residents were spoken with and care practices were observed as part of the inspection process. Following the inspection visit telephone conversations were held with the Registered Manager. What the service does well:
The home provides good quality care and support for up to six residents who have high levels of dependency and limited verbal communication skills. Resident’s holidays are arranged on an individual basis, and one person had flown abroad for the first time. Staff are actively trying to involve the residents in planning the menu and have produced a menu book in picture form. The resident’s rooms and communal areas viewed on this inspection were well decorated and furnished to a good standard. Staff receive a range of appropriate training to enable them to care for the residents. Seven staff have achieved National Vocational Qualifications at Level 2 and 3. Four people are presently undergoing assessment for NVQ. The Registered Manager and the home’s deputy manager are completing NVQ level 4. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 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. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.4.5 The published information regarding the home is not available in a format that is suitable for the existing or potential service users. EVIDENCE: The home needs to apply for a change in the registration certificate to include personal care for a current resident who additionally has a physical disability. An application to vary registration conditions must be submitted with the fee and a revised statement of purpose for the home. Mencap forms including service user guides and individual care plans, policies and other documents used by the home are not produced in a format that is user friendly for residents who have limited verbal or written communication. There has been no progress made in producing the home’s guide and information for service users in video form; this issue was a recommendation of the previous report but not completed by the home. Although there has been no admission to the home in the last year, the process of admission does include visits to the house prior to becoming resident. Contracts relating to terms and conditions of each resident’s placement must be signed off by the home and the individual service user or his/her representative; this issue was a recommendation of the previous report but not completed by the home. Two residents files were reviewed, and although both contained a contract, neither had been signed by the resident or a representative.
Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 The home provides good quality care and support for the residents who have high levels of dependency and limited verbal communication skills. EVIDENCE: Care plans have been drawn up along with risk assessments of abilities and care needs of individual residents and the plans are clear, comprehensive and regularly reviewed. As is the case with other documentation, care plans are not in a format suitable for residents with verbal and written communication difficulties. Holidays are arranged to suit individual resident’s choices and one person had a first experience this year of flying abroad with staff. Group meetings with residents have been found to be impracticable however experienced staff and families are regularly involved in helping with decisions relating to residents. Records relating to residents and confidential telephone discussions are contained within the office.
Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Residents are given opportunities for personal development through daytime activities. A wider range of leisure activities is still being considered. EVIDENCE: Residents are encouraged to be as independent as possible and to develop their personal and daily living skills. The environment and staffing arrangements gives the service users support and supervision as required. All of the residents attend specialist day care services, on a full time or part time basis. The staff team have not yet established a plan for evening and weekend leisure activities that would be suitable and interesting for individual residents. Residents are encouraged to stay with staff whilst household tasks are performed for example when their rooms are cleaned. Family contact is maintained where appropriate. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 11 Residents holidays are arranged on an individual basis, taking into account individual likes and dislikes. Residents eat in two dining rooms and are assisted by staff. Residents attending day centres take sandwiches for their lunch, the main meal being in the evening. Residents are assisted to contribute to the menu by looking at pictures of meals. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 The general health care needs of residents are met. EVIDENCE: Residents are registered with local health practices and their general health is monitored by the home staff and any problems identified, dealt with at an early stage. Records of visits to healthcare professionals are maintained. The home has not involved each resident and their families where appropriate in planning for illness, ageing and death. Managers of the home acknowledged that these aspects of care needs to be discussed. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaint and protection processes are adequate and sufficient to protect residents. EVIDENCE: The home has a policy and procedure on the Protection of Vulnerable Adults and staff confirmed they had received training, or were about to attend courses, on the reporting of abuse. A number of compliments from families were recorded. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Although the home was generally comfortable, the lack of urgency in repairing showers and the hot water supply puts service users at potential risk regarding personal hygiene. EVIDENCE: Repairs and maintenance of three shower facilities and a hot water supply had been reported two weeks previously to the landlords of the premises but no firm dates established to safeguard the personal hygiene of service users. An immediate requirement was issued during the inspection to have these repairs completed urgently. The home has specialist bath and shower equipment that is suitable for the care needs of a physically disabled resident. Communal areas were well furnished, clean and pleasant. There were no malodours in the home. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36 The staff team are experienced, knowledgeable about the resident group, and competent. EVIDENCE: Staff receive a range of appropriate training to enable them to care for the residents. Seven staff have achieved National Vocational Qualifications at Level 2 and 3. Four people are presently undergoing assessment for NVQ. The Registered Manager and the home’s deputy manager are completing NVQ level 4. Staff are given formal supervision every 6 to 8 weeks. Staff on duty were approachable, supportive and had easy rapport with the residents. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 The home continues to ensure that the residents’ rights and best interests are considered on a daily basis, however there needs to be a formal annual system of Quality Assurance review. EVIDENCE: The Registered manager is currently completing a National Vocational Qualification at level 4. There was no evidence available of an annual Quality Assurance review process that involved the views and feedback of residents. Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 3 3 1 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 1 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Penrith Drive Score x 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x 1 x x x x DS0000012886.V264571.R01.S.doc Version 5.0 Page 18 No 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 YA27 Regulation 12,13 Requirement Repairs and maintenance of three shower facilities and a hot water supply must be completed as a priority. This was an Immediate Requirement made during the inspection. An application to vary registration conditions must be submitted with the required fee and a revised statement of purpose to include a named, current resident with a dual diagnosis of learning disability and physical disability. The Statement of Purpose and Service User guide must be available in a format suitable for people living at the home. Contracts relating to terms and conditions of each individual resident’s placement must be signed off by the home and the individual service user or his/her representative A plan for leisure activities that would be appropriate and of interest to individual residents must be developed. A quality assurance process must be established that
DS0000012886.V264571.R01.S.doc Timescale for action 18/11/05 2 YA1 4,6 31/01/06 3 YA6YA1 5 31/01/06 4 YA5 5 31/01/06 5 YA14 16 31/01/06 6 YA39 YA2724 31/01/06 Penrith Drive Version 5.0 Page 19 publishes an annual review of the home’s service user surveys and informs an annual development plan for the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Penrith Drive DS0000012886.V264571.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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