Inspection on 13/06/07 for Pentrich Residential Home

This inspection was carried out on 13th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pentrich Residential Home 11/12/09

Pentrich Residential Home 23/11/09

Pentrich Residential Home 25/09/09

Pentrich Residential Home 29/05/09

Pentrich Residential Home 03/06/08

Pentrich Residential Home 04/12/07

Pentrich Residential Home 29/06/06

Pentrich Residential Home 12/01/06

Pentrich Residential Home 27/01/05

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

CARE HOME ADULTS 18-65 Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ Lead Inspector Sarah Sadler Key Unannounced Inspection 13th June 2007 09:00 Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 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 Pentrich Residential Home DS0000061162.V334806.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 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. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pentrich Residential Home Address 13 Vernon Road Bridlington East Yorkshire YO15 2HQ 01262 674010 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) Mr Olu Femiola Vacant Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 Brief Description of the Service: Pentrich is registered to provide accommodation and personal care for a maximum of thirteen (13) younger adults who have a mental health problem. Three (3) of the service users may be over the age of 65. Nursing care is not provided. Should such care be required on a short-term basis then it will be provided by the community health services. Pentrich is a linked double fronted property situated in a residential area of Bridlington and is conveniently located for all of the main community facilities including the public transport network. A parking area is available at the front of the property. There is also restricted on-road parking. The property has three floors with the service users’ accommodation located on two floors. The accommodation consists of seven shared bedrooms and two single rooms. One room has en-suite facilities. Bathing/toilet facilities are available on each floor of the property. A dining room and two lounges, one designated for the use of service users who smoke, are located on the ground floor. The property does not have passenger lift and is consequently only considered suitable for service users who are fully ambulant. Current fees for the accommodation and personal care of service users range from £300 to £650. The registered person provided this information. The service users are charged for ‘additional’ services such as: Hairdressing, chiropody, toiletries, magazines and newspapers, some social activities and transport. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection material completed by the home, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit to the home on the 13th June 2007. This unannounced site visit was undertaken by one inspector over one day; the site visit commenced at 09.00 am and finished at 4.45 pm. On the day of the site visit the service users were relaxing in the home, Time was spent in the main area of the home observing everyday life and conversations were held with several service users. Further conversations were held with two staff members; there were no visiting relatives or health professionals available to talk to. There is currently no registered manager as they have recently left their post. Two senior members of staff and the registered person assisted the inspector. A tour of the premises was undertaken and service users’ files and other records were examined. Questionnaires were utilised as part of this inspection, they were sent to Health and Social care professionals and service users. Two social care responses and ten service user responses were received. Responses from service users reflected that they were happy living in the home, however the professional responses did raise concerns as to some of the standards in the home. Service users did not add any additional comments to their surveys, Comments from professionals included; ‘The home appears neglected’ and ‘ It needs a professional manager to pull things together’. Responses from the surveys are included within the report. The registered manager has previously ensured that notifications of incidents within the home have been forwarded to the CSCI, for example when service users have had an accident or are unwell and require hospital treatment. There have been no complaints to the CSCI or directly to the home. There has been one safeguarding adults investigation, which was investigated by the Local Authority, and no protection issues were found. The registered person provided a list of dates that he had attended the home to check the quality of the service as per the requirements of regulation 26. A brief summary as to the actions undertaken during the visit was also included. What the service does well: Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 6 People are happy with the food provided which is of a good quality and meets their dietary needs. Service users are happy with the support they receive from the staff. Service users are able to complain and there is a complaints policy in place to assist them with this. What has improved since the last inspection? What they could do better: Service users do not have care plans in place to provide information to staff about the service user and their needs and assist staff with meeting of them. Risk assessments, which help identify and prevent the risk of harm must be completed to help protect people. These should include the identified risk and what procedures are in place to protect people from the risk. There are few leisure activities provided and these should be introduced so that service users’ leisure needs can be met. Records relating to people’s health needs must be completed so that staff have up to date and accurate records and can fully assist service users in the meeting of these needs. Service users must be supported by increased levels of staffing as currently there are not enough staff to fully meet peoples needs. Service users must be supported by staff who are adequately trained and qualified to meet their needs. The environment must be improved through a programme of refurbishment and redecoration to ensure that service users live in a clean and comfortable home. Staff recruitment procedures must be improved upon to ensure that all staff have a Criminal records bureau (CRB) or POVA first check in place, which would help to ensure that only people suitable to work with vulnerable people are employed. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 7 The fire practices and procedures must meet with the requirements of the Local Fire Authority to ensure that service users are protected from the risk of harm from fire. Health and Safety checks, including those for electrical wiring must be completed to help ensure that service users live in a safe environment. A registered manager must be in post to help to ensure the effective running of the home and that service users’ needs are fully met. 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. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 8 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 Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to and whilst living in the home to ensure that the home are fully aware of and can meet the service users current needs. EVIDENCE: Three service user files were examined. Each of these contained an initial assessment completed by a Local Authority. These assessments had been undertaken to determine the individual’s needs prior to them moving into the home. There was no evidence of updated assessments or care plans in the service user files until January 2007, when a new assessment has been undertaken. Discussions with the registered person regarding the previous and updated assessments prior to January 2007, reflected that these records are not available. Although the home has an up to date assessment of the service user that could be used to produce a plan of care, which will provide care staff with the basic information for meeting the service users’ needs, previous information would Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 10 assist them to complete a full picture of the service user and how their needs have changed and developed over time. Some of the service users have lived in the home for a number of years. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can make some decisions in their lives. However care planning and risk assessments are not in place to help to ensure that needs are met and people are safe. EVIDENCE: Of the three service user files examined none contained an up to date and fully completed care plan, detailing their strengths and needs and the support required to meet their needs. Old records included a short and long term goal plan, with no details of how staff were to support service users to ensure that these needs are met. One service user was aware of having a plan of care and one was not. Care plans would assist the staff to ensure that they are aware of, and know how to meet individual needs and without these there is the potential for service users to be placed at risk. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 12 Service users were observed in the home to be able to choose how to spend their time. People were observed to spend time in the rear courtyard, smoking lounge, main lounge area or their bedroom. Some service users were observed to be able to access their local community without additional support from staff. People confirmed when asked at the visit and in the surveys they returned that ‘yes’ they were able to do as they like. Service users have two files which include their personal information. In the one that includes their daily diary notes the risk assessments are blank. In the second file there are basic risk assessments. These were not clear or comprehensive; there were no dates on them and no evidence of review. Clear, comprehensive and up to date risk assessments support the service users to live their lives as they wish whilst reducing the risk of harm occurring. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users receive a healthy diet and are supported to maintain contact with friends and family. However opportunities for leisure activities and access to their community are limited and do not ensure that their leisure needs are met. EVIDENCE: There was little evidence of activities undertaken, apart from walks, watching TV and listening to music. One service user undertakes part time paid and voluntary employment. A staff member confirmed that the service users are able to attend a coffee morning once a week, a bingo session another day, going for walks and out shopping. Structured activities offer people the opportunity for stimulation and entertainment, accessing their local community Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 14 would assist service users to develop a sense of belonging and also offer the opportunity for developing friendships. Service users’ rooms included photos of people’s families. A staff member stated, when asked, that people receive visits and telephone calls from their families. However individual records contained no details of these visits; such as if they were a positive experience for the service user and their family or if any additional support was required with this. At the last visit a requirement was made regarding service users dignity and that people had their cigarettes and personal monies withheld and given as treats. There have been no changes in practice since the last visit and consequently no evidence to suggest that people now have free access to their cigarettes and personal monies. One person was observed to ask for and be ‘given’ their cigarette. Service users are supported to meet their dietary needs. The individual assessment includes details of people’s likes and dislikes and the cook was aware of this. The lunchtime meal was of a good quality and all service users said that they enjoyed the food provided in the home. Lunch was a relaxing social occasion for service users to meet up. Where necessary service users are offered additional support from staff with eating their meal. Some records are kept of individual’s weights to help the service users and staff monitor peoples dietary needs. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to have their medication needs met. However record keeping does not ensure that peoples health needs can be fully met. EVIDENCE: Service users spoken with were all happy living in the home. Service users’ daily notes included some details of their personal care needs, for example, ‘had a bath today’. Service users are able to choose their clothes and their appearances reflected their individual personalities. Service users were observed to get up as they wished and people’s appearances reflected their individual personalities. Only limited information was available regarding the health needs of the service users and the support received in the meeting of these. All three of the service user files examined, included recently introduced sheets to record any visits to or from health professionals. With only three entries being made Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 16 on one sheet. However previous diary notes related visits to health professionals. Unclear health records do not assist the staff to fully support the service users in the meeting of their health needs, and may cause confusion preventing these needs being adequately met. One professional response noted that: ‘there have been times when health needs are not always noticed.’ People are supported to receive their medication by the care staff. Records are kept of all medicines entering, administered and disposed of in the home. Medication is stored in a cupboard, which both in the morning and afternoon of the visit was found to be unlocked, this was later rectified. There are no controlled drugs stored in the home and there are no risk assessments relating to medication or offering service users the opportunity to self medicate. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are able to raise concerns and felt sure these would be dealt with, but are not protected from the risk of harm. EVIDENCE: There are policies and procedures available within the home, which support people to raise any concerns. The complaints policy contains timescales for responses and the details of the CSCI should someone be unhappy with the response within the home. Staff and the service users spoken with were all confident that they were able to raise any concerns and that these would be dealt with appropriately. The senior staff member confirmed that there are no records of complaints as there have been none in the home. The home has a policy regarding protecting vulnerable people and both of the staff on duty were either aware of this policy or responded appropriately when asked as to the actions they would take should a safeguarding adults situation occur within the home. However none of the staff have undertaken formal training regarding this issue and there was no evidence that this policy has been amended to ensure that it meets the ‘Safeguarding Adults’ policies. There was no evidence that staff have received training in the use of restraint to ensure that if this is used within the home, people are restrained safely and the risk of harm is minimised. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 18 The recruitment procedures used within the home do not ensure that service users are safe and protected from the risk of harm. This is described in more detail later in the report. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a home that, although they are happy with, requires a large amount of redecoration and some refurbishment. EVIDENCE: Redecoration of the hall, landing and stairway areas has taken place. However as part of this the carpet has been removed away from the edges/walls and leaves the carpet grippers exposed. In many areas the carpet has been covered in tape to help reduce trip hazards. However there are areas where there remains the potential for trips to occur and the registered person confirmed on the day of the visit that the carpet will be replaced within 28 days of the visit. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 20 Bathrooms were also in need of or close to the need for redecoration. One bathroom had a bath panel, which had been broken and was taped up; a toilet seat was missing, with another appearing very old and worn. One shower area was mouldy and a shower door was stored in a service users’ room. No explanation for this could be offered. This does not provide service users with a relaxing or pleasant environment in which to meet their personal hygiene needs. Service user rooms all contained personal times of the service users offering them the chance to develop their own areas and reflect their individuality. One service user has a large room and has been able to furnish this into a bed sit type room. Although service users were on the whole, happy with their rooms standards varied. One room had been redecorated (the large room), however as far as staff were aware others had not been redecorated in over 7 years. One mattress was damaged and had been taped up, and one bedroom had a carpet, which was ‘bleached’. One service user would like their room redecorated but is aware that for this to take place they would have to vacate this room and stated that they would not like to do this and that there would be nowhere else for them to go. A service user also commented when asked about the standards of decoration in the home ‘ you’ve got eyes’. The communal areas of the home are also in need of redecoration with paint missing on the walls of the lounge and the ceiling being very faded. Service users are provided with high back chairs, although several of these had the foam either missing, loose or taped back on to the arms. The dining room contained a small television, used by service users. An individual service user had purchased this television and it is required that the home should provide such items for communal use. The kitchen area is also nearing the time for refurbishment. There are two cupboard doors missing and the flooring is in need of further attention. Some areas of the floor have already been taped up to reduce the risk of trips or falls. The registered person confirmed that following the replacement of the hall and landing carpets the kitchen is to be refurbished. There is a cleaner employed within the home two hours a day, five days a week. However due to the size of the home and need for improvements it is recommended that the registered person consider increasing the domestic support within the home. There is a separate laundry area, which provides the necessary equipment to support service users with their laundry. Fire procedures within the home do not currently meet the requirements of the local fire authority. No records were available to ensure that the fire detection and alarm system were up to date and in good working order. Doors were held open by wedges, including the door to the smoking lounge. No recent checks Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 21 had been undertaken of the emergency lighting. The fire fighting equipment has been checked within the last year. Currently the front doors of the home are not connected to the fire alarm and can only be opened with keys held by the staff. There is no fire risk assessment in place. A fire officer from the Local Fire Authority was contacted at the time of the visit. He advised that a visit to the home would be taken the following day. Although with immediate effect the use of door wedges was to cease, all doors should be closed, particularly at night and specifically those doors, which lead onto the stairwell. An immediate requirement notice was issued to the home regarding this and the registered person agreed to carry out these actions. Also that following the visit of the fire officer the registered person would confirm in writing to the CSCI by 5 pm that day, how they would meet the requirements of the local fire Authority. This was not received and after further discussion this was received 5 days later. The fire officer confirmed in their visit that door wedges were still in use, and in addition issued a Deficiencies notice to the home, as it does not meet the requirements of the Local Fire Department. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported by insufficient numbers of staff, who have not been adequately recruited and who are not well trained. EVIDENCE: The duty rotas reflected that there are usually two staff on duty in the daytime, and one waking and one sleeping night staff. In discussion the service users felt that there were enough staff, however the staff did not feel that numbers were adequate and the representative of the registered person also confirmed that the registered person is to increase the staffing numbers. In doing so it would ensure that there are adequate staff to support service users to attend hospital appointments without leaving one staff alone, also offering the opportunity for more staff to complete or offer leisure activities to service users. There are only limited staff records held by the home. All staff complete an application form prior to employment and references are sought. However the registered person confirmed that up to date Criminal Record Bureau (CRB) Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 23 checks or Protection of Vulnerable Adult checks are not undertaken prior to people commencing work and that previous CRB checks are accepted. This does not ensure that people do not hold a conviction that would prevent them from working with vulnerable people, or that they are not registered on the POVA list which prevents them from working with vulnerable people. Service users’ safety is not assured and this was discussed at length with the registered person and his representative. The registered person is aware that in order to help to ensure people’s safety, the correct recruitment procedures must be followed. One staff member stated that they would not recommend the home to a family member. And that there is no discipline with the service users and felt that the home would be better if they were allowed to discipline the service users. An induction into the home is undertaken to ensure that staff are aware of the safety issues, including fire, when they commence employment within the home. There is no evidence that the induction meets the requirements of Skills for Care, which would ensure that staff have adequate basic knowledge in the meeting of service users’ needs. The two recently employed staff confirmed that they are both qualified to National Vocational Qualification (NVQ) level 2 and 3 and consequently have not undertaken an induction into the home. Training which would help to ensure that staff have the necessary skills to be able to fully support service users in the meeting of their needs has not taken place. The registered person confirmed that the home does not meet the requirement that 50 of the staff team are qualified to National Vocational Qualification (NVQ) level 2 or equivalent. There are plans are in place for staff to undertake some training, but no training has taken place since the last inspection visit. This includes mandatory training for example, Health and Safety Moving and Handling, and Equal Opportunities or specialist training relating to the mental health needs of the service users. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is not adequately managed and which does not ensure that their health and safety needs are met. It offers some limited opportunities for them to be involved in its development. EVIDENCE: There is no manager in place within the home, although the registered person confirmed that he is currently recruiting a person for this role. The registered person has undertaken some monitoring visits to audit the home and check the standards of care provided. He has completed reports regarding this as are the requirement of regulation 26 of the Care homes Regulations 2001. However he Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 25 stated that many of the requirements in the home relate to the lack of a manager being in post. The registered person did not initially reply in writing to confirm that he would ensure that the home would meet the requirements of the Local Fire Authority, as issued in the immediate requirement, on the day of the visit. And consequently continued to breach Regulation 23 of the Care Homes Regulation 2001. A competent and qualified manager would assist the home to meet the required National Minimum standards and ensure that people’s needs were met and people were safe. One professional commented, ‘ The staff have not really had adequate support’. There is not a fully operational quality assurance system in place, which would enable service users and their representatives to be involved in the ongoing development of the home. Initially when asked the registered person was not aware of any quality assurance work, however he later found service users surveys that had been partly completed. There were no surveys for other stakeholders including relatives or other professionals and no reports or information have been compiled into a quality assurance report. Service users are supported with the managing of their finances. There are records kept of the service users’ finances held within the home. Service users sign when they receive their monies from the home and receipts are kept of all purchases made with or on behalf of the service users. These records are regularly checked by more than one person to ensure the opportunity for errors is reduced. Health and Safety issues are not addressed systematically or in a timely fashion. There is a record that Gas checks have been undertaken and that the gas systems are safe in the home. There was no evidence that the electrical wiring or electrical equipment is safe. No risk assessments for safe working practices have been completed. There are only 3 product data sheet held to support staff in the correct handling of chemicals and spillages, and no evidence that staff have read and understood these. Accident records are kept to record if a service user or staff member is injured in the home and the actions taken to attend to the injury and support the individual. The hot water supply in the bathrooms and in service users’ rooms exceeded the recommended 43 ° centigrade, with no risk assessments or warning signs in place to assist in the prevention of someone being scalded. The registered person must ensure that the risks of scalding are identified and reduced to protect service users and staff from the risk of harm. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 x LIFESTYLES Standard No Score 11 X 12 1 13 2 14 X 15 2 16 1 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 x 1 X 1 X X 1 x Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 17 (4) Requirement The registered person must ensure that service users’ records are stored securely and safely within the home for a minimum period of 3 years. The registered person must ensure a comprehensive and up to date care plan for each service user, which details the individual strengths, needs and how these can be met. The registered person must ensure that there are up to date risk assessments in place to ensure that service users are supported to live their lives as they wish, whilst the opportunity for harm to occur is managed and reduced. The registered person must ensure that service users are offered opportunities and supported by the staff team to undertake leisure activities. Staff control of service users and the restriction of service users’ rights must be kept under review to ensure that they do not undermine the service users’ dignity or become institutional DS0000061162.V334806.R01.S.doc Timescale for action 13/07/07 2 YA6 14 13/07/07 3 YA9 13 13/07/07 4 YA12 16 13/08/07 5 YA16 12(1)(4) 31/07/07 Pentrich Residential Home Version 5.2 Page 28 practices. (This refers to service the control of their cigarettes and personal money and the use of ‘treats’.) 6 YA19 12 The registered person must ensure that peoples health needs are fully met; with accurate record being kept. The registered person must ensure that there are risk assessments in place to ensure that peoples medication needs are met safely. The registered person must ensure that medication is always stored securely. The Adult Protection procedure must comply with the Local Authority protocol to ensure that all allegations of abuse are promptly reported to the appropriate agency. A restraint policy is to be implemented and staff provided with training on the subject. This is an ongoing requirement with a previous compliance date of 01/09/06. The registered person must ensure that the carpets within the home are of a good standard and do not pose a threat to the safety of the service user. The registered person must ensure that the bathroom areas of the home are kept in a good state of repair. The registered person must provide equipment, for example, a television, and not rely on these being provided by individual service users. The registered person must ensure that the kitchen is kept in a good state of repair, that it can be easily cleaned and does not pose a risk to the health and DS0000061162.V334806.R01.S.doc 13/08/07 7 YA20 13 13/08/07 8 9 YA20 YA23 13 13(6) 13/08/07 30/06/07 10 YA24 13,23 11/07/07 11 YA24 13,23 13/09/07 12 YA24 16 13/08/07 13 YA24 13,23 13/10/07 Pentrich Residential Home Version 5.2 Page 29 safety of the service user. 14 YA24 23 (2) (b)(d). A programme of refurbishment and redecoration of the premises, along with timescales, is to be provided for the Commission for Social Care Inspection. (Previous requirement timescale of 01/03/06 not met). The registered person must ensure that service users are protected from the risk of harm from fire and that the home meets the requirements of the Local Fire Authority. The registered person must ensure that there are adequate numbers of staff on duty at all times, to ensure that service user needs are safely met. The registered person must ensure that the correct recruitment procedures are followed in order to protect service users. Staff must only be employed after a Criminal Records Bureau (CRB) and POVA check and at least a POVA first check has been undertaken and returned as satisfactory. The registered person must, ensure that for the safety of the service users, all staff employed with only a POVA first check must not work unsupervised. This must be in anticipation of a full CRB check being received. The registered person must ensure that staff have the necessary basic skills upon commencement of their employment in order to meet service users’ needs. Staff must be inducted into the home to meet the requirements as stated DS0000061162.V334806.R01.S.doc 13/10/07 15 YA30 23 14/06/07 16 YA32 18 13/08/07 17 YA34 19 30/06/07 18 YA34 19 30/06/07 19 YA35 18 13/09/07 Pentrich Residential Home Version 5.2 Page 30 by ‘Skills for Care’. 20 YA35 18 The registered person must ensure that there is a staff training and development plan in place, which would offer staff the necessary training to be able to competently meet service users’ needs. The registered person must ensure that staff receive both mandatory and specialist training in order to be able to effectively meet the needs of the service users. The registered person must ensure that the home is effectively managed to meet service user needs. A manager must be employed within the home. A Quality Assurance Monitoring system is to be developed by which all aspects of the service provided can be assessed and reviewed on a regular basis. This will consequently enable the Registered Persons to verify that the aims of the home are being achieved. This is a previous requirement with a compliance date of 1/11/06. The registered person must ensure that the Electrical Wiring in the home is safe and does not pose a risk to service users. The registered person must provide the evidence that the portable electrical appliances have been tested by a competent person, are safe and do not pose a risk to the service users. The registered person must ensure there are up to date risk assessments for safe working practices in the home. DS0000061162.V334806.R01.S.doc 13/09/07 21 YA35 18 13/10/07 22 YA37 8 30/06/07 23 YA39 24 30/06/07 24 YA42 13,23 11/07/07 25 YA42 13,23 11/07/07 26 YA42 13,23 30/07/07 Pentrich Residential Home Version 5.2 Page 31 27 YA42 13,23 28 YA42 13,23 The registered person must ensure that there are adequate Control of Substances Hazardous to Health (COSHH) systems in place within the home. The registered person must ensure through a risk assessment basis, that the hot water systems do not pose a risk of scalding. 30/07/07 11/07/07 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 YA2 Good Practice Recommendations The registered person should ensure that records are kept of the service users to ensure that a clear audit and assessment of need can over time be undertaken to reflect the changing and developing needs of the service user. The service users’ right to make decisions and choices for themselves should be regularly reviewed. This would help to ensure that as far as possible people are making decisions and leading their lives as they would wish. Consideration should be given to reducing the number of shared bedrooms by, for example, making them single accommodation when vacated by one of the present occupants. The registered person should ensure that written records are kept of the visits to service users by families and friends and the outcome of this visit for the service user. The registered person should ensure that to assist in the safeguarding of service users, all staff are trained in ‘Safeguarding Adults’ procedures. The registered person should consider increasing the hours worked by the domestic staff in order to assist with the necessary environmental improvements required in the home. The registered person should provide evidence of how the DS0000061162.V334806.R01.S.doc Version 5.2 Page 32 2 YA7 3 YA11 4 5 6 YA15 YA24 YA30 7 YA35 Pentrich Residential Home home plans to meet the recommendation, that 50 of the staff team are qualified to a National Vocational Qualification (NVQ) level 2 or equivalent, to assist in ensuring that an adequately qualified staff team are supporting service users. Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Pentrich Residential Home DS0000061162.V334806.R01.S.doc Version 5.2 Page 34 - 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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