CARE HOME ADULTS 18-65
Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ Lead Inspector
Pauline O`Rourke Key Unannounced Inspection 4th December 2007 09:30 Pentrich Residential Home DS0000061162.V355160.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.V355160.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.V355160.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 ‘Post 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.V355160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 29th August 2007. 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 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 people who smoke, are located on the ground floor. The property does not have passenger lift so is only suitable for people who are fully ambulant. On the 4th December 2007 the fees for accommodation and personal care ranges from £300 to £650. The registered person provided this information. People are charged for ‘additional’ services such as: Hairdressing, chiropody, toiletries, magazines and newspapers, some social activities and transport. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided through a random inspection carried out in August 2007. Information provided by the registered person on an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Comment cards returned from people living at Pentrich A visit to the home by one inspector that lasted for six and a half hours. • • During the visit to the home six people who live there, three staff and one professional were spoken with. Care records relating to four people, four staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Pentrich for people living there. The assistant manager was available to assist throughout the visit and Mr Femiola, the proprietor was available for one hour during the visit. What the service does well:
Each person living in the home had a care plan and this told staff as to the help and support each person required to retain their independence and to develop new skills. The staff knew about these plans and had to review it every month. The people living in the home said that the staff were nice and provided them with the help they needed. It was seen that the interactions between staff and people in the home were relaxed, friendly and respectful. People in the home said that the meals were good and they enjoyed all the food provided. One person said that he helps by popping to the shops for the cook. They said that they could have drinks whenever they wanted and they sometimes helped in the kitchen, this helps to develop and maintain their personal and social skills. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection?
The last key inspection was carried out in June 2007 followed up by a random inspection in August 2007. There was little improvement in the service between these dates. A new assistant manager was appointed and started work at the time of the random inspection. The assistant manager has worked hard to improve a variety of areas in the home. Since the random inspection in August the assistant manager has reimplemented the admissions process. She has also located historical records relating to the people in the home and is currently organising them. The people in the home now have a care plan. This document informs the staff of the help and support required by each individual. It also includes risk assessments and information about visits by other professionals. Where some has limitations put on their money or cigarettes this is now documented and reviewed every month along with the care plan. She has also introduced a programme of internal and external activities for people in the home. The medication trolley is now kept locked and chained to the wall when it is not in use. Some of the environmental improvements identified in June and August have been implemented. There remains some work to do with the environment. The fire doors are now held open by electronic devices that are linked to the alarm system, this means that they can be safely held open and no longer present as a fire risk. The number of staff on duty has not increased but the assistant manager is looking at ways of maximising the hours they currently work. This would involve leaving some of their hours unplanned so that they have some time do work on a one-to-one basis with people in the home. An umbrella organisation has been organised to carry out Criminal Records Bureau disclosure checks for new staff. The adult protection procedure now complies with the Local Authority protocol to ensure any allegations of abuse are dealt with promptly. There is a quality assurance system in place but this has not been fully maintained. The assistant manager is currently pulling together information in a report of the quality assurance work carried out in 2006 and will provide this to the commission within the next four weeks. Environmental and COSHH risk assessments have now been carried out. The hot water outlets have been identified as ‘hot water’ and people in the home have a risk assessment in place to ensure they are aware of the risks. The portable appliance tests have been carried out and the electrical safety certificate was available. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 7 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. Pentrich Residential Home DS0000061162.V355160.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.V355160.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): 1 and 2 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to live at Pentrich have an assessment of the support they require before moving in to the home. This enables the staff to have an understanding of the support they require once they are admitted. EVIDENCE: The provider has not addressed the Statement of Purpose and this remains an outstanding issue from the last two inspections. The Statement of Purpose is a legal document that should give a clear picture of the services that are provided and not provided by the home. The updated document must be sent to the Commission. There have been no new admissions in to the home and the files seen contained assessments carried out by the placing authority. In discussion with the assistant manager it was clear that someone would only make any future admissions following an assessment from the home, where possible. She is looking to provide a more user-friendly assessment process that includes documentation in pictorial format so that those people who cannot read can be more involved in the admissions process. The records are stored in the office and the door is kept locked when the office is empty. If the assistant manager
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 10 is not on duty then a senior member of staff has the key to the office. This means that these documents are available at all times to staff and other professionals who may require information from them. The home has been without a Registered Manager since February 2007 and this has had a detrimental affect on the quality of the records kept in the home. The assistant manager has located historical records of the people living in the home, including annual assessments and reviews carried out in multi disciplinary meetings. She is currently in the process of sorting these records out so that she only has the records for the last three years in the home. Pentrich Residential Home DS0000061162.V355160.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 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can make some decisions in their lives. The care planning and risk assessments are now in place to help ensure their needs are met and that their independence is maintained. EVIDENCE: Four case files were seen and they each contained an individual care plan that had been drawn up with the agreement of the person concerned. The plan looked at the areas where a person needs support as well as the areas in which they are more independent. Any restrictions placed on the person were agreed and documented. These areas covered money and cigarettes. The key workers review the care plans monthly and a record of this is kept. Discussions with the manager and some of the people using the service revealed that they had consented to having to ask for money or cigarettes because they knew they would not be able to make either last if they had them all at once. Staff said that where they had tried to help people with
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 12 managing their money and/or cigarettes and they had not been successful it had been detrimental to their mental health needs. People spoken with during the inspection said they were happy with the current arrangements. The assistant manager said that she is continuing to look at ways people might be given their independence back in these areas. During the day people were seen to make their own choices about where they wanted to be in the home, whether they were going out or what they did whilst at home. Each person has a daily diary and their activities are recorded so that staff can use this information to monitor and review their care plan. One person went out with a community psychiatric nurse and staff were supportive of her when she was getting ready for this. Throughout the day staff displayed patience when dealing with quite agitated people and always treated them with respect. All of the people in the home now have appropriate risk assessments in place. These are reviewed monthly at the same time as the care plan. Pentrich Residential Home DS0000061162.V355160.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 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are being offered more structure to their day this means their social needs are being met and developed. They are encouraged to maintain contact with their families and friends. People are supported with their dietary needs EVIDENCE: Since the last inspection programme of in-house activities has been developed and staff and people who live in the home said that they enjoyed this improvement in structure. One person has a paid part time job as well as voluntary work and is well known in the local community. The manager is aware that further developments in accessing community activities is needed and this is part of the home improvement plan for the next twelve months. People spoken with said that they enjoyed going out to the weekly bingo and a local coffee morning. One person does not go out very often and this is their own choice,
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 14 as they do not like going out. The staff record what activities have been done and by whom on the daily records. People in the home access local facilities as individuals and less often as a group. One person goes to a local church on a regular basis another enjoys going to a dance class and another goes to an art class. These have been improvements since the last inspection, however, the assistant manager is aware that these links need to be developed further to benefit the people in the home. Historical records seen in someone’s file showed that they had been appropriately supported when they had concerns about having a personal relationship with someone else in the home. Support was provided in-house and through the local health care teams. People are supported to keep in contact with their family and one person said that staff help them to write letters to their family. Another person said that the staff helped them to telephone their relatives. During the inspection staff were seen to interactive in a positive way with people in the home, they used the persons’ form of address and were relaxed with people. People who live at Pentrich were seen to access any area of the building they wanted. Several people choose to spend their time in their rooms and staff were aware of this and monitored it appropriately. Other people were seen moving around and changing where they were sitting during the visit. There were clear signs for the provision of smoking within the home and one lounge is clearly set-aside for the people who smoke. People are supported with their dietary needs. The assessment information on file includes likes and dislikes and the cook was aware of this. People spoken with said the food was good and they enjoyed their meals in the home. Mealtimes are seen as a social occasion and they are the one time when all the people in the home are together. When necessary people are discreetly offered support with their meal. Everyone is weighed regularly and advice is sought from health professionals if anyone has a problem with their weight or diet. Pentrich Residential Home DS0000061162.V355160.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health care needs are met. EVIDENCE: The four case files seen now contained a detailed care plan that informs staff of the support required by the individual concerned. Any restrictions are stated in the plan and there are separate agreements also in the file. The key worker reviews the care plans every month and a separate record of this is also in the file. Information about specialist support is also available in the care plan. One person is currently receiving specialist support from health professionals and this is clearly indicated in their care plan. The routines of the day are flexible the assistant manager is looking at ways to make it more flexible in that people currently get their night clothes on soon after the tea meal and she is trying to change this so that activities on an evening can be introduced. The four files also contained details of visits made by health professionals. These include the well-woman clinic, optician, district nurse, Macmillan nurse, community psychiatric nurse (CPN) interventions and reviews and hospital
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 16 appointments. People spoken with said that they could access their GP when they wanted to and staff were supportive with this. During the visit a CPN visited a client who then went out with her. Medication was seen to be securely stored. The trolley is now fixed to the wall when not in use and at all times during the visit it was seen to be locked except when staff were using it. The administration records were up to date and accurate. The medication is provided in a monitored dosage system and staff that administer the medication have completed a Distance Learning Course in the Safe Handling of Medicines. Pentrich Residential Home DS0000061162.V355160.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 and 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies are in place to ensure the protection of people who live at Pentrich, however staff still require training in the use of restraint. EVIDENCE: There is a complaints policy in the home that meets the requirements set out in the Care Home Regulations 2001. People living in the home know whom they can talk to if they need to make a complaint. One service user said ‘although I can’t read or write I would tell staff and they would help me write my complaint down’ another said ‘the carers always have chatted to me and listened if I’ve had any problems and always helped me sort it out’ The assistant manager has introduced a complaints box in the front entrance hall so that people can make complaints or suggestions about the service anonymously No complaints have been received in the home or by the Commission since the last two visits to 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. The provider has made arrangements with an umbrella body to process Criminal Records Bureau and POVA applications prior to the commencement of a new member of staff’s employment. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 18 In discussion with the proprietor the philosophy of the home was mentioned and he said there was clear policy to de-escalate any situation, which, may turn aggressive rather than use restraint. The restraint policy, which, would, include this information, has not been implemented, nor have staff received appropriate training in this subject. Whilst de-escalation is the preferred way of dealing with aggressive situations staff need to be aware of this and of subsequent actions needed if de-escalation does not work Pentrich Residential Home DS0000061162.V355160.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 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home where some improvements to the décor have been made but where there remains further need of refurbishment EVIDENCE: A tour of the premises was undertaken and whilst some improvements have happened the following was found: • The kitchen has had a new floor and the cupboards were tatty but useable and had passed an inspection by environmental health. • The fridge and freezer temperatures were recorded and there is a cleaning schedule in place. • There is a baby monitor in place for one person who is terminally ill and spends all their time in their bedroom. This has been discussed with her and she feels well supported with this arrangement, it is recorded in her care plan and reviewed monthly by the key worker.
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 20 • • • • • • The lounge chairs were worn and one was damaged, the fabric on the armrest was ripped. This chair needs replacing. The downstairs toilet still had a stained floor and there was no toilet roll holder, the glass in the door whilst frosted allowed people to see in to the toilet, this needs to be rectified. The second toilet (next to the toilet mentioned above) had exposed pipe work and the light switch was hidden away behind the pipe work. Room 10 the furniture was missing handles and looked worn and tired. The toilet and shower room on the top floor was tired and in need of updating. Room 4 had a unpleasant odour and this needs resolving. The main lounge would benefit from being decorated as everyone has previously used this lounge the smokers and non-smokers. The other bedrooms seen were personalised by the occupant and in tidy order. There was no evidence of a planned maintenance programme and the provider has to provide the Commission with this document. This is an outstanding requirement from the last two inspections. The assistant manager told the inspector that she did not have any budget for refurbishment and the proprietor held this. The assistant manager said she had been in discussions wit the proprietor to employ a handyman/gardener so that day-to-day issues could be dealt with quickly and bigger jobs could be tackled in-house. Feedback received from people in the home said ‘the home needed to improve on the décor and general repairs’. People spoken with said that they liked living at Pentrich and it was very much their home. There is a cleaner employed in the home and she is responsible for all the communal areas of the home and the bathrooms and toilets. People who live in the home are responsible for the cleaning of their own rooms. This task is undertaken with the key worker who provides support and guidance in this task. There is a separate laundry area, which provides the necessary equipment to support people with their laundry. At the previous inspections it had been noted that fire doors were held open by wedges. Electronic devices that are linked to the fire alarm system have replaced these wedges. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 21 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, 33 and 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff who are enthusiastic and well supported but who have received little training and have been poorly recruited support people. EVIDENCE: There have been no new staff employed at Pentrich since the last inspection. The assistant manager has introduced an umbrella agency to carry out Criminal Records Bureau disclosures and POVA checks. She was clear on the need for these checks and references prior to the commencement of someone’s employment in the home. She is looking to re-do the current Criminal Records Bureau checks as a matter of good practice as many of them are over 3 years old. Staff files seen contained an application form, two references, a Criminal Records Bureau disclosure, evidence of supervision and some training records. The assistant manager has obtained the ‘Skills for care’ induction pack and will introduce it to the next new member of staff. The staffing level has not improved since the last two inspections but the assistant manager is looking at ways staff can be released to allow them time to take out the people in the home. One member of staff spoken with said
Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 22 that since August they had more time to spend with people in the home and they were getting paid for taking people out for appointments and shopping. Staff receive regular supervision and notes were seen on their files. Staff said that they found this a useful process that allowed them to discuss work issues in a confidential environment. Staff have not received training in mental health issues or in the aging process. There was no evidence of a training and development plan for staff or that they receive at least five paid training and development days each year. People spoken with said ‘the staff are nice’ and ‘the staff always have time for us’ Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 23 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 and 42 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are living in a home where the management has improved and subsequently their views are listened to. The health and safety of the people in the home and the staff is promoted. EVIDENCE: There is no manager registered or not in post, only an assistant manager. The assistant manager has experience in mental health and has spent the last 31/2 months trying to improve a failing service. As there is no Registered Manager in post the proprietor should be visiting the home on at least a monthly basis, following this visit he must produce a report that must be sent to the Commission. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 24 There is a quality assurance system in place, but due to the previous lack of management this has slipped. It consists of sending questionnaires to the people in the home and their visitors. The system also uses information from the house meetings, which happen every two months, staff meetings, and staff supervision. The assistant manager was putting together a report for 20062007 and will send the Commission a copy of this report. It is proposed that this information will help to inform the annual development plan for the home. Since the last inspection the assistant manager has introduced COSHH risk assessments for all the chemicals used in the home and these liquids are now kept in a locked cupboard. There are risk assessments for the people in the home regarding the use of hot water. Signs are displayed above all hot water taps in the building so that people are warned in advance that the water may e hot. There are risk assessments in place to encourage safe working practices. The electrical system has a certificate valid for 5 years dated 11/10/2004, the portable appliances were tested on 21/11/07 and the fire equipment was serviced on 28/11/07. On inspection of the gas certificate it was seen to be out of date, the last inspection took place on 20/11/2006. The assistant manager was unable to organise a date as she did not have the authority. The proprietor who was available for 1 hour during the inspection organised British Gas to call out on 17/12/2007 to service the gas systems in the home. A certificate of safety must be supplied to the Commission when this has been completed. All accidents are recorded and when necessary would be reported to the Commission. Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 25 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 1 2 2 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 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 X X 2 X Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4 Requirement The registered person shall provide the Commission with an up to date copy of the Statement of Purpose for Pentrich. Timescale for action 31/01/08 2 YA23 13(7) The registered person must 31/01/08 ensure that staff receive training in the use of restraint techniques and that there is a policy in place to determine the use of restraint. 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, 30/06/07 and 30/09/07 not met. 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 and 30/09/07 not met 31/01/08 3 YA23 13(6) 4 YA24 23(2) (b)(d) 31/01/08 Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 27 5 YA35 18 The registered person must ensure that staff have the necessary basic skills upon commencement of their employment in order to meet peoples’ needs. Staff must be inducted into the home to meet the requirements as stated by ‘Skills for Care’. 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 people’s 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 people in the home. 31/01/08 6 YA37 8 The registered person must ensure that the home is effectively managed to meet people’s needs. A manager must be employed within the home. This is an ongoing requirement with a previous timescale of 30/06/07 and 30/09/07 not met. The registered person must visit the home at least once a month and produce a report on the conduct of the home and provide this report to the Commission. 31/01/08 26 Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 28 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 YA7 Good Practice Recommendations People’s 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. The registered person should ensure that records are kept of the people in the home to ensure that a clear audit and assessment of need can over time be undertaken to reflect the changing and developing needs of the individual. The registered person should ensure that to assist in the safeguarding of people, all staff are trained in ‘Safeguarding Adults’ procedures. 2. YA2 3. YA24 Pentrich Residential Home DS0000061162.V355160.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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
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