Inspection on 14/05/10 for Penvose Residential Home

This inspection was carried out on 14th May 2010.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penvose Residential Home 14/12/09

Penvose Residential Home 04/03/09

Penvose Residential Home 24/11/06

Penvose Residential Home 06/12/05

Penvose Residential Home 26/05/05

Penvose Residential Home 30/09/04

Penvose Residential Home 25/05/04

Penvose Residential Home 06/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Key inspection report Care homes for older people Name: Address: Penvose Residential Home 1/2 Tothill Avenue St Judes Plymouth Devon PL4 8PH     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Megan Walker     Date: 1 4 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Penvose Residential Home 1/2 Tothill Avenue St Judes Plymouth Devon PL4 8PH 01752663191 01752663191 penvoseresident@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Joyce Sylvia Reed Name of registered manager (if applicable) Type of registration: Number of places registered: care home 15 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 15 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other cattegory (Code OP) Dementia (Code DE) Date of last inspection Brief description of the care home Penvose is registered to provide care and accommodation for up to 15 older persons who may also have dementia. The home does not offer a service to people whose mental health issues cause them to display anti-social behaviour or aggression. The home does not provide an intermediate rehabilitation care service, however it Care Homes for Older People Page 4 of 37 Over 65 0 15 15 0 1 4 1 2 2 0 0 9 Brief description of the care home occasionally admits people whom need short-term respite care. It is not registered to provide nursing care. The home was originally two houses built on a hill so access to many rooms requires people to be able to manage short flights of stairs between the two lounge rooms. Stair lifts provide access to the first floor. Penvose is not suitable for people who use a wheelchair. On the split level ground floors are two lounges and the dining room. There are 13 single bedrooms and one double. None have en-suite toilet facilities. The home is situated in a residential area of Plymouth a short bus ride from the city centre. It is also opposite a large park. At the back of the house is an enclosed patio garden and at the front there is a garden. Limited off road parking is available for visitors at the rear of the home otherwise on street parking is available subject to parking restrictions. Penvose has a no smoking policy. The current fees at Penvose range from £345.44 to £400.34 per week, subject to individual assessment of needs. Additional charges include a hairdresser, a chiropodist, personal toiletries and newspapers. Information about Penvose can be obtained directly from the home. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is zero stars. This means the people who use this service experience POOR quality outcomes. This key inspection was undertaken by one regulation inspector to check compliance with regulation. The fieldwork part of this inspection was unannounced and took place on Friday 14th May 2010 between 07:45 and 18:30. An Expert by Experience joined the visit from 10:30 until 14:00 and visited individuals in their rooms and the lounges during the morning, and ate lunch with the people eating in the dining room. He spoke to eight of the nine people living at Penvose. The Care Quality Commission (CQC) considers an Expert by Experience as a person who either has a shared experience of using services or understands how people in this service communicate. Care Homes for Older People Page 6 of 37 This inspection included talking to people who live at the home and all the staff working at the time of this visit, observation of interactions between the staff and the people using this service, a tour of the premises, and inspection of care plans, staff files, medication and other records and documentation. Four surveys were returned from people living in the home. Three surveys were received from relatives and we also spoke to them. In addition we used the last Key Inspection report and all other information relating to Penvose received by the CQC since the last inspection to inform this inspection. Since the last inspection Plymouth Social Services has imposed its commissioning policy on Penvose because of its rating. Therefore no new residents have moved into Penvose since the last inspection. We therefore did not inspect this outcome group. We are considering taking enforcement action because there outstanding requirements from two previous inspections, and the registered provider has failed to make significant changes to improve this service. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Five requirements were made at the key inspection in March 2009 and repeated in the last key inspection in December 2009. Three of these were met by the time of this inspection however one was only partially met and one was not met: Staff have been provided with theoretical training in first aid however they have yet to do practical training which is necessary to ensure they have the skills to respond in an emergency. Care Homes for Older People Page 8 of 37 Two members of staff have completed a moving and handling course with a Train the Trainer course meaning that they can train the staff team. This has not happened. The staff team has not been trained in safe moving and handling practices to ensure they assist the people using this service in a way that protects their health and safety. This requirement was due to be met by 31/07/2009. Staff recruitment records do not contain all the references and proof of identity as required by regulations to protect the people using this service from harm. This requirement was due by 31/03/2009. At the last key inspection in December 2009 two Immediate Requirements were made. One of these was unmet on the day of our visit as we found a fire door held open because the approved hold-open device was not working. This means that in the event of a fire people would be at risk because approved hold-open devices are not maintained in working order. Further concerns about the lacklustre approach to fire safety were found at this inspection. We found that staff have not had any practical fire training. This means that in the event of a fire people would be at risk because the staff may not be aware of the procedure to be followed in case of fire, including the procedure for saving life. We have written to the Devon and Somerset Fire and Rescue Service about our concerns regarding fire safety at Penvose. One further requirement made at the last key inspection in December 2009 was not met by the time of this visit: The Job Description of the Matron and any senior staff involved in management of Penvose must be reviewed, in order that the responsibility for all management tasks is made clear, the person is accountable for their achievement, and the staff are given time for these tasks. This requirement was due to be met by 05/03/2010. A further concern from this inspection found that the management style does not promote a home that is run in such a way that creates an open, positive and inclusive atmosphere. The staff are not encouraged to maintain good personal and professional relationships with the people using this service because the registered provider has a task focused approach towards the provision of care. This means that the people using this service do not benefit from personalised and individual care unless the staff adopt maverick behaviour that they know to be against the wishes of the registered provider. Also as a consequence of this inspection we found that the registered provider and the staff need further training to safeguard the people who use this service by ensuring they are up to date with current legislation and practice about the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DOLS). Recommendations from both the key inspections in March 2009 and December 2009 are repeated following this visit: Care Homes for Older People Page 9 of 37 Staff should receive regular supervision to provide them with support and to review their work performance and training needs. Staff should receive training in good practice in the care of people with dementia. Care plans should be further developed to include peoples social and cultural needs. More social activities and outings should be provided, as well as engaging the people who live at Penvose in activities of daily life in the home. An assessment of the property should be commissioned from an Occupational Therapist, and their advice followed with respect to making the home as accessible as possible for the people living here, to enable them to be as independent as possible. As a consequence of this inspection further recommendations were made about changing practices currently in place that compromise peoples privacy and dignity; and, writing and implementation of a routine programme of maintenance and renewal of the fabric and decoration of the premises to ensure the people using this service live in a safe, well maintained environment, with routine checks and renew of equipment when it is worn out or corroding. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 37 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not inspected. Evidence: Not inspected on this occasion. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 are not involved in their plan of care or supported or encouraged to make decisions as part of an independent lifestyle. Peoples care needs have not been thoroughly documented. Care practices are knowledge based so staff do not always meet the needs of the people living at the home. Evidence: Five relatives returned surveys to us of which four expressed satisfaction with the service provided. Their comments included: They have friendly interaction with service users. They make sure the service users are always clean and tidy. They always send for a doctor if they have concerns about service users health. It [Penvose] gives personal care - by looking after the physical and mental welfare of the residents. In answer to the question What does the service do well? one relative told us General care. A resident told us that the staff Cares for residents and the home could nothing Care Homes for Older People Page 13 of 37 Evidence: better as Penvose residential home is very comfortable to be a resident in. Another resident told us the staff Look after me. Personal care was given behind closed doors. Staff were seen and heard to knock on bedroom doors and await a reply before entering. Staff spoke respectfully with residents and all seemed to enjoy light banter with residents giving as good as they got. Those who chose to spend all (or most) of their time in their bedrooms commented that the staff visited frequently and found time to sit and chat. Staff told us that they were not allowed to sit and chat with people as the registered provider did not consider this a valuable use of their time. They told us that they regularly pop in to see the people who choose to stay in their rooms to chat and spend one to one time with them. They were aware that this was to the detriment of those who prefer to sit in the lounge to whom they made fleeting comments as they passed through the lounges. A family member told us that the daily records in the care plan state that her relative who resides at Penvose is washing herself. The family member told us that she does not think her relative has sufficient capacity to know or remember if she has washed herself. The family member confirmed that a bath is offered once a week only, there is no choice. They also said that they were concerned that the cleaner assists people with bathing. We asked the care staff about daily routines for individual residents. They told us that they try to offer two baths each day, always in the morning. We asked about choice, for example in the evenings or before bed. We were told that everyone prefers to have a bath in the mornings, and more staff is on duty in the mornings. This means it is more practical. We were told that the cleaner is employed part time as a cleaner and part time as a carer to help with tasks such as bathing. During our tour of the premises we found several toiletries in a bathroom. We advised the matron and the registered provider to ensure that when care staff assist the people using this service with personal care in a communal bathroom, that any personal toiletries are returned to the persons room and put away so the persons privacy and dignity is not compromised. We looked at three care files. Each had a photograph and a resident information sheet that gave information about the persons doctor, their next of kin and family contact numbers and the reason for their admission. Each had a plan of care and this was basic. Care Homes for Older People Page 14 of 37 Evidence: One care plan was signed by the matron. It was not signed by the person whose care plan this was or a relative or independent representative. The care plan had a record of the residents personal events, eg. bath weekly, chiropodist visits, and dentist visits. There was a weekly weight chart because a risk of weight loss was recorded in the care plan. There were food and fluid intake charts however these were in a muddled date order. We asked the matron about these charts and if care staff are held accountable for gathering information as there was no evidence to show that the care staff followed up on this information. We were concerned that there may be an over expectation on the care staff skills of knowing what and how to monitor charts, and the expected outcomes. We asked about the input by district nurses as usually they would take a lead responsibility for requesting the gathering and monitoring of such information. We were told that information is collected and monitored alongside regular weight checks. This is shared with the district nurses and/or the persons doctor. In another care plan we saw a risk assessment about oral hygiene. The daily records showed a note about a tooth broken on dentures. There were also three separate entries over a period of eight days that the person had run out of denture cleaner. We asked about this. Denture cleaner had been bought but there was no evidence to show that any action was taken about the broken denture. The last recorded dentist appointment was seven months before this daily record entry. In the same care plan we found an accident recorded in the daily records but not in the accident book. This was another example of poor record keeping. Two Good Practice Recommendations were made at the last inspection about developing the care plans to give staff more detailed information about individuals. We were concerned that the care plans we looked at still needed more detail and information. For example, if the assessment identifies the person is at risk (e.g. falling, malnutrition), the care plan should give care staff clear instructions about how a persons care should be delivered. The care plans we looked at did not include a psychological needs care plan or a social care plan which would have given staff information about the persons interests and what they enjoyed doing. A life history was not completed, which would have given staff an insight into the character and lifestyle of the person. The matron told us that she planned to do these with the help of the care staff in the future. She also told us that all the care plans are being revised and re-written with new risk assessments. From this discussion about the care plans we acknowledged that these are being reviewed however including more details about what to do, why and how could aid care staff in seeing that everyone is an individual with different needs. Care Homes for Older People Page 15 of 37 Evidence: We found that record keeping did not support the staffs knowledge of the people living at Penvose which was extensive. We found that the care home has good relations with the local surgeries and district nurse teams. Care staff can accompany individuals to appointments if this is the persons preference. Health and social care professionals have told us about excellent examples of co-ordination and multidisciplinary care for individuals by the matron and the staff team. We found that record keeping did not support the good health and personal care practice that the staff provide to the people living in the home. All the medication is kept in a lockable cupboard in a lockable office. The controlled drugs cabinet was locked and the controlled drugs book completed correctly with two signatures and tablets counted. We observed a medication round. Medications were signed for correctly. No water was provided when giving tablets which made it difficult for swallowing. One resident swallowed their tablets with hot tea. Care Homes for Older People Page 16 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Routines within the home often mean that people do not have a choice and control over their lives. Improvements are needed to ensure that all people using this service have access to varied and appropriate activities, and are encouraged to participate in daily living routines. The people using this service are provided with good quality meals and they are offered a choice of food, where they prefer to eat their meals and when they would like to eat their meals. Evidence: A care plan we looked at stated on the resident information sheet that this person Likes to help with folding sheets and napkins, and helping with dishes. We asked the care staff about residents involvement around the home. They told us that residents are not involved in daily living activities or routines around the home. A relative who returned as survey wrote: Would like more encouragement for my mother to interact. Care Homes for Older People Page 17 of 37 Evidence: A member of the care staff has expressed an interest in organising activities. These include bingo, seasonal craft work, quizzes, karaoke, skittles and there is the occasional visit by an entertainer. There is a Bring and Buy stall set up in one of the lounges. At the time of our visit preparation was in hand for the forthcoming World Cup Football as several residents have an interest in this sport. A Christian service of worship is conducted once a month by the vicar from the nearby church. If people wish to attend a church of their choice arrangements can be made by the care staff to take them. There are no organised trips however some residents told us that their relatives take them out. The house is decorated at time of national celebration and commemoration. The staff told us that they try to make Penvose a homely home. They also said that the involvement with residents depends who is on duty and some staff do not want to do things. The matron told us that regular activities include in the mornings having background music playing in the lounges, watching television, armchair exercises(fortnightly), a service of worship once a month and at Christmas. We were told The girls do things if they have time. We did not find that the involvement of the people living at Penvose in daily living activities or varied organised entertainment has changed since our last visit. Meal times are usually about 08:15 for breakfast: 12:15 lunch; 17:15 tea; and supper drinks and biscuits at 20:00. Food is available all day and night if requested. People can choose to have their main cooked meal at tea time if they prefer. At lunchtime normally there is a choice from three main courses and two desserts. The day of our visit was a Friday and chips and peas with either fish or egg was being offered for lunch. The dessert was home made rice pudding. The plated meals looked appetising and were of a suitable temperature. Most diners cleared their plates. Some people chose to eat in their bedroom. No one was seen to require assistance with the meal. The teatime meal was to be a choice of hot or cold food from a very varied selection. People said that they could have an alternative if they did not like the menu choices. Comments about the food included, No trouble with the food, Food very good, Wholesome food, Good home cooking, I enjoy my food, Good choice, You only have to ask and they bring it, You get a good meal here and Food very nice. Dry goods are sourced from a national retailer and wholesaler with fresh vegetables and meat coming from local trusted retailers of good repute. The kitchen store was well stocked with good quality products. The cook advised that she has a free hand in making up purchasing orders which are then authorised by the registered provider. At the time of our visit the menu was still that of winter. The cook told us that the residents are always involved in menu planning and she was already starting a consultation with them for ideas for the summer menu. Care Homes for Older People Page 18 of 37 Evidence: Care Homes for Older People Page 19 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has suitable complaints policy and procedure however some people using this service were not aware of it. Staff are trained about protecting vulnerable adults however the lack of training and staff knowledge about restraint has the potential to put people at risk. Changes are needed in work practices to show that care is person centred and not institutional. Evidence: Everyone living at Penvose at the time of this visit told us that they would speak to either the registered provider or the matron if they were unhappy about anything. In the survey returned to us they all ticked that usually the staff listen to them and act on what they say. We saw the Complaints Procedure displayed in the hall. It did not have the correct address for anyone wishing to contact the CQC about a concern or a complaint. The matron told us that she would amend this. A requirement made at the last inspection regarding the training of all staff about safeguarding vulnerable people from abusive practices has been met. By the end of June 2010 all the staff will have attended the local authority Alerters training. The matron was expecting to attend the local authoritys safeguarding training for Care Homes for Older People Page 20 of 37 Evidence: managers in the forthcoming month. We discussed other training relating to safeguarding vulnerable adults, including the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS), and what it means for staff working with people in registered care services. This is legislation that came into force on 1st April 2009 and applies to people living in services registered under the Care Standards Act 2000, regardless of who funds their place. It is legislation that protects people who use services. It ensures staff act only in the best interests of the person who uses the service because they only use restraint as a management of behaviour in accordance with guidelines in the Mental Capacity Act 2005 Code of Practice and the Mental Health Act 1983 Code of Practice, including a best interest assessment. We were told that the registered provider will be attending training about the Mental Capacity Act and the Deprivation of Liberties Safeguards. There were no planned or booked dates for any training. Care Homes for Older People Page 21 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual bedrooms appeared homely. The accommodation and grounds are spacious, but are tired and in need of refurbishment and redecoration. Evidence: The exterior of the premises look inviting and the home is well known locally for its success in the Plymouth in Bloom competition over many years. The interior is dated but homely with comfortable furnishings and is very clean. There were no malodours. The bedrooms visited were pleasant and contained items of personal memorabilia. People were content with the laundry arrangements. Two people volunteered, Im lovely and comfortable here and You would have to go a long, long way to find anything better than this place, if at all. Since the last inspection a new carpet has been fitted in the entrance hall and hall. Also two bedrooms have new carpet and one bedroom has had washable flooring fitted. The call bells have been upgraded so they can only be cancelled once a staff member has gone to the room from where the call was made. This means that staff cannot cancel the bell without seeing the person. Bedroom door locks have not been fitted on any bedroom doors since the removal of Care Homes for Older People Page 22 of 37 Evidence: Yale locks many months ago. The registered provider told us that she had asked residents if they wanted a lock on their door, and none had said they did. For this reason on previous inspections we have recommended that suitable locks are fitted to vacant rooms to promote the privacy and dignity of people moving into the home. At the time of this inspection only nine rooms were occupied however locks have not been fitted to vacant bedrooms. In a bathroom we found a tin of talc, a sponge, nail clippers, a bar of soap and towels. The bath record book included a record of when people had their nails cut. The mats to prevent people from slipping in the bath were worn out and needed replacing. A mobile raised toilet seat was rusty. A toilet cistern top was dislodged and insecure on top of the cistern. The registered provider and the matron agreed to replace any worn items such as mats and toilet frames. They also agreed to check that commodes in peoples bedrooms were not rusty. We suspect that bleach used for the deep cleaning of commodes and toilet frames was the main reason for the metal corrosion. We asked the matron to heed caution with the use of bleach and seek out alternative disinfectants that do not contain bleach. We advised that assistance with nail cutting should be recorded on individual daily records and care notes, not in a communal book left in a bathroom. Also we reminded the registered provider and the matron that the care staff must ensure that when they assist people living in the home with washing and bathing, they use peoples personal toiletries. This will ensure the privacy and dignity of each individual and protect them from an institutional practice of using common toiletries. It will also help prevent cross infection. Care Homes for Older People Page 23 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels and skill mixes on each shift need to be reviewed to ensure that people are always cared for in a safe way. Not all staff are adequately trained to meet the needs of the people living at the home. Recruitment systems used at the home are still not robust and have the potential to place people at risk. Evidence: On the day of our visit there were nine people living at Penvose. We spoke to eight people who said that usually there were sufficient staff on duty to meet their needs. Call bell response time was said to be immediate or within a few minutes both day and night. Extra baths and/or showers were available on request. All staff spoke English as a first language and there were no communication difficulties. Everyone spoken with opined that they rose and retired at times of their choosing. One person added, If you want to have a lie in they wont harass you. Without exception the people living at Penvose spoke well of the staff and home saying, Cant complain about anything here, Im quite happy here, I get on with the staff very well, I cant fault anything, We have lots of laughs, The girls are helpful and listen to us, They always have time to stop and chat with us, The owners are very kind and nice people, I cant find any faults, and We are well looked after here. The people we spoke to told us that visitors were welcomed by the staff and usually offered Care Homes for Older People Page 24 of 37 Evidence: refreshments. The people we spoke to told us that the staff undertake shopping for them as well accompany them to doctors appointments if they wish. Observation of the staff interactions with the people living at Penvose throughout this visit found that the staff had routines indicative of an institutional approach to caring for people. Staff spoke to us about the homes routines and the tasks they are expected to achieve. They expressed frustrations about the homes task based ethos that does not allow them to give person centred care meeting individual needs. They said they had to keep one eye over their shoulder to look busy and could not spend time chatting to the people living here. One carer said that she likes working here. She also likes looking after the residents but they need more things to do. Care staff spend more time doing things to and for the people who use this service, rather than encouraging as much independence as possible. We found that those people who choose to stay in their bedrooms have a lot of interaction with the staff, quality one to one time, however those who prefer to sit in the lounges are left for long periods of time only seeing the staff as they passed through the lounges on their way from one job to the next. Care staff are responsible for assisting people with personal care including baths (we confirmed that at the time of this visit nobody needed more than one carer to assist them), handling and administration of medications,laundry, preparation of breakfast, tea and supper, serving all meals, clearing away after all meals and washing up after all meal times. At the time of this visit the care staff were also covering the cleaning duties because the cleaner was on long term sick leave. A carer told us we are trying to fit it all in. We were told that the cleaner is employed part time as a cleaner and part time as a carer to help with tasks such as bathing. We advised the matron that terms and conditions of employment and contracts should reflect the job title and job role. This will ensure that staff are accountable for their work. It will also help avoid confusion such as a family member who raised concerns that the cleaner was assisting her relative with bathing. At the last inspection a recommendation was made that staff should engage the people living at Penvose in activities of daily living, and provide social activities that stimulate them. We asked the care staff how they involve people in helping out with daily living activities and routines such as laying the tables or helping fold sheets and towels. They told us that residents are not involved in daily living activities or routines around the home. The matron told us that the girls do things if they have got time. The registered provider told us the carers get a lot of time on their hands. Care Homes for Older People Page 25 of 37 Evidence: We asked staff about training. They confirmed that they had completed a local authority course about safeguarding vulnerable people from abuse.This meets a requirement made at the last inspection. They told us they have completed basic first aid and fire safety awareness courses however both of these are distance learning theory-only courses. Staff still need to have practical training in both subjects to ensure that they have the necessary skills to respond in an emergency and to assist people in a manner that protects their health and safety as well as that of the person being assisted. The matron and two care staff have completed a moving and handling course as well as a Train the Trainer course. This means the matron is trained to train the staff about moving and handling however at the time of this inspection this had not happened. This means there is still an outstanding requirement due to be met by June 2009 that the registered person must make suitable arrangements for the training of staff in first aid and to provide safe moving and handling of people. All staff were working through a distance learning basic food hygiene course and the matron was planning for all the care staff to do a distance learning course on dying, death and bereavement next. We looked at two staff files. Neither had a photograph of the staff member or the date the person started work at Penvose, and there were no records of induction, training or supervision. One file had two character references only and the other had a reference from a previous employer and a character reference. A requirement was made at the last inspection stating that no one must be employed at the care home without satisfactory outcomes that meet the Care Homes Regulations 2001. The matron was aware that staff files are still incomplete with no start dates or information about induction, training or supervision. We advised the matron and the registered provider that the Application Form for employment at Penvose needs updating to ensure it is fully compliant with current legislation. Care Homes for Older People Page 26 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this 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 placed at risk because the registered provider compromises health, safety and welfare. A dysfunctional management style at the home is having a negative impact on the quality of the service provided. There continues to be no evidence of proactive leadership towards improving practice and standards in the home. Evidence: A requirement was made at the last inspection that The home owner must ensure that the home is conducted in a way that makes proper provision for the health and welfare of service users by clarifying the role and responsibilities of the matron and other senior staff in a Job Description. Since the last inspection we have met and discussed this with the registered provider. We had a further telephone conversation about this following a meeting the registered provider had with the local authority Safeguarding Lead Officer. This meeting was called because the local authority commissioners had concerns about the future of the care home. They were particularly Care Homes for Older People Page 27 of 37 Evidence: concerned about the management of Penvose. On each occasion the registered provider assured us that it was her intention to retire however continue to be the registered provider. She confirmed that the matron would be applying to the CQC to become the registered manager. By the time of this inspection this had not happened. The registered provider was still the registered manager. Job roles and responsibilities were still not clarified. At the last inspection we found that the matron had a half day as supernumerary for management duties. Consequently at that time we suggested that this needed to be reviewed in consideration of her responsibilities. At the last inspection we also found that tasks had gradually moved from the registered manager to the matron without proper review, and due to the shared responsibilities there had been no process of review. We had therefore suggested there should be consultation between the registered manager, the matron and the staff team to consider and agree the best way forward. On the day of this inspection visit we found that in the morning there were two care staff, the cook and the matron on duty from 08:00 until 14:00. From 14:00 to 20:00 the matron was on duty as a senior carer with one carer. Two night care staff were due in at 20:00 to work the night duty until 08:00 the following morning. The registered provider was in her office all day however we did not see her actively participating around the care home. The staff were all very supportive of the matron and expressed concern that the expectations put on the matron by the registered provider were too high. The matron told us that since the last inspection she has been expected to fulfill managerial duties as well as continue with her duties as a senior carer. For example, two Good Practice Recommendations were made at the last inspection about developing the care plans to give staff more detailed information about individuals. The matron told us that she has been revising and re-writing all the care plans. She had started writing new risk assessments for each person and planned to write picture profiles to provide staff with a view of the persons life and interests. The care plans we saw were basic, needing a lot more detail adding to them. As there was no provision to cover the matrons care hours and thereby release her to full time managerial duties and responsibilities she did not have the the time to invest in writing full and comprehensive care plans. We did not feel confident that she would achieve meeting these recommendations of the last inspection in the near future. We discussed at length during this visit with the registered provider and the matron about the registered provider retiring from the registered manager position. This would allow for the matron to officially become the manager and thereby submit an application to the CQC to be considered for registration. We also urged the registered Care Homes for Older People Page 28 of 37 Evidence: provider that due to the changes in legislation, if we had not received an application from the matron by the end of June 2010, she would have to apply to be registered under the registration regulations of the Health and Social Care Act 2008. This would mean a delay of a further three months at least as the application would not be eligible for consideration until October 2010. We tried to seek clarity from the registered provider about the current situation and arrangements however the registered provider was unable to give us any clear direction. She told us that there was sufficient staff to achieve all that needed doing and that they had time on their hands. We emphasised our concerns that because there was no structure to the managerial roles and responsibilities at present, this meant that there was no clear picture of how the home will run after the registered provider formally retires from her current position of registered manager. We suggested to both the registered provider and the matron that they must ensure a clear job description and duties are in place before the registered provider retires. We were concerned that the matron was not learning the operational aspect of the home from the registered manager and, because of restrictions on her time (i.e. senior carer hours and staff deployment and skill mix), there was no provision for any sort of management and leadership training. There was a list of outstanding recommendations from previous inspections that have not been met, including improving the detail of care plans and the provision of regular staff supervision. This was because the matron did not have sufficient time to set aside for these purposes. We told both the registered provider and the matron that it must be clear to everyone - people living in the home, staff working in the home, families, visiting social and health care professionals and any other visitors or people telephoning into the home, who is in charge on a day to day basis. We also agreed with them that provision would be made to cover the matrons senior carer hours so she has solely managerial duties and responsibilities. We suggested that a change in the matron job title should also help reflect to both staff and outside professionals the change in leadership. We also talked about a review of the current staffing structure and the delegation of responsibilities to senior staff to relieve the matron to fully embrace her new role. Following our inspection visit, we received a letter of resignation from the registered provider the following week stating that she would be retiring with effect from 30th May 2010. We received a completed application for registration as manager from the matron a month later. Information we have gathered since the inspection visits from various sources shows that the registered provider is coming in to the home less however she still calls in daily. There is still no clear job description and duties for the matron/manager. No provision had been made prior to this change of role to relieve Care Homes for Older People Page 29 of 37 Evidence: the matron/manager of her carer role and hours. The matrons care hours have been advertised and interviews are planned for sometime in July. We discussed at length with the registered provider our concerns that care staff spend a lot of one to one time with people who choose to stay in their rooms however this is to the detriment of the people who prefer to sit in the lounges. We asked her to encourage the care staff to take the time to sit and chat with everyone regardless of where they are, rather than focusing on time and tasks. We gave the registered provider examples of people who had told us how much they appreciated the care staff because they chatted with them throughout the day. We highlighted this with examples from the care staff who felt they had to do this secretly because they said they would get into trouble for time wasting. We spoke to the registered provider and the matron about our concern that the management of the home does not create an open, positive and inclusive atmosphere, and the home is not run in the best interests of the people who reside there. A formal quality assurance system is in place at the home. Relatives questionnaires and Resident questionnaires had been given out at the time of the last inspection. At the time of this inspection there was no summary of the feedback. The matron told us she was organising questionnaires for social and health care professionals. There are no regular meetings for people who live at the home to enable them to express their views of the home. People living at Penvose are encouraged to either handle their own financial affairs or to make alternative arrangements however some peoples monies are held by the home. We checked these and found they were correct with receipts and two signatures each time money is taken out or paid in. This was a requirement at the last inspection. We suggested that for reasons of confidentiality each persons accounts should be kept in a loose leaf folder to replace the current Residents Records book. The Accident Book was seen. We found that an accident we had seen written in someones daily records was not recorded in the Accident Book. We were not confident that accidents are recorded correctly and safely because record keeping was found to lapsing in care plans and daily records. The CQC is notified of any serious incidents affecting the health, safety or well being of any of the people living at Penvose. Care plans inspected did not have risk assessments relevant to the individual person included in them. The matron told us these were still pending being written. We are not confident with the current situation regarding the management and expectations put upon the matron that these will be Care Homes for Older People Page 30 of 37 Evidence: written in the near future. On our arrival at the home a fire safety door guard was bleeping because the battery was dead. We had to ask the matron to change the battery as no-one was taking responsibility to do this even though it was a fire safety measure. At the last inspection an Immediate Requirement was issued because hold-open devices had been fitted, but were not in working order, and may not have been for some time, as wooden door pegs were in use. During our tour of the premises we found a bedroom door that did not close at all. We asked the matron to ensure that all bedroom doors were checked routinely to ensure they close fully into the latch and comply with British fire safety standards and regulations. We inspected the Fire Log and confirmed that the emergency lighting, emergency exits and fire alarms had been checked regularly, dated and signed. All the smoke detectors have been replaced with heat detectors. These were also checked. The matron explained that all the staff have taken a distance learning theoretical fire safety training course however there have been no practical training sessions either with a professional fire safety trainer or in-house training sessions for any staff. One member of staff told us that she has worked at Penvose for three years and never done a practical fire drill. There were no individual assessment of need for anyone living at Penvose in the event of the need to evacuate the home. We have written to the Devon Fire and Rescue Service to alert them about our findings and concerns. On the day of our visit the home was clean and tidy, free from offensive odours throughout. A log book has been set up for the person responsible for the maintenance of the home. Staff can record any maintenance issues they find in this log book and he signs and dates when it is done. We reminded the registered provider and the matron that this should include replacement of worn out and corroded equipment such as bath mats to prevent slipping, and equipment with metal frames. It should also include fire safety devices that need replacement batteries with urgent timescales if this is not a task staff are deemed competent to deal with immediately on finding themselves. Care Homes for Older People Page 31 of 37 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 26 19 People must not be 31/03/2009 employed at the home unless satisfactory outcomes have been obtained in relation to all the information as detailed in Schedule 2 of the Care Homes Regulations 2001 Two written references must be obtained in relation to the applicant prior to the commencement of their employment to ensure as far as possible only suitable staff are employed. 2 26 13 The registered person must 31/07/2009 make suitable arrangements for the training of staff in first aid and to provide safe moving and handling of the people who use this service. This is to ensure staff have the necessary skills to respond to an emergency and to assist the people who use this service in manner that protects their health and safety and that of the person they are assisting. 3 31 12 The home owner must ensure that the home is conducted in a way that makes proper provision for the health and welfare of 31/05/2010 Care Homes for Older People Page 32 of 37 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action service users by clarifying the role and responsibilities of the matron and other senior staff in a Job Description. This is to ensure that people with management responsibility know what they must do and are given time in which to do it. 4 38 23 All fire doors must be kept 31/12/2009 shut, unless held open by an approved hold-open device. This is to protect residents from harm in an emergency. Care Homes for Older People Page 33 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 13 You must arrange training 24/09/2010 on the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DOLS) for all staff to ensure they are up to date with current legislation and practice. This will ensure that people using this service are protected from being placed at risk of harm or abuse. 2 32 12 You must encourage and 09/07/2010 assist staff to maintain good personal and professional relationships with the people using this service. This will ensure that the home is run in such a way that you create an open, positive and inclusive atmosphere, and the home is run in the best interests of the people who reside there. Care Homes for Older People Page 34 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 38 23 You must ensure by means 09/07/2010 of fire drills and practices at suitable intervals, that all persons working in the care home, and so far as practicable, people living in the care home, are aware of the procedure to be followed in case of fire, including the procedure for saving life. This is to ensure all staff have the necessary skills to respond in the event of a fire to protect the people living in the home in a manner that protects their health and safety as well as that of the people living in the home. 4 38 23 All fire doors held open by an approved hold-open device must be maintained in working order. This is to ensure that everyone in the home will be less at risk in the event of a fire in the home. 26/06/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 You should further developed care plans to give staff fuller information about peoples health conditions, and include a Care Homes for Older People Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations personal profile to give staff an overview of the persons life. This recommendation is carried forward from the last inspection report. 2 10 Staff should ensure when they assist people using this service with personal care in a communal bathroom, that any personal toiletries are returned to the persons room and put away so the persons privacy and dignity is not compromised. You should engage the people using this service in activites of daily living, and on a regular basis provide social activities that stimulate and engage people. This recommendation is carried forward from the last inspection report. 4 19 You should produce and implement a routine programme of maintainence and renewal of the fabric and decoration of the premises to ensure the people using this service live in a safe, well maintianed environment. You should routinely check and renew equipment when it is worn out or corroding. This will ensure that the people using this service are safe when they use equipment and also help protect them from cross-infection. You should ensure that the findings of the quality assurance questionnaires are collated and a report written that can be distributed to interested parties. 3 12 5 19 6 33 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 37 of 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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