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Inspection on 24/11/06 for Penvose Residential Home

Also see our care home review for Penvose Residential Home for more information

This inspection was carried out on 24th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Penvose provides a clean, homely environment for older people in need of twenty-four hour care. Staff are caring and work well as a team for the benefit of the residents. A very low staff turnover is an advantage for the residents` welfare and well-being. The home recently has a new manager who is very motivated, competent and approachable. Food is plentiful, choices of menu are available and dietary needs are met. As one resident pointed out: "You won`t die of malnutrition living here!"

What has improved since the last inspection?

The garage and utility room are being rebuilt for safety reasons. The finished areas will provide ample storage space for the home as well as a purpose built utility room.

What the care home could do better:

Thorough recruitment procedures must be adhered to in order to safe guard the residents. Care staff must wear protective aprons when preparing and handling food for reasons of hygiene and to prevent cross-infection.

CARE HOMES FOR OLDER PEOPLE Penvose Residential Home 1/2 Tothill Avenue St Judes Plymouth Devon PL4 8PH Lead Inspector Megan Walker Unannounced Inspection 11:00 24 November, 12 December 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penvose Residential Home Address 1/2 Tothill Avenue St Judes Plymouth Devon PL4 8PH 01752 663191 UPDATED 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) Mrs Joyce Sylvia Reed Mrs Joyce Sylvia Reed Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One Service User named elsewhere with the MD (E) category may reside at the home. One service user, named elsewhere, who is out of category may reside at the home. 6th December 2005 Date of last inspection Brief Description of the Service: Penvose is privately owned and aims to provide long-term residential care for people over the age of 65 years. The home has the registration categories of OP for up to 15 older persons and DE (E) for up to four older persons who have dementia. The home does not intend to provide a service for 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 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 service users to be able to manage short flights of stairs between mezzanine floor levels. A stair lift provides access to the first floor. Penvose is not suitable for wheelchair users. On the split level ground floors are two lounges and the dining room. There are 13 single and two double bedrooms, none of which has 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 are large gardens. The home has a cat, two budgies and a cockatiel. 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 £278.46 to £305.24. Additional charges include in-house hairdresser (£5-£18), Chiropodist (£8), and sundry items at commercial rates. This information was given in the Pre-Inspection Questionnaire returned to the Commission in August 2006. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork part of this inspection was unannounced and took place over two days, Friday 24th November and Tuesday 12th December 2006. It included a tour of the premises, observation of interactions between staff and residents in the home, talking to residents, staff and relatives, and inspection of care plans, staff files, medication and other records and documentation. The Registered Provider, Mrs Joyce Reed and the home’s manager were present at the time of this visit. Part of the time was spent talking with each of them about the dayto-day routines, as well as the management of the home. In addition other information used to inform this inspection: • The Pre-inspection Questionnaire completed by the Registered Provider. • The previous two inspection reports • All other information relating to Penvose received by the Commission since the last inspection. Of twenty-one Comments’ Cards and Surveys sent out, the Commission received back – • Four “Relatives/Visitors” Comment Cards • Four Comment Cards from “Health and Social Care Professionals in Contact with the Home” • Three Comment Cards from General Practitioners • Two Care Workers Surveys Three requirements (one outstanding from the last inspection), and three “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: Penvose provides a clean, homely environment for older people in need of twenty-four hour care. Staff are caring and work well as a team for the benefit of the residents. A very low staff turnover is an advantage for the residents’ welfare and well-being. The home recently has a new manager who is very motivated, competent and approachable. Food is plentiful, choices of menu are available and dietary needs are met. As one resident pointed out: “You won’t die of malnutrition living here!” Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about where to live. EVIDENCE: A colour leaflet with information and photographs of Penvose is available for prospective residents and their families. This will be revised in the near future to reflect the change of manager. Inspection of residents’ files found that each resident had a contract with terms and conditions of residency. This included the room they were to occupy and the weekly fee for residing in the care home. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 9 Conversations with both residents and their relatives showed that in most cases residential care has been sought due to a crisis. Commonly this was a fall or poor health requiring hospital admission. At the time of this visit there were also residents who had come in for a short convalescence period after a stay in hospital. (This was possible because there were two vacancies, at other times it would be dependent on room availability.) When it was practical prospective residents had visited prior to deciding if they wished to move into the home. They had stayed for a few hours and had had at least one meal. Some family members spoken to said that they had had to choose a care home on behalf of their older relative. They too had been able to see the home and meet the residents and staff before making a decision. Care files showed pre-assessments of care needs as well as care plans for individual residents. Although it was a requirement from the last inspection, prospective residents still only receive a verbal confirmation that their assessed needs can be met within the home. During this visit the benefits of written confirmation outlining what was being offered were explained to the Registered Provider and to the manager. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a staff team that is respectful and reliable will ensure that their care needs are met. EVIDENCE: All the residents’ care files have been updated. Care plans have been put on to a computer programme to aid ease of use. The assessments of care needs and the subsequent plans of care were detailed yet informative. The manager had designed a front sheet of contact details and basic information that can be photocopied and sent with a resident should they, for example, be admitted to hospital. She had likewise compiled a medication record including drug sensitivities. Hospital ward staff apparently complimented this record when a resident recently had an emergency hospital admission. The care plans seen had realistic short term care aims that could be reviewed and changed as Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 11 needed. As all the care plans have only recently been revised and updated the manager intends to go through each one with the individual resident (and relatives if appropriate) to ensure that they agree its contents. These will be signed on this occasion and then at each subsequent review. The medication was seen kept in a lockable, fixed cupboard and there was a separate fixed, lockable cupboard for controlled medication. A lockable ‘fridge’ has now been provided should any medication need to be kept cool. The medication records were all seen and were up to date and signed accordingly. A photograph of the resident was attached to their medication record. At the time of this visit, none of the residents required any controlled medication, and no one was responsible for their own medication. Three senior staff members had attended a “Boots” “Medication Handling Course”, and additionally the manager and deputy manager had completed a course on “General Medicines Management”. It was evident from observation of interactions between residents and staff, and from talking to residents that they felt well looked after and respected. There was an easy-going atmosphere. When asked, more than one resident said that they would ask for something if they needed it and would let staff know if they didn’t like something. All the residents spoken to during this visit spoke highly of the care they receive. They considered it to be personalised to suit them. Family members also confirmed that they were pleased with the care their relative was receiving at Penvose. If the information was available, the care plans had details of specific wishes regarding preferences for funeral arrangements. A local funeral director had produced a booklet containing useful contacts and other general and helpful information about what to do after someone dies. The Registered Provider explained during this visit that giving these booklets to relatives had proved to be successful as it gave them a step-by-step guide on how to arrange a funeral. The manager was in the process of arranging “Funeral training” for staff to give them an insight into the role of the undertaker. The Registered Provider stated that there was always a representative staff group at every resident’s funeral and this was especially important for those residents without families or friends. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with their lifestyle at Penvose and enjoy the food offered to them. EVIDENCE: Residents have a variety of activities available to them. A Residents’ Meeting has been set up to give residents (and relatives should they wish to attend) a regular opportunity to talk about their likes and dislikes in the running of the home, including things they would like to do. Recently the residents and staff sponsored a local primary school “Anti Bullying” Week. The school is developing local community links and Penvose residents and staff are now invited to school events. A local mobile book club comes to the home regularly to offer a library service as well as read to residents. There are plans for a reminiscence group, “Plymouth Past”, to be set up in the near future. Residents who are more mobile go out with the Registered Provider to a local dogs and cats home that provides a “Pet A Pet” service. Once a fortnight residents have the opportunity to join in with an “Armchair” exercise group. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 13 Penvose is not specifically a faith-based home however it has links with a local Church of England church. A service of worship is available at the home to those residents who wish to attend once a month. During the weeks leading up to Christmas it is planned that the local church choir will come to the home to sing Christmas carols, and on the evening of this visit a few residents were going to the local primary school Christmas Carol Service. The manager is endeavouring to make arrangements for another resident who has expressed a wish to attend Christmas Eve Midnight mass. Due to a few incidents concerning a then resident who was Catholic and not English, it was suggested to the Registered Provider during this visit that it could be helpful for prospective residents if they knew about the home’s Christian Protestant contacts. She agreed to add this in to the Statement of Purpose and Service User’s Guide when it is revised. It was noted that since one of these incidents staff no longer assume residents’ “Englishness”, for example, during international sports events, and this had been a useful lesson. The residents had all been consulted about food and a four weekly menu had been compiled to try and meet all the preferences. A new resident said it was good old fashioned cooking and very enjoyable. A junk food day once a week has been introduced because a number of residents missed their days out with young grandchildren who wanted burgers & chips or sausages & beans. A relatively new resident required a gluten free diet & this was catered for, as were residents with diabetes controlled by diet. Although the menu didn’t show a choice at lunchtime, residents were seen being asked what they would prefer. The manager agreed during this visit that she would revise the written menu to show residents a choice and an alternative at lunchtime. All the residents were asked what they would like for breakfast and again at teatime. All the residents asked said that they enjoyed their food and that there was always food available if they were hungry between meals or if they had been out at the home’s meal times. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and their families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. Residents’ best interests come first however they could be at risk if staff checks are not thorough. EVIDENCE: Since that last inspection the Commission has not received any complaints about Penvose. The home’s Complaints procedure was seen displayed in the main hall near the front door. The Registered Provider confirmed that should a resident or a relative raise anything with herself or a staff member, she would endeavour to sort out the matter to everyone’s satisfaction. Inspection of staff files found that some were incomplete, for example, references had been requested but no action had been taken if there was no response. Also police checks had not been done properly. The individuals concerned were working in the home the manager confirmed. She was made aware of the missing documents and advised of the risks it meant to residents. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Penvose has a homely, safe and well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: Since the last inspection building work has gone ahead to replace the garage and utility room because they were old and unsafe. When this work is completed it will provide ample storage space above the garage and a purpose-built utility room that complies with building regulations. The new utility room will house a domestic washing machine that the Registered Provider explained was for delicate items of clothing. (This is additional to the industrial machines in the laundry room.) Prior to work starting the manager completed risk assessments, including fire safety and evacuation, for residents Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 16 and staff as well as the builders. Also the building area was “made safe” by completely blocking it off from the home. All the occupied bedrooms seen were personalised. Some residents were spoken to in their rooms. They said that they had chosen how the furniture was arranged and confirmed that they had been able to bring in pieces of their own furniture. Some bedrooms had personal telephone lines and the manager confirmed that these could be fitted in other rooms if requested. None of the bedrooms had locks however during this visit the Registered Provider confirmed that she was purchasing suitable locks to fit on doors of empty rooms. Locks would also be fitted if any residents requested one. All the bedrooms had risk assessments on the environment of the room and how that could affect its occupant(s). On recommendation from the Fire Safety Officer all the doors had been encapsulated and an “Asbestos-free” certificate had been issued to the home. The home was found to be clean and hygienic throughout. It was also found to be in good order and upkeep. The Registered Provider confirmed that the plans to upgrade the kitchen were going ahead, probably in the summer. A building company had agreed to do the job and already advised about the health and safety measures that it had taken in other care homes when rebuilding their kitchens. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff group is motivated and caring. The proposed training plan will enhance this and progress the quality of care being given to residents. EVIDENCE: At the time of this visit the home had a staff group that worked well together. A minimal turnover helped to maintain good morale and promote residents’ confidence. In response to the Care Workers Survey questions one staff member wrote: “We (staff) listen to each other. As a team we strive to make improvements.” The number of staff with a National Vocational Qualification (NVQ) in Health and Social Care was below the required 50 . The manager who has recently come into post was aware of this shortfall. She was putting together a training plan that would ensure all staff had mandatory training. Additionally arrangements were being made with a local District Nurse to provide in-house training such as Diabetes and catheter care. All the staff responsible for dispensing medication had done a medication administration and handling Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 18 course. Since the last inspection staff had attended a half-day seminar in Dementia Care. The manager was seeking further training on dementia and mental health in old age for all staff to attend. Inspection of staff files found that some were incomplete. For example references were missing and Criminal Records Bureau (CRB) checks (police checks) were not done properly. The manager was made aware of these missing documents and that CRBs are not portable, that is, they cannot be moved from one work environment to another. She agreed to request different referees and to send for new CRB checks for Penvose. It was suggested to the manager at the time of this visit that a checklist that might help. This would ensure all the appropriate checks were complete when she was employing new staff in the future. The manager was also made aware of the risks to residents if recruitment checks were not thorough. (SEE ST 18). During this visit it was recommended that all full time staff should sign a copy of the European Directive on Working Time including a disclaimer in case anyone chose to work over 48hours including overtime, in any seven day period. Observation of staff during this visit saw them being polite and respectful to each resident. There was a lot of light-hearted chatter as well as gentle encouragement when it was needed. Residents said that they “got on well with staff”. Generally they felt that the staff group were able to look after them and provided good care. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health, safety and welfare is promoted and protected by a conscientious Registered Provider who is keen to achieve positive outcomes for residents and staff. EVIDENCE: Mrs Reed, the Registered Provider, is actively involved in the day-to-day running of the home. There were clear lines of accountability and the management of the home was transparent and honest. Observation during this visit saw that the staff group respected her yet did not feel intimidated. Some of the residents spoke highly of Mrs Reed and the newly appointed manager. Mrs Reed is planning to reduce her hours next year and it was Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 20 evident during this visit that she felt confident about dividing the existing workload between the manager and herself. Staff commented that there had already been changes and they were expecting more that would benefit the residents by improving the running of the home. The home’s manager had achieved the Registered Manager’s Award (RMA) and at the time of this visit had started a Level 4 NVQ in Health And Social Care at Plymouth Business College. She had also gained a Mentors Award and recently she and Mrs Reed took a six-month course in Environmental Management, a course about making the home environmentally friendly and environmentally aware. Residents have been asked their views on the running of the home however this had not been extended to staff, families, friends and other visitors to the home. The manager agreed she would put together a questionnaire, give it out to staff and visitors to the home and then write a summary of the results with actions that it may prompt. Residents’ views and ideas are also sought via minuted Residents’ Meetings. The Registered Provider explained that she tries to encourage residents’ families to take responsibility for money if the resident is not able or does not wish to do it him or herself. The financial records of the few residents who had money held in the home were inspected and were recorded with receipts in place for items purchased on behalf of residents. There was a discrepancy about one account that had had money taken out during this visit but the staff member had not completed the financial record. The manager agreed to talk to all senior staff about such negligence and its implications. The Registered Provider confirmed that all the maintenance checks were complete and up to date. The new utility room is being built to meet all the building regulations including under floor insulation. Buckets and mops were replaced during this inspection and were colour-coded for different areas. Goggles and face masks were seen provided in the sluice room for staff protection when emptying and cleaning commodes, etc. Gloves and aprons were also seen for staff to use however they were reminded during this inspection about wearing them for food preparation and handling at teatime. One of the part time cooks has completed the “Safer Food, Better Business” training and the other cook is due to start it soon. This will then enable the staff to implement a new kitchen routine that would comply with the Food Standards Agency regulations and recommendations. The Accident Book was seen and accidents had been recorded correctly. The Commission had been notified of any incidents affecting the health, safety or well being of any of the residents. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 21 Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 2 X X 3 Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 14(1d) 14(2) Requirement The Registered Provider must confirm in writing to a new resident or their representative that the assessed needs of that person can be met by the home. Timescale for action 30/12/06 2 OP18 OP29 13(4c)(6) Sch 2 3 OP35 Sch 4 (9) 17(2, 3a) This requirement is outstanding from the previous inspection and the timescale extended. The Registered Provider must 10/01/07 use a thorough recruitment procedure when employing new staff to ensure the safeguarding of vulnerable residents. Recruitment checks must be fully completed for the staff files identified lacking essential documents. The Registered Provider must 12/12/06 ensure that all financial records of monies held on behalf of residents are accurate and up to date. Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 24 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 2 Refer to Standard OP24 OP28 Good Practice Recommendations The Registered Provider should continue with the proposed plan to install locks on doors of bedrooms that are vacant, and on any doors of rooms where residents request a lock. The Registered Provider should strive to achieve a minimum ratio of 50 of the home’s staff having at least Level 2 of a National Vocational Award in Health and Social Care by 2008. The Registered Provider should progress with the proposed quality assurance surveys to gather the views of residents’ relatives, staff and other visitors to the home to determine whether the home is meeting the needs of residents and that the services that the home is providing are of a satisfactory standard. 3 OP33 Penvose Residential Home DS0000003489.V308236.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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