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Inspection on 26/05/05 for Penvose Residential Home

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

This inspection was carried out on 26th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Mrs Reed and the staff team provide warm and homely accommodation in a traditional setting. Most of the staff have worked at the home for a long time. Residents spoken to felt that staff have built good relationships with them. The meals are wholesome and varied. They consist of locally bought fresh produce. Special diets are catered for and individual preferences are respected.

What has improved since the last inspection?

Some areas of the home have been redecorated including the dining room and 4 bedrooms. The rear yards of the home have been resurfaced and paved to provide off road parking spaces for visitors. Gardens have been improved and replanted.

What the care home could do better:

All residents must have a preadmission assessment carried out by the home prior to a resident being admitted to ensure staff are able to meet their care needs. There must be a photograph of the resident on their personal case file. Leisure and social activities should be organised to suit all residents including those who have varying levels of dementia and memory loss. Staff must attend training courses to learn more about people with dementia and their care. Staff supervision must be introduced whereby staff meet with the manager on a one to one basis at least six times a year. Residents` bedroom doors must be lockable to avoid confused residents wandering into other people`s rooms. The registered person must introduce a Quality Assurance System to gather the views of people living in the home and their relatives and representatives to see whether they are satisfied with the services the home is providing. Hazard data sheets that explain the use of substances used in the home which may be hazardous to health must be obtained from the manufacturers.

CARE HOMES FOR OLDER PEOPLE Penvose Residential Home 1/2 Tothill Avenue St Judes Plymouth PL4 8PH Lead Inspector Sheila Giblin Announced 26 May 2005 th 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 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 D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Penvose Residential Home Address 1/2 Tothill Avenue, St Judes, Plymouth, Devon, PL4 8PH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 663191 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 D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30th September 2004 Brief Description of the Service: Penvose is privately owned and aims to provide long-term residential care for older people. The home has the registration categories of OP for 15 older persons and DE(E) for dementia sufferers. The home does not intend to provide a service for people who have long standing mental health problems, which cause them to display anti-social behaviour or aggression. The home does not provide an intermediate rehabilitation care service but it does occasionally admit people who need short-term respite care. The bedrooms are mainly single and two doubles. Stair lifts provide access to the first floor but access to many rooms requires service users to be able to manage short flights of stairs between mezzanine floor levels throughout the home which was originally two houses. Penvose is not suitable for wheelchair users. The living rooms are situated on the ground floors and consist of two lounges and a dining room. The home is situated in a residential area of Plymouth a short bus ride distance from the city centre and it is also opposite a large park. Limited off road parking is available for visitors at the rear of the home otherwise on street parking is available at certain times of the day. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place over 8 hours. Mrs Reed the owner of the home provided a pre-inspection questionnaire prior to the inspection which held current information regarding the residents living in the home and staff employed. All fourteen residents were introduced and six spoke to the inspector at length. Residents’ care plans and files were viewed, there was a tour of the building and all the bedrooms were inspected. Lunch was eaten in the dining room with the residents. Staff on duty spoke to the inspector and contributed to the inspection in a helpful and positive way. What the service does well: What has improved since the last inspection? What they could do better: Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 6 All residents must have a preadmission assessment carried out by the home prior to a resident being admitted to ensure staff are able to meet their care needs. There must be a photograph of the resident on their personal case file. Leisure and social activities should be organised to suit all residents including those who have varying levels of dementia and memory loss. Staff must attend training courses to learn more about people with dementia and their care. Staff supervision must be introduced whereby staff meet with the manager on a one to one basis at least six times a year. Residents’ bedroom doors must be lockable to avoid confused residents wandering into other people’s rooms. The registered person must introduce a Quality Assurance System to gather the views of people living in the home and their relatives and representatives to see whether they are satisfied with the services the home is providing. Hazard data sheets that explain the use of substances used in the home which may be hazardous to health must be obtained from the manufacturers. 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. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, 6 The systems for preadmission assessments are not robust resulting in the risk of residents being admitted whose needs cannot be fully met in the home. EVIDENCE: Senior staff have been pressurised to take an emergency admission at very short notice without undertaking a preadmission assessment to ensure they can meet the care needs of the resident. Otherwise residents are invited to visit the home prior to admission but they said that they rely on their relatives to make the decision for them. Penvose does not admit people for intermediate care. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 Residents can feel confident that their health care needs will be met. EVIDENCE: Every resident had a care plan which contained appropriate information and details of personal and health care needs. Residents’ files showed entries and correspondence relating to health care issues, investigations and consultations with health care officers. Not all the residents’ had a photograph on their personal file. One resident manages her own medication and a safe storage facility has been provided in the bedroom. The community nurse visited the home during the inspection to provide nursing care for a resident. She spoke well of the staff and the assistance and cooperation she receives. She said that staff alerted her to any problems and asked for advice. Residents said they were treated with respect and they felt their personal care was provided sensitively. Staff were observed knocking on bedroom doors and addressing residents in a warm and courteous manner. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Residents can be sure of a comfortable lifestyle at Penvose but there has been no progress in introducing a stimulating activities programme. EVIDENCE: On arrival at the home music was being played in the lounge. Residents said they enjoyed having the inspector to talk to. Some residents regularly go out with their relatives. One resident attends a day centre facility and goes out every week with a community escort as part of a plan of care. There was no formal activities programme and those activities that are provided periodically did not take into account the needs of those residents with confusion and memory loss. Residents were seen sitting in the lounges and in their rooms watching TV. Only two residents said they had any hobbies or interests. There is a monthly religious service for hymn singing and holy communion for those who wish to participate. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents can feel confident that any complaints they have will be taken seriously and that their views are listened to and acted on. EVIDENCE: Penvose had a written complaints procedure and had received no complaints since the last inspection. There were written policies relating to the protection of vulnerable adults and whistle blowing policy. The home had a copy of the updated local guidance “Protection of Adults at Risk – Multi Agency Procedures and Guidance – Alerter’s Guidance”. Residents said they had no complaints about the care they receive. Those able to give an account said they felt confident to ask the staff to sort out any problems as they arose. All the residents said that the staff were very kind and considerate and always treated them with respect and spoke to them kindly. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Mobile residents can be confident that Penvose will provide safe, clean, comfortable accommodation. EVIDENCE: The accommodation has been well maintained. Rooms are decorated as they become available with carpets being renewed as necessary. Water temperature regulation valves ensure temperatures are maintained at a safe level at hand basins and in bathrooms. Water temperatures are monitored and recorded. All radiators and hot pipe work has been guarded to safeguard residents from the risk of hot surface burns. Originally the home was two houses converted into one some years ago. The accommodation for residents is laid out on two floors with access by stair lifts to the upper floor. However, some rooms are linked by short flights of stairs with some toilets and bathrooms being on mezzanine levels. Handrails are in place to assist the movement of residents. The home is not suitable for wheelchair users. Residents’ bedrooms are almost all large spacious rooms with bay windows. Bedroom doors do not have locks. Some relatives have Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 13 indicated in writing that they prefer the resident’s bedroom remains without a lock. Only one room has an en suite toilet. The furnishings are traditional in style providing comfortable chairs and beds. Personal possessions were seen in all the bedrooms. Some residents have bought their own specialist beds. One resident at risk of falling out of bed had cot sides on the bed. This had been documented in the care plan and risk assessed. There are two lounges with a music centre and TV in one. Most residents sit in the lounges for part or most of the day. Residents can stay in their rooms if they wish. The dining room is well furnished and also houses an organ and two bird cages. There is also a cat living in the home. Smoking is allowed in the staff room but there were no residents who smoked at the time of this inspection. External doors have alarms or are locked to ensure confused residents don’t wander out onto the road. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Residents can be confident that the staff are loyal and long serving and provide a stable experienced workforce to meet their needs. EVIDENCE: The duty rota showed that there were 2 – 3 care staff available in the mornings: this included a trainee member of staff who did not undertake personal care but not the Registered Provider who was on the premises most days. Two care staff were available in the afternoons and evenings, with 1 waking and 1 sleeping night staff. In addition to the care staff, the home employed domestic staff 20 hours per week of cleaning time. There is a history of low staff turnover at Penvose. Staff training has included fire safety. Three staff have completed NVQ 2 and 3. This does not meet the National Minimum Standards target of 50 by 2005. The requirement for staff to undertake a course to address the needs of residents with dementia has not been met. This was discussed and information provided by the inspector to Mrs Reed. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, 38 Residents are assured of a well managed home overseen by the owner supported by competent senior staff. EVIDENCE: Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 16 Mrs Reed has run Penvose for over twenty years. In terms of experience and competence the registered owner has the ability to meet this standard, and has enrolled to undertake NVQ4 in Care and the Registered Manager Award. Mrs Reed has a qualification in advanced management. There was a calm friendly atmosphere in the home. Mrs Reed was finalising a residents’ questionnaire to gather their views regarding their satisfaction about the services being provided in the home. Staff maintained a system of recording that was clear and easy to access. There was no formal supervision system in place whereby staff meet with their manager at least six times a year on a 1:1 basis to discuss their personal and professional development. The Home had a written policy relating to access to files and Service Users had access to their records. All records were kept securely in the matron’s or Mrs Reed’s office. Evidence was provided that staff had received fire safety training in June 2004 which was due for updating on 16th June 2005. Other health and safety training had been provided in May 2004 and first aid training was to be up -dated in June 2005. Evidence was provided that testing of portable electrical appliances had been undertaken in September 2004. Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 1 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 3 x 1 2 2 Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 3 12 Regulation 14 16 Requirement Every resident must have a preadmission assessment prior to coming into the home An appropriate activities programme must be introduced that takes account of the particular needs of those residents with dementia as discussed and agreed. TIMESCALE EXTENDED Bedroom doors must be fitted with appropriate locks. TIMESCALE EXTENDED Staff must undertake training to address the care needs of people with dementia. TIMESCALE EXTENDED A quality assurance system must be implemented to gather the views of residents and their relatives 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. TIMESCALE EXTENDED A staff supervision system must be implemented whereby staff receive 1:1 sessions with the manager at least 6 times per year to discuss their professional Timescale for action 1st July 2005 1st July 2005 3. 4. 24 30 23(e) 18(1)(c) 1st September 2005 1st September 2005 1st September 2005 5. 33 24 6. 36 18(2) 1st September 2005 Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 19 7. 8. 37 38 17, Sched 3.2 13(4) and personal development which are recorded. TIMESCALE EXTENDED A photograph must be held of each resident on their personal file. Hazard Data sheets must be obtained from manufacturers of substances used in the home that come under COSHH Regulations as discussed and agreed. TIMESCALE EXTENDED 1st July 2005 1st July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Penvose Residential Home D52-D04 S3489 Penvose V216044 260505 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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