CARE HOMES FOR OLDER PEOPLE
Penvose Residential Home 1/2 Tothill Avenue St Judes Plymouth Devon PL4 8PH Lead Inspector
Megan Walker Unannounced Inspection 6th December 2005 13:00 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.V249604.R01.S.doc Version 5.0 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.V249604.R01.S.doc Version 5.0 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.V249604.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 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 people 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 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. Service users moving into the home who have caged birds may bring their birds with them. Mrs Reed, the Registered Provider, has a small dog that is also a regular visitor to the home. 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 has a no smoking policy. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection on Tuesday 6th December 2005 between 13h00 and 17h45. The inspector toured the premises. All the residents were introduced to the inspector and six residents offered comments and views about living at Penvose and the care services they receive. Time was spent talking with the Registered Provider Mrs Joyce Reed, Sharon Spry, Deputy Matron, and Joan Blank, Matron, all of whom were on duty at the time of the inspection. Care records and other records and documents were inspected. There were eight requirements from the last inspection. With the exception of three requirements these had all been met or were being addressed by the time of this inspection. There are three additional requirements to be met following this inspection. What the service does well: What has improved since the last inspection?
An initial assessment is now completed prior to anyone moving into the home and staff are taking steps to ensure that this happens with each new referral. Staff training in dementia is currently being sought, and all staff will be undertaking some form of NVQ study during next year. Mrs. Reed has gained an NVQ Level 4 and the Registered Manager’s Award since the last inspection. She is the oldest person in the UK to achieve this as acclaimed in the local press recently. The home now has Hazard Data sheets, obtained from all the manufacturers of substances used within the home. The Deputy Matron has also started to compile an Advice folder with information such as prevention of Salmonella, Legionnaire’s Disease, and medical alerts. All such information is kept in the main office as a point of reference and is always available for staff to read. Every resident now has their photograph on their Individual Service User’s file, on their medication record, and on their bedroom door.
Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 6 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. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 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.V249604.R01.S.doc Version 5.0 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 the following standard(s): 1,3,4 Improved information is now available for prospective service users to help them and their families in making their decision to live at Penvose. Prospective residents do not receive formal assurance that their needs will be met when they move into the home. EVIDENCE: The Statement of Purpose and the Service Users’ Guide has been updated and made available to all residents and/or their families. The Commission has also been given a copy. An Initial Assessment form has been compiled for use in pre-assessment of prospective residents, however, Mrs. Reed stated that at present the home has no formal method of informing new residents that their assessed needs can be met. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 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 the following standard(s): 9, 11 The handling of resident’s medication is satisfactory, but the storage of controlled drugs and medicines requiring refrigeration needs to be more secure. The home’s policies and procedures for handling dying and death need to be revised. EVIDENCE: At the time of the inspection no resident was responsible for his or her own medication. However should someone wish to self-medicate, they would be required to sign a disclaimer and also require the consent of their GP. The home has a contract with the pharmacy at “Boots” for its supplies of medication. The storage and records of the administration of medicines were inspected. The storage of general medicines was satisfactory but the storage of controlled medicines and medicines requiring refrigeration was not sufficiently secure. The medication administration record sheets were seen to be clear and up to date. The home has a “Residents Admission” book in which it is recorded individual residents’ burial wishes. This information is not obtained until someone is dying hence is unavailable should a resident die suddenly. During a conversation with the Deputy Matron and Mrs. Reed about ways to resolve this
Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 10 sensitively, they agreed to try introducing the subject at the four week review held after the initial trial period. It was observed during this inspection that with the consent of the GP, residents could remain at the home when they are dying, and that staff provide care appropriately. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 14 The residents’ lifestyle experienced in the home matches their expectations and reflects their preferences. EVIDENCE: Residents are encouraged by the Registered Provider and staff to be as active and independent as is possible for each individual. Residents spoken to expressed their satisfaction with their lifestyle at Penvose. One resident commented that she had always dreaded the idea of living in a care home, however now that she has moved to live at Penvose, she is glad that she made the choice. All the residents’ bedrooms were individual and personalised with possessions brought with them. The home enables residents to maintain and participate in Christian practices such as a monthly Protestant Service, and attendance at a local church. The Roman Catholic priest has also visited to give Holy Communion when asked. Discussion with staff about meeting needs of people of other faiths showed that they have an awareness of religious and cultural preferences, and would respect them. One member of staff explained about a 6th month care home placement. She had undertaken this in a city with diverse and multiple cultures and beliefs, all of which influenced care needs and thereby care practice. She has subsequently talked to staff at Penvose about these experiences.
Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 17 Residents can feel confident that their legal rights are protected. EVIDENCE: Mrs Reed gave several examples of situations when she and/or senior staff had recommended to residents the use of legal assistance and advocacy. She also demonstrated how this has benefited the individual residents. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 0 None of the above standards were inspected on this occasion as they were all assessed as met in the report of the inspection done on the 26th May 2005. EVIDENCE: Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff are competent in doing their jobs. EVIDENCE: Since the last inspection Mrs. Reed, the Registered Provider, has completed the Registered Manager’s Award (R.M.A.), and a N.V.Q. Level4 in Care. Ms. Sharon Spry, the deputy matron, has started the R.M.A. course, and expects to complete this by December 2006. She then intends to take the necessary components of the NVQ Level4 in Care to achieve the requirements of the National Minimum Standards. As part of her Personal Development Plan, Ms. Spry intends to train as a mentor, starting a course in April 2006. Both Mrs. Reed and Ms. Spry will be commencing an Environmental Management course in the New Year. Two carers are expected to start an N.V.Q. Level 3 course in January 2006. All staff are due to renew their First Aid and Food Hygiene training in 2006. The annual Fire Training for all staff was in June 2005. Ms. Spry explained that the information given at the last inspection on Dementia Care training had been followed up, however for a number of reasons, the home is currently seeking an alternative training provider. It is intended that all staff will receive training in Dementia Care at the earliest opportunity next year. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Residents can be sure that safeguards are in place to protect their financial interests. EVIDENCE: A sample of residents’ financial records were inspected. All the accounts balanced. Receipts were kept for all transactions. Discussion with Mrs. Reed and Joan Blank, the Matron, showed that they are both very conscientious about service users’ welfare including financial interests, and when required they would take any necessary measures to protect this. During the inspection a situation regarding a resident’s money arose, and this was observed as being dealt with in a correct and respectful manner. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 16 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 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 17 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(1(d)) 14(2) Requirement Timescale for action 2 3 OP9 OP11 The Registered Provider must confirm in writing to the resident 31/01/06 or their representative that the assessed needs of that prospective resident can be met by the home. These needs must be reviewed regularly and documented accordingly on the individual’s care plan. 13(4(a)(c) A locked facility for medicines ) kept in the ‘fridge’ must be 31/01/06 provided. 12 The Registered Provider must ensure that there is sufficient detail on each individual 31/01/06 resident’s care plan regarding his or her wishes for care when dying, and after death. This information must be kept on the individual service user’s file to respect confidentiality. Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 18 4 OP12 16 5 OP24 23(e) 6 OP30 18(1)(c) 7 OP33 24 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 This requirement has been partially met since the previous inspection. Appropriate door locks must be installed when rooms become vacant or if individual service users request this facility or if circumstances in the home change. This requirement is outstanding from the previous inspection and the timescale extended. Staff must undertake training to address the care needs of people with dementia. This requirement is outstanding from the previous inspection and the 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. This requirement has been partially met since the previous inspection. TIMESCALE EXTENDED 31/05/06 31/05/06 31/05/06 31/03/06 Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 19 8 OP36 18(2) 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 and personal development, which are recorded. This requirement is outstanding from the previous inspection and the timescale extended. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Penvose Residential Home DS0000003489.V249604.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Ashburton Office 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
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