CARE HOME ADULTS 18-65
Penwith Respite Care Limited 38 Polweath Road Treneere Penzance Cornwall TR18 3PN Lead Inspector
Paul Freeman Announced Inspection 21st September 2005 11:00 Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 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 Penwith Respite Care Limited DS0000009127.V251227.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Penwith Respite Care Limited Address 38 Polweath Road Treneere Penzance Cornwall TR18 3PN 01736 330638 01736 330638 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) Penwith Respite Care Limited Mrs Christine Doyle Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Penwith Respite Care Ltd is located at modern purpose built premises that is rented from Cornwall County Council and is situated on a residential estate on the outskirts of town centre of Penzance. The home is close to local shops, facilities and bus routes. The service offers planned respite care to adults with a learning disability. The aim of the service is to provide service users and their carers with regular patterns of stays for up to a maximum of four nights each month. Stays at the home are arranged through the Cornwall County Council Social Services Department. Emergency stays are also considered by the service. This is a popular service and up to 10 people can be accommodated at any time. The majority of the accommodation is on the ground floor level and has suitable access for disabled people. All the bedrooms are single and nine are located on the ground floor. The communal space is also on the ground floor and comprises of a large L shaped lounge/dinning room and a separate smaller lounge area. The kitchen is located next to the dining area and has recently been refurbished to a high standard. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over two days on 21September 2005 and 29 September 2005 and lasted for nine hours. The Inspector looked over the building and at a number of records and documents. The Inspector communicated with 3 people who use the service and observed the care, support and services provided to residents. Four of the staff and the registered manager were spoken to. The service had also provided the Commission with written information about the services and facilities at the home before the inspection visits occurred. Thirty seven written comments about the services and facilities were also received from relatives or service users representatives and over thirty comments were also received from users of the service. The Inspector found the requirements and recommendations set at the last inspections had been worked upon. What the service does well:
The statement of purpose has recently been improved and details the philosophy of the home as well as the services and facilities that are provided to service users. This provides service users and prospective service users with a clear picture of the arrangements at the home. Each person staying at the home is also provided with a written contract by the County Council and the service also issue terms and conditions of residency that detail the arrangements that are not covered in the contract. It is evident that positive relationships have been established between the staff and service users, relatives and service users representatives and professionals. On arrival service users are warmly greeted and are treated in a dignified and respectful manner. The staff is keen to make sure service users independency skills are not compromised and each individual person is valued. Service users presented as having confidence in the staff and during the inspection the staff on duty were mindful and attentive about the needs of the service users. A range of activities is provided during each stay within the home and the local community. The activities reflect the interests and hobbies of the person concerned and are detailed in their care plan. Service users are consulted about how they spend their leisure time on a daily basis. There are no barriers to relatives or friends visiting service users during a stay provided the service user has no objections. The service user will determine where the visit occurs. Relatives told the Inspector they always found the staff to be welcoming and supportive. A relative said there was no barriers to raising any issues or concerns and staff always responded in a positive manner. Service users decide what food they have at each mealtime and clear records are kept about each individuals preferences and any food that may adversely
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 6 affect their health. Staff monitors the nutritional input to make sure that a healthy diet is provided. The kitchen has recently been refitted and refurbished to a high standard. The equipment is well maintained and serviced and a good standard of cleanliness and hygiene are in place. The care staff cook and prepare the meals and each staff member has been suitably trained. Service users health needs are well met at the home. If any issues arise the relatives or representatives are advised and a general practitioner is consulted when required. Each care plan details any particular health issues an individual may experience and where necessary this also includes guidance to the staff about the care, support and any indicators of poor health they need to take account of. Any complaints or concerns are dealt with positively and users of the service or their families are encouraged to raise any issues they have. The environment is maintained to a high standard and wherever possible the furnishings, fixtures and fittings are of a domestic nature. A good standard of decor is provided and settings presents as warm and homely. The two communal areas on the ground floor can be used as flexible spaces according to the service users needs or choices about the activities they want to undertake. A secluded garden runs along one side of the home that is accessible to people who experience a disability. All the bedrooms are for single occupancy and the majority also have ensuite facilities. Many of the bedrooms are personalised by the occupants for the duration of their stay. Toilets, bathroom and shower facilities are distributed throughout the home and within easy access of communal areas. A good standard of hygiene and cleanliness was evident and there were no offensive odours at the home. Staff are provided with a range of training opportunities to improve and develop their skills and abilities to meet the needs of service users. The training includes speaclist courses for staff working with people who experience a learning disability as well as NVQ and core skills training. Robust recruitment, selection and vetting arrangements are in place for new staff. New staff also undertakes a satisfactory induction programme to make sure they are able to provide the standard of care required. Staff commented they were well supported by the managers and their colleagues. It is evident the staff work well as a team and are a highly motivated and enthusiastic workforce who work positively with service users. The home is well run and managed in order that the needs, choices and preferences of the service users can be met and the individuals concerned are provided with a varied and stimulating experience at the home. Positive arrangements have also been established to consult with service users and their relatives or representatives about the care and support provided. Satisfactory arrangements are also in place to provide a safe, healthy and hygienic environment that promotes the health and wellbeing of service users. What has improved since the last inspection? Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 7 The registered persons have developed a positive format to record service users care plan. Each service users has a care plan that details the care and support they required, the best way to provide the care needed and their preferences and choices. Relatives or representatives of the service users as well as any professional involved with the person are consultes about the content of the care plan. As far as possible the service users also play a lead role in determining the contents of the plan. The revised care planning arrangements will be applied to each service users over the next year. The plans are formally reviewed and this occurs at least every six months. In addition the staff at the home will consider the plan during each stay to make sure it accurately reflects the care and support required. The risk management arrangements have been made more robust to make sure that any risks service users may encounter are taken account of and where appropriate suitable steps are taken to minimise any unreasonable risks. If any particular action is required by the staff this is clearly recorded in the persons care plans. Medicines are managed safely at the home and satisfactory records are maintained. The policy and procedure for medicines has been improved recently and provides staff with clear guidance about the arrangements in place. Service users are able to administer their own medicines when it is safe to do so. Before this occurs the staff at the home complete a suitable risk assessment to make sure this is a safe practise. The records that detail the concerns and complaints received at the home have been improved and to ensure confidentiality is not compromised. The records also detail the action that is taken and the conclusion or outcome regarding the matter. What they could do better:
When a risk assessment is completed there are not always satisfactory records to indicate what action the staff has taken. Clear records need to be established to demonstrate compliance with the regulations and provide a record of the events that that have occurred. Although a range of activities is available within the home some of the activities can be improved by being more age appropriate. The records about the training that staff are undertaking and have completed and the recruitment documents required by regulation need to be improved so that a comprehensive picture is provided. Measures continue to improve and be developed to monitor the quality of the services and facilities. The registered manager said that within the next year an annual quality assurance report would be provided for service users and their relatives or representatives to consider. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 8 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. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5. The home has a good statement of purpose that details the services and facilities provided. This helps prospective service users to make an informed choice about staying at the home and informs service users of the care, support and facilities available. Each service users is provided with a written contact and a statement about the terms and conditions of residency. This also makes clear to services users the arrangements at the home. EVIDENCE: The statement of purpose and has recently been reviewed and improved by the registered persons. The document details the services and facilities provided and outline the philosophy of the service. The information complies with the requirements of the national minimum standards and the Care Home Regulations 2001. Each person staying at the home is also provided with a written contract by the County Council and the service also issue terms and conditions of residency that detail the arrangements that are not covered in the contract. This provides service users with a clear picture of the arrangements at the home. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Positive arrangements have been established to provide care plans that are user lead and provide staff with clear information, guidance and direction about the service users needs, choices and preferences. The indications are that the new arrangements will meet with the standard required when they have been applies to all service users. The management of risk has improved and clear guidance is provided to staff when required. The arrangements to assess risk are not satisfactory and suitable records of the assessments need to be completed. This will make sure that service users rights are upheld and provide a clear record of the action taken by the registered persons. EVIDENCE: Each user of the service has a care plan that details their needs and where appropriate the most suitable manner to provide the care and support required. The format for recording care plans has been revised and the new format is in the process of being established for all users of the service. The new arrangements are very positive and take account of the service users views and aspirations as well as reflecting the opinions of their relatives or representatives and any professional that is involved with the person concerned. The care plans record the service users preferences and choices
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 12 and the evidence indicates that service users are involved in planning their care in a manner that reflects their skills and abilities. The care plans are also written in a manner that promotes the service users dignity, respect and independence. The staff at the home has developed a programme to establish the revised care plan arrangements for all service users within the next twelve months. The care plans are formally reviewed at least every six months but the record of the reviews are not always signed or dated. The Inspector noted the staff use the care plans appropriately and this acts as the basis for the care and support that is provided. It was evident that positive and strong relationships have been established between staff members and users of the service. It is also noticeable the staff make every effort to provide an environment where service users feel in control of the care and support they receive. The arrangements to manage risk have also improved following the last inspection. The registered person has established suitable arrangements to take every reasonable step to minimise risk around the home. The arrangement to manage risk positively that an individual service users or staff member may experience have also been further developed. Where a concern arises any action the staff are required to take are recorded in the service users care plan. The staff also will take account of any identifiable risks before a new service user stays at the home. The guidance recorded in care plans is positive but it was not possible to determine from the records the assessment that had been completed or how the decision had been reached. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 15, 16 and 17. A range of activities is provided at the home and in the local community that reflect the individual service users preferences and choices. Some of the inhouse activities could be improved to make sure that service users participate in age appropriate experiences. The activities provide service users with a varied and positive experience during stays. Visitors are welcomed at the home and service users are able to keep in touch with family and friends if they wish. Dietary needs of service users are satisfactorily catered for and a varied selection of foods is available that meets service users tastes and choices. EVIDENCE: A range of activities is provided to service users within the home and the local community. The activities reflect the interests and hobbies of the service users and individual preferences are detailed in the persons care plans. Service users are also able to assist with domestic duties at the home providing it is safe and they choose to do so. Therefore the staff at the home promote, support and provide service users with opportunities for personal development.
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 14 Some of the activities and equipment for leisure pursuits would benefit from improvement given a number are not age appropriate and potentially compromise the individual’s dignity and rights. The statement of purpose states that family and friends are welcome to visit service users and the service user determines where they meet with visitors. One carer said they always received a warm welcome and found the staff very approachable and accommodating to any issues or concern they may have. There are no set menus at the home and each service users chooses what they have for each meal. Clear records are maintained about service users preferences and choices and of any foods that could detrimentally affect their health. A record is also kept about the actual meals service users have had and this enables staff to monitor that a satisfactory nutritional diet has been provided. The kitchen has recently been refurbished and refitted to a high standard. The equipment in the kitchen is well maintained and regularly serviced. Good standards of hygiene and cleanliness are also evident. The care staff prepares and cooks each meal and each member undertaking this duty has been appropriately trained. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The health needs of service users are well met with evidence of good multi disciplinary working taking place. The staff have a good understanding of service users support needs. This is evident form the conduct of the staff and the positive relationships that have been formed with service users. The medication at the home is managed satisfactorily and promotes good health. EVIDENCE: The records indicate the staff at the home takes careful account of service users health needs. Detailed records have been established that note any specific or particular health issues an individual may experience. This information is also included in the individuals care plan. If any concerns arise the individuals relatives or representatives are consulted as well as a general practitioner when this is required. During the inspection one service user was unwell and the inspector noted the positive and attentive manner in which the staff provided care and support. The personal support provided to service users is individualised and this can be evidenced from the information provided in the service users care plans. It is also evident that staff treat each person as an individual and make sure they provide care in a satisfactory manner to the person concerned. Service users
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 16 are not hurried or rushed to complete a particular task and during the inspection the staff consistently provided clear advice and guidance to the person concerned during any interaction with a service users. Medicines are kept safely and appropriate records are maintained. The policy and procedure for the storage and administration of medicines has recently been reviewed and meet the required standard. The staff administering medicines has been suitably trained and the Registered Manager regularly audits the arrangements to ensure that a good quality service is provided. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has an open approach to concerns or complaints and any issues are dealt with efficiently and promptly. Suitable records have also been established that detail the action taken and the conclusion. This makes sure that service users are confidant their views are listened to and acted upon. EVIDENCE: The home has an open approach to any concerns or complaints that are received and robust arrangements are in place to deal with any issues that are raised. A record is maintained of all concerns and complaints that are raised, the action taken and the outcome. The format for recording this information has been improved and meets with the requirements of the DATA Protection Act. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. The standard of the environment and facilities is very good and provides service users with an attractive and homely setting. A good standard of hygiene and cleanliness is also provided to make sure that service users health is not compromised and they experience a positive environment. EVIDENCE: The environment is maintained to a high standard and wherever possible the furnishings, fixtures and fittings are of a domestic nature. A good standard of decor is provided and settings presents as warm and homely. The records confirm that equipment and furniture is replaced when required and a suitable standard of lighting is also provided. The two communal areas on the ground floor can be used as flexible spaces according to the service users or choices about the activities they want to undertake. A secluded garden runs along one side of the home that is accessible to people who experience a disability. A gardener has recently been appointed in order that this facility can be further developed. All the bedrooms are for single occupancy and the majority also have ensuite facilities. Many of the bedrooms are personalised by the occupants for the duration of their stay.
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 19 In one bedroom (room 4) the ensuite facilities are not separated from the sleeping area and this needs to be addressed. Toilets, bathroom and shower facilities are distributed throughout the home and within easy access of communal areas. A range of disability equipment to promote independence and safety is provided in the bathrooms, toilets and other areas of the home. A good standard of hygiene and cleanliness was evident and there were no offensive odours at the home. The laundry is located in the centre of the building and suitable equipment that is regularly maintained and serviced is provided. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Staff morale is high resulting in an enthusiastic workforce who work positively with service users to provide a positive experience and good standards of care that reflect the individuals needs, choices and preferences. Staff are well trained and this also promotes the quality of the service provided. The records about staff training are not satisfactory. Robust recruitment, selection and vetting arrangements are in place to make sure that service users are not placed at risk. EVIDENCE: The documentary evidence indicates that a range of training opportunities is regularly provided for the staff. The training ranges from subject and includes the core skills required to provided good quality care e.g. infection control, NVQ levels 2 and 3 and the LADAF course that is designed for people working in learning disability settings. The staff stated they were very positive about the training opportunities and were confident they improved and develop their skills and abilities to meet the needs of service users. The registered manager said that each staff member had an individual training plan that was linked to the annual appraisal arrangements. The records regarding staff training were found not to be up to date. The staff duty roster indicated that sufficient numbers of staff are employed for waking hours and overnight to meet the needs of service users. The records regarding the recruitment, selection and vetting of new staff evidence that robust arrangements are in place. All applicants complete and
Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 21 sign an application form but they are not required to disclose any criminal offences as part of the application. Checks regarding the Criminal records Bureau and POVA are subsequently completed. Two references are also obtained but the records examined did not include photographs of the employees as required by regulation. Recently appointed staff stated they had experienced a very positive induction programme that provide them with sufficient information in order to meet the requirements of the post. The induction programme ensures that staff has the necessary competencies to provide a good standard of care as well as a clear understanding about the working practices of the home. The staff said they were well supported by the managers and their colleagues and commented upon the positive team work and collaboration that exists. The Inspectors observations found an enthusiastic workforce who works positively with service users to provide a positive experience and good standards of care that reflect the individuals needs, choices and preferences. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is well managed and provides service users with a service that individually promotes their needs and independence. The systems for service users consultations are reliable and quality assurance measures are in the process of being established. This will assist the providers to further improve and develop the services and facilities. A good standard of hygiene and safety is provided around the home to make sure that service users health and welfare is not placed at risk. EVIDENCE: The home is well run and well managed. The registered persons have a clear commitment to providing quality services and facilities that promote the service users needs, wishes, choices and preferences. Thirty seven written responses were received by the Commission from relatives or service users representatives and all indicated satisfaction with the services and facilities provided. Some of the feedback included; “PRC is first class”, “very well cared for”, “an excellent much needed service”, “excellent Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 23 staff”, “welcoming” and “impressed with the standard of care”. It is noticeable that the carers or service users that responded made no adverse comments. The providers regularly consult with services users and their relatives and representatives about the services and facilities provided. The arrangements to undertake an annual quality assurance process continue to be established and the registered manager stated they are at the final planning stage and envisaged that comprehensive arrangements would be in place within the next year. Satisfactory policies and procedures are in place to promote safe working practices and suitable steps are taken to provide a hygienic and safe environment. The equipment and services provided to the home are regularly serviced and monitored and satisfactory fire arrangements are in place. Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x Standard No 24 25 26 27 28 29 30
STAFFING Score 4 2 X 3 3 3 4 LIFESTYLES Standard No Score 11 2 12 x 13 4 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Penwith Respite Care Limited Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 X 2 X X 3 x DS0000009127.V251227.R01.S.doc Version 5.0 Page 25 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 YA6 YA9 Regulation 15 13 Requirement The improved care planning arrangements must be applied to all service users. When any situation arises that could potentially compromise the safety and well being of a service users a written risk assessment must be established. The ensuite facilites in room 4 must be partitioned or seperated from the bedroom area. Records must be maintined that detail the training staff members have sucesfully completed. The documents detailed in schedule 2 of the Care Homes Regulations 2001 must be obtained for each membeer of staff. Robust quality assurance measures must be estabilshed and a report of the finding made avaliable to the Commission and service users. Timescale for action 30/09/05 30/12/05 3 4 5 YA25 YA32 YA34 23 18 19 30/01/06 30/12/05 30/11/05 6 YA39 24 30/09/06 Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 26 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 YA6 YA34 Good Practice Recommendations The records of all reviews should be signed and dated. The application form for new employees should also provide applicants with the opportunity to make a criminal records disclosure Penwith Respite Care Limited DS0000009127.V251227.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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