Inspection on 28/03/07 for Penwith Respite Care Limited

This inspection was carried out on 28th March 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penwith Respite Care Limited 16/12/08

Penwith Respite Care Limited 21/09/05

Penwith Respite Care Limited 28/06/05

Penwith Respite Care Limited 28/02/05

Penwith Respite Care Limited 07/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Penwith Respite Care Limited 38 Polweath Road Treneere Penzance Cornwall TR18 3PN Lead Inspector Richard Coates Key Unannounced Inspection 28th March 2007 09:15 Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 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.V333421.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 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.V333421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penwith Respite Care Limited Address 38 Polweath Road Treneere Penzance Cornwall TR18 3PN 01736 330638 01736 330638 penwithrespite@msn.com 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.V333421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Penwith Respite Care Ltd is located at modern purpose built premises on a Penwith Housing Association estate on the outskirts of town of Penzance. The premises are rented from Cornwall County Council. 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 respite stays for up to four nights each month. Stays at the home are arranged and contracted through the Cornwall County Council Department of Adult Social Care. The service can consider admissions for emergency stays in negotiation with Cornwall Department of Adult Social Care. The bungalow accommodates up to 10 people. The majority of the accommodation is on the ground floor. There is suitable access to, and within, the building for disabled people. All the bedrooms are single; nine are located on the ground floor. The communal space comprises a large L shaped sitting and dining room, and a separate smaller sitting area. The kitchen is located next to the dining area. Cornwall Department of Adult Social Care determines the fees for each service user through an individual financial assessment. Prospective service users and their representatives should seek information from Cornwall Department of Adult Social Care. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced inspection to review compliance with the requirements set in the last inspection report dated 21 September 2005 and to inspect against the national minimum standards identified as key standards by the commission. The provider submitted a pre-inspection questionnaire for the inspection visit. The inspector spent time at the home over two days inspecting records and documents, touring the premises and having discussions with the registered manager, staff, service users and some relatives. The commission also sent a postal survey to service users and their families and carers. What the service does well: Penwith Respite Care provides comfortable and homely respite care for up to ten service users, with sufficient staff to meet their needs and respond to individual preferences. The service provides respite breaks to nearly seventy people. This is a very different situation from a care home which provides care and accommodation to ten long-term residents. There are significant implications for the workloads of the managers and staff in keeping up to date nearly 70 care plans, risk assessments and reviews, as well as introducing new service users to the service. However, these tasks are completed to a good standard. Prospective residents and their representatives receive wellpresented informative material to support them in making a choice about the home. The provider obtains copies of commissioning assessments from Cornwall Department of Adult Social Care and carries out risk assessments. Residents’ healthcare needs are clearly recorded, monitored and addressed during their short stays. The staff have a confident and sensitive approach to supporting service users and are concerned that service users should have a good quality of life. Residents are supported to participate in a range of activities according to their individual needs and preferences. Staff interact with residents in a warm adult manner, and pay considerable attention to providing a quality service. They support residents to make choices and decisions about their daily lives, and to enjoy ordinary valued living in the community. All the bedrooms are single; many have en suite toilets. There are good shower, bathing and washing facilities. The premises are clean, hygienic and well maintained. The home is effectively managed and provides a popular and highly valued service. Service users clearly enjoy their stays here and commented, “It is a good place to stay”, “The food is excellent” and, “They have been very good here”. Responses to questionnaires reported, “I am very impressed with the professionalism and dedication of the staff” and “Very willing and eager to assist”. Penwith Respite Care Limited DS0000009127.V333421.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. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 7 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. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 8 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.V333421.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider’s policy and practice ensure that prospective service users and their representatives receive information about the home in order to make an informed choice. The needs and aspirations of a service user who was recently admitted to the home were effectively assessed. EVIDENCE: Admission to Penwith Respite Care bungalow is arranged through Cornwall Department of Adult Social Care assessment and commissioning systems. These commissioning procedures should ensure that the provider receives a detailed assessment of the needs and aspirations of each prospective service user. The records for the last service user admitted were sampled. The provider had obtained detailed pre-admission assessments from Cornwall Department of Adult Social Care and Cornwall Partnership Trust. The records also included a detailed plan for the introduction of this service user to the home with clear guidance for staff. The records of other service users included assessment and commissioning information. The home has a statement of purpose and a service user guide, which provide the information, required in Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 10 the regulations. Responses to the commission survey consistently stated that sufficient information had been received. The deputy manager stated that she intends to develop a simple language and picture version of the service user guide and complaints procedure. This would provide accessible information about the facilities and services to prospective service users. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The written care plans reflect the changing needs and personal goals of residents so that staff can provide effective care. Staff support service users to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Each user of the service users has a care plan that details their needs and, where appropriate, the most suitable manner to provide their care and support. Staff have developed an improved format for recording care plans. This revised format has been completed for some users of the service; for other service users the previous style of care plan is still in use. The new care plans are an improved person-centred format covering the individual’s needs, abilities, lifestyle preferences and potential risks. Care plans take account of Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 12 the service users’ views and aspirations and reflect the opinions of their relatives or representatives and any professional involved with the person. The care plans are written in a manner to promote the service users’ dignity and independence. The care plans provide clear directions and information for staff about meeting service users’ needs and aspirations. They provide easy access for the staff but are not user friendly for all service users. The manager and staff involve service users in their care plans as far as their disabilities will allow. It would be good practice for staff to make a record of discussing and explaining a service user’s care plan with the person. The care plans are reviewed at least every six months, using a new ‘Agreement form’, which sets out in detail lifestyle choices, preferred activities, risks and how personal care needs are to be met. Reviews focus on the service users’ views and aspirations, involving them in planning their care in a manner that reflects their skills and abilities. For the main annual review, the provider will invite all those involved with the person’s care, and the service user must be present. The second review each year will be a less formal internal review of the care plan. Where appropriate and manageable within the time available, staff attend reviews at the John Daniel Centre. Staff encourage service users to take decisions about their daily lives and provide appropriate assistance where this is required. There was evidence in the records of residents being supported to make decisions. During the inspection staff were supporting service users to make decisions, for example, about their choice of room, their evening meal, activities and personal care. The arrangements to manage risk have improved following the last inspection. Situations that could compromise the health or welfare of a resident are assessed. The registered manager seeks out information about potential risks for each service user before admission. A recent assessment for the use of bedrails for a specific service user provided a good example of this. The records of service users case tracked all contained written risk assessments with directions for staff in managing these risks set out in the care plan. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support residents to take part in individually planned social and leisure activities in the home and in the local community. Residents eat a varied diet and enjoy their mealtimes. EVIDENCE: Staff support service users to engage in a range of activities 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 care plans. Service users also assist with tasks around the home providing it is safe and they choose to do so. Service users were satisfied with the range of activities and said that they regularly visited local public houses and shops, went for walks and visited popular spots. It was important for some service users that they Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 14 were able to watch their favourite television programmes. They said that they were supported to choose how to spend their time. Service users made comments like, “It is a good place to stay” and, “They have been very good here”. The statement of purpose states that family and friends are welcome to visit and the service user determines where they meet with visitors. One carer stated they received a warm welcome, they found the staff friendly and approachable, and they had confidence in the staff and management. The responses to the commission’s survey were consistently positive about the standard of the care, the services and the facilities provided. The home does not plan rigid set menus. Service users choose what they have for each meal. The choices for the evening meal take account of what the person has eaten for lunch. This ensures balance and variety, because some people have a large main meal at their daily activity and others have just a sandwich. Service users reported that they enjoyed the food, and were able to have their choices and preferences. They said that there was always sufficient. They reported that staff knew their likes and dislikes, and specific dietary needs. They enjoyed working with staff in the kitchen. Staff maintain records of service users preferences, dislikes and allergies. Staff also keep records of the food eaten by each service use to monitor their diet. A number of service users have specific dietary requirements, for example for their food to be cut up, for a soft diet, and for assistance with eating. These needs are detailed in their care plans and set out in information in the kitchen. There has been a move towards encouraging healthier eating, and fresh fruit and vegetables are always available. The kitchen was clean and hygienic with equipment of a good standard. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ preferences and views are taken into account in meeting their personal care and health care needs. The procedures and management of medication protect service users, with clear written guidance for staff. EVIDENCE: Care plans provide directions and information to staff about meeting the service users’ individual needs and preferences. Staff treat each service user as an individual and pay great attention to providing care in a satisfactory manner. Service users were not hurried or rushed during assistance with care. Staff interact with service users in a warm and supportive manner. They make every effort for service users to feel that they have choices about the care and support they receive. Conversations with staff indicated that they reflect on their care practices and communication with service users, and it is important to them to provide a quality service. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 16 The records indicate that the staff take careful account of service users health needs. Individual records detail each individual’s health care needs and take this into account in the care plan. When there are concerns, staff consult the service user’s relatives, or representatives, or a general practitioner, when this is required. Given the short stay respite care provided here, staff rarely become involved with accompanying service users to routine planned medical appointments. Service users bring a supply of their prescribed medicines with them for their short stay. This is a very different situation from care homes with long term residents, which often manage the whole process for their medicines, including ordering, on their residents’ behalf. The provider has drawn up a detailed policy and procedure which covers the required areas and reflects the specific arrangements here. Each service user’s medicines are logged in at admission and checked out on departure. Medicines are stored in a locked medicines cupboard in a secure closet. Residents or their representatives sign a form of consent to the administration of medication. A number of residents are currently administering their own medication. The provider has drawn up criteria for assessing the service user’s safety to self-administer. All administrations of medicines are witnessed and the record signed by a second worker. The records were consistently signed and appeared well maintained. There are no controlled drugs in current use. Staff are trained to administer rescue medicines for seizures, following clear written guidelines from clinical specialists. Staff who administer medicines have completed training in the safe handling of medicines. The last visit for advice from the pharmacist was recorded as July 2006. The pharmacist drew up a new contract for these visits on 27 February 2007. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Penwith Respite Care has a corporate complaints procedure so that the views of service users and their representatives should be listened to. The arrangements for the protection of vulnerable adults safeguard service users. EVIDENCE: Penwith Respite Care provides a written complaints procedure. A copy of the leaflet “How to Make a Comment, Compliment or Complaint” is included with the home’s statement of purpose. Responses to the commission survey confirmed that residents and their representatives knew how to complain, if necessary. The provider is intending to produce for service users a simple language and picture guide to raising concerns. Staff reported that they discuss with each service user, as far as possible, how to make staff know if they are unhappy about anything. Two complaints have been received since the last inspection. The records for these complaints indicated that the complainants had been satisfied with the response. Service users said that the manager, deputy and staff were approachable and listened to their views. They reported that staff were “kind” and they clearly had confidence in the management and staff. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 18 Staff are provided with training on the protection of vulnerable adults from abuse as part of their induction. This is followed up with refresher training. Penwith Respite Care has an adult protection policy and procedure which complies with the standard and reflects the Cornwall multi-agency code of practice. The registered provider has a copy of the new Cornwall multiagency agency adult protection policy and procedure. Staff have attended the multi agency foundation training in adult protection. The registered manager has attended the multi-agency training to be a trainer in adult protection. It is planned for the deputy manager to complete this training. Staff were aware of their responsibilities to report any concerns about the abuse of a vulnerable adult. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable, spacious and well-maintained home, which provides a safe and suitable environment. EVIDENCE: The home is situated in a residential area of Penzance. The environment is well maintained and wherever possible the furnishings, fixtures and fittings are of a domestic nature. The decor is generally in good condition and the home is warm and homely. The building is accessible to wheelchair users. The service user accommodation is, with the exception of one bedroom, on the ground floor. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 20 The two communal areas are the original main L-shaped sitting room and dining area, and a smaller sitting area in the added part of the building, with television, games console, computer and karaoke machine. These rooms are used flexibly according to the service users’ preferences about activities. There is a sensory area in the main communal room. There are new tables and storage cabinets in this room. A garden runs along one side of the home and is accessible to people with mobility disabilities. This has recently been provided with garden furniture. All the bedrooms are for single occupancy and the majority also have en suite facilities. The toilets, bathroom and shower facilities are situated throughout the home, within easy access from communal areas. Some bedrooms have been themed – for example there is a ‘sporting’ room and a ‘wildlife’ room. All the bedrooms now have their own television with DVD player. The en suite facilities in room 4 have been separated from the sleeping area with a suitable curtain. This enhances the privacy and dignity of the service user. A range of disability equipment to promote independence and safety is provided in the bathrooms, toilets and other areas. The tiling in the original older shower room is showing some deterioration, cracking and other signs of wear and tear. The paintwork around the doors and doorframes of the bathrooms and bedrooms in the original part of the building is also chipped and scuffed in places. The secure storage facilities for cleaning materials, wipes and personal care materials have been significantly improved. The premises were clean and hygienic and there were no offensive odours. Hand wash, disposable towels and alcoholic hand cleanser are available throughout the building. The laundry is located in the centre of the building. The floor and walls are tiled. The washing machine and tumble dryer are of industrial standard. Service users and responses to the questionnaire reported that the home was always clean and fresh. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team is effective in supporting service users. Recruitment practice is generally safe, but has not completely protected the well being of service users. Staff complete appropriate training to meet the needs of service users. EVIDENCE: Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 22 The staff roster details the staff on duty, and includes the time worked by the registered manager. There are at least three staff on duty during the morning and in the afternoon and evening when service users are in the home. This increases to four staff to support varied activities or to provide specific contracted one-to-one working. There is one waking night staff and a worker sleeping in on call at night. There are three male staff currently. This is a reasonable level given the requirement to meet the complex care needs of female service users. The providers employ an ancillary worker to clean all basins, toilets, bathrooms and showers. The provider maintains a bank of relief staff to ensure minimum staffing levels and to cover contracted one-toone sessions. The records of two staff appointed in the last year were case tracked. They contained completed application forms, interview records, evidence of identity and records of Criminal Records Bureau disclosures and ‘PoVA First’ checks. However, only one reference was on file for each worker; the provider had requested the second reference but had not pursued this when no response had been received. The provider has written job descriptions and person specifications. Staff receive a statement of their terms of employment. The staff records now contain photographs but do not appear to include consistently copies of certificates of qualifications. The provider has introduced induction training to the Skills for Care common induction standard. The records for a worker recruited before the new standards were introduced did not include a signed and dated record of her induction. Staff records consistently detailed training in moving and handling, health and safety, safe handling of medication, first aid, food hygiene and adult protection and include supervision records. There is a written schedule of staff meetings for the next year with a two-hour training session on a relevant topic before each meeting. The pre-inspection questionnaire states that 75 of the regular staff are qualified to National Vocational Qualification level 3 or above. The level of qualification of the relief staff is lower. Staff reported that they were effectively trained to do their jobs. They received good formal and informal support and supervision. Managers were approachable and endeavoured to resolve issues and concerns. Staff felt that the home excelled at providing good quality individual care and support with communication to service users in an inclusive atmosphere. The provider has achieved the Investors In People Award. . Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed to fulfil its aims and objectives and to meet the needs and aspirations of the service users. There are sound arrangements to ensure the safety and welfare of service users and staff. EVIDENCE: The registered manager is Mrs Christine Doyle; there is an experienced and qualified deputy manager. Mrs Doyle states that she has sufficient dedicated time to carry out her management role and she regularly works with service users as one of the staff on a shift. She exceeds the qualification requirement Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 24 with a level 5 qualification in the Management of Care. She has attended training to keep her skills and knowledge up to date, and belongs to the Association for Real Change, a body for those involved with people with learning disability. The provider has carried out a survey earlier in the year with a questionnaire for service users, their relatives and representatives. A summary of the outcomes is not yet available. The responses are almost exclusively positive, although a small number of carers were not sure that staffing levels were always sufficient. The provider retains a health and safety consultant. The accident records were satisfactorily completed. The records comply with the Data Protection Act. The provider submitted the list of required maintenance and safety records on the pre-inspection questionnaire. A sample of these was checked against the original documents and was accurate. The last visit from the environmental health officer for a food hygiene inspection was in July 2005, and no requirements or recommendations were set. The records case tracked contained moving and handling risk assessments which gave staff clear directions. The registered provider has completed a fire safety risk assessment. The records show regular tests on the system and emergency lighting. There are weekly fire drills, with staff training built into the drill, and three monthly fire training for night staff. The fire procedure is posted at strategic points around the building. The provider has installed a new integrated alarm and door closing system which includes flashing lights on the fire alarms. An additional fire exit has been installed at the end of the new part of the building. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 26 No 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 Standard YA34 Regulation 19(1)(b) and Schedule 2 para 3. Requirement The registered person must obtain two written references for all staff where this has not been completed during recruitment. Timescale for action 31/05/07 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 3 Refer to Standard YA1 YA6 YA24 Good Practice Recommendations The service user guide should be available in a user friendly format for prospective and current service users. The registered person should ensure that care plans for all service users are completed on the new format. The registered person should review the condition of the tiling in the older shower room and produce a plan for refurbishing it. Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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. Extracts may not be used or reproduced without the express permission of CSCI Penwith Respite Care Limited DS0000009127.V333421.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!