CARE HOMES FOR OLDER PEOPLE
Penlee House Penlee House 23 Fore Street Tregony Truro Cornwall TR2 5RN Lead Inspector
Diana Penrose Key Unannounced Inspection 6th March 2007 09:40 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 Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Penlee House Address Penlee House 23 Fore Street Tregony Truro Cornwall TR2 5RN 01872 530665 01872 530222 amanda.body@btconnect.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) Roseland Care Ltd Mrs Barbara Joy Floyd-Norris Care Home 31 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (31), of places Physical disability over 65 years of age (15), Terminally ill over 65 years of age (1) Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents to include one named person only under the age of 65 years Date of last inspection 4th October 2005 Brief Description of the Service: Penlee is a Grade 2 listed property situated in large wooded gardens, within the village of Tregony. There is a level walk to the village, which offers shops, a post office, a public house and three churches. There is a car park with level access to the Home. The home provides nursing and residential care for up to thirty-one residents. Accommodation is provided on two floors, with two separate staircases and a shaft lift. There are 25 single rooms and 3 double rooms, 16 rooms have en suite facilities and there are 3 assisted bathrooms. There is good wheelchair access within the home and to the garden. There is a large comfortable lounge on the ground floor and a light airy dining room. The home can provide rehabilitation for residents who require help with mobilisation or limb strengthening but do not have the facilities for intermediate care. Suitably qualified nurses and care assistants provide nursing and personal care within a relaxed friendly atmosphere. Structured activities are provided every afternoon, run by experienced staff trained in rehabilitation. One member of staff is responsible for the organisation of activities; she has attended the Care Activities Co-ordinators Course and several other courses in relation to activities. Information about the home is available in the form of a statement of purpose / residents’ guide, which can be supplied to enquirers on request. A copy of the most recent inspection report is available in the home. Fees range from £265.25 to £650.00 per week; this information was supplied to the Commission in the pre-inspection questionnaire received on 03/01/07. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. The construction of the new Penlee House Nursing Home is nearing completion and will provide a much larger purpose built facility. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An inspector visited Penlee House Nursing Home on the 06 March 2007 and spent eight and a half hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 04 October 2005. All of the key standards were inspected. On the day of inspection 27 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered manager to gain their views on the services offered by the home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered manager has complied with the two requirements set at the last inspection. Residents and relatives expressed high satisfaction with the care and services provided at the home. Overall the home is providing a very good quality of care to the residents placed there. The retirement village and new Penlee House Nursing Home are being constructed in the grounds of the home but have caused minimal disruption to the service. The new nursing home is nearing completion and a photo shoot was taking place during the inspection to finalise the brochure for the new home. Staff, residents and visitors were involved in this and there was great excitement although understandably mixed feelings about the imminent move. What the service does well:
The service provides a well maintained home set in lovely surroundings. It is very clean, warm and comfortable. There are excellent measures in place for the prevention of infection. Residents are only admitted following an assessment to ensure the home can meet their needs. Prospective residents and their family are invited to visit the home prior to any decisions being made to live there. One resident said “I was given a leaflet and lots of information about the home before I moved in”. Resident’s healthcare needs are met and specialist healthcare professionals visit the home as required. Appropriate equipment is provided for pressure relief and moving and handling purposes. Residents have an individual care
Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 6 plan and risk assessments are undertaken. All residents spoken with said the care is very good and they are happy living in the home. They are treated with respect and dignity and their privacy is upheld at all times. They also said their individual preferences are respected and they can choose what they do each day. One resident said “I could not be better cared for anywhere”. Visitors said they are always made welcome in the home and that staff spend time with them as well as the residents. Social activities take place each weekday and are co-ordinated by a carer who has undertaken appropriate training in this area. Time is spent on one to one sessions when staff and residents get to know each other. There is a nutritious menu with choices available; residents said the food is excellent. One said the food is better than that in a hotel she goes to and it is consistently good. Fresh fruit and vegetables are included and there are homemade cakes provided each day. The front lounge, now used as a dining room, is a light airy room providing a cosy atmosphere. Residents were chatting over lunch and said they enjoyed the meal. Those who chose had lunch in the lounge or their bedroom. There are very few complaints but there is a system in place that ensures complaints are dealt with promptly and records are kept. There is a suitable policy for the prevention of abuse; staff have received training in the protection of vulnerable adults and the procedure to be followed. There is a robust recruitment procedure and appropriate training is provided for staff. There are appropriate staffing levels with a skill mix to meet resident’s needs. A qualified nurse is on duty at all times. Residents said the staff are kind and caring and very patient. One said, “They are my extended family”. 55 of care staff have an NVQ qualification in care and 40 are working towards a qualification. The Registered Manager is a highly qualified nurse who has managed the home since 1994. She is a competent manager who is very motivated and keen to keep up to date with nursing and management. She has a keen interest in palliative care and a member of the Liverpool Care Pathway, Central Cornwall, Steering Group Staff and residents spoken with thought highly of her, they said she is very approachable and works extremely hard. Residents said she runs a good ship without being too strict. The management endeavour to ensure that working practices are safe. Relevant service checks take place as required and are up to date. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Social, religious and cultural needs are must be included in the care plans. The manager said this will be done and she hopes to include life histories for each resident. Each resident requiring restraint such as cotsides must have an individual risk assessment undertaken to verify the need for such equipment and to minimise the risks. Daily records could be more detailed and informative, this has already been recognised as an area for improvement by the registered provider. Please contact the provider for advice of actions taken in response to this
Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 9 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 Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1and 3. 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable information is given to prospective residents enabling them to make an informed choice as to where to live. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide suitable care. EVIDENCE: Evidence was provided in the form of records, interviews with residents, relatives, staff and manager. The home has a suitable combined statement of purpose / resident’s guide that has been reviewed and updated. A copy of the home’s contract is issued with this to prospective residents. Signed contracts were seen but not necessarily signed before or on admission to the home. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 11 There is a form for initial enquiries where basic information about the prospective resident is recorded. Prospective residents and their relatives are encouraged to visit the home before deciding it is the right one. The registered manager or her deputy visits prospective residents to undertake an assessment of needs. This is recorded onto the care plan paperwork and is completed on admission. Information from social workers or hospital nurses is included where appropriate. Prospective residents and their relatives are welcome to visit the home at anytime and relatives talked about this. The registered manager said the home provides rehabilitation for residents requiring help with mobilisation or limb strengthening. There is no facility for intermediate care. Some staff have received training in respect of rehabilitation and residents have access to physiotherapists, occupational therapists and specialist nurses as required. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident that inform and direct staff in the care provision, social, religious and cultural needs must be included more fully to provide a holistic approach. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines that assure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives and staff. Each resident has a written care plan that is reviewed monthly. Residents said they are not involved in the compilation of their care plan although the resident or their representative has signed care plans. Social, religious and
Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 13 cultural needs must be included more fully in the planning of care for individuals. The registered manager said she was hoping to get life histories compiled for all residents. Risk assessments include Waterlow scoring, nutrition, moving and handling and mobility. Consent is sought from residents /representatives for the use of cotsides. There must also be a risk assessment for residents requiring cotsides, this was discussed with the registered manager. Daily records could be more informative, the registered provider said she is working on this. Residents spoken with said their health needs are met very well and they have access to their GP or other health professionals when required. The manager said that links with specialist healthcare professionals is very good. She is hoping to introduce The Gold Standard Framework and Preferred Place of Care into the homes palliative care framework. There is appropriate moving and handling and pressure relieving equipment and hospital style beds are provided. Care practice was observed to be appropriate during the inspection and carried out in a calm, efficient manner. Medicines are administered from individual pots/packets that are stored safely in individual labelled trays in a trolley. No residents are self-administering at the moment. Records are kept of all medicines entering and leaving the home. The medicine charts are clear and there were no gaps observed in the administration records. Medicines were administered in a professional manner at lunchtime. There is a homely remedies policy and a list approved and signed by a doctor. There are relevant reference books and patient information leaflets are available for staff or residents to refer to. Care staff receive some medicines training, the manager said she would ensure that basic training is included in the induction programme. All nurses have undertaken ‘medicine matters’ training. Staff were observed to uphold resident’s privacy during the inspection and knocked on doors before entering. Residents said their privacy is always respected and they are treated with dignity. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is very good. This judgement has been made using available evidence including a visit to this service. The home provides organised activities daily and staff spend time with residents, aiming to offer a lifestyle that meets their needs. Links with family and friends are excellent and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food that aims to meet their taste and preference although residents were not aware of the menu. EVIDENCE: Evidence was provided in the form of documentation, observation, and interviews with residents, relatives, staff and manager. All residents spoken with said there are activities every day, they were not sure how activities were chosen but the manager said they vary according to the residents accommodated and their preferences. This should become more evident when the care plans include social needs and life histories. Residents talked about flower arranging, bingo, games and a trip to a local pantomime. There is a weekly Communion service and local clergy visit. A list of activities is
Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 15 displayed and records of attendance are kept with reasons for non-attendance. One carer is the activities coordinator and she has undertaken several courses in respect of activities and rehabilitation. There were no set activities during the inspection because several residents were involved in the photo shoot for the new homes’ brochure, one to one time was being spent with residents as well. Staff interaction was good during the inspection and staff from all areas were observed talking with residents. There is a record of visitors to the home and there were visitors in the home during the inspection. Residents said they could receive visitors in private and at any time. Visitors spoken with said they are always made welcome in the home and can call whenever they like. They said staff are very friendly and helpful and have plenty of time for everyone. There is a residents / relatives discussion group where relatives can be involved in the running of the home. Residents said they choose when they get up and go to bed. Some residents were having breakfast late into the morning. They said they choose what clothes to wear and how they spend their day. They said they choose whether to stay in their room or go to the lounge. All residents were suitably dressed in clean clothes. Residents’ rooms were personalised with their own belongings and furniture. Some residents control their own money. The cook said there is a 4-week menu with choices available. She said they tried asking residents to order their meals each day but it didn’t work, she said the staff know what residents like and it works. She said there are more choices available than those written on the menu. Residents said they did not know what was for lunch but they knew they would like it; they all said the food is very good. Fresh vegetables and fruit are included each day and cakes in the afternoons are homemade. Residents all said the meals were of an excellent standard. Snacks and drinks are available between meals; water and juice is provided in all rooms. Meals are served in the dining room, lounge or private rooms; it is the individuals’ choice. The lunchtime meal was observed to be unhurried suitable aids such as plate guards were in use and appropriate assistance was given. The catering staff have undertaken Intermediate Food Hygiene training and appropriate NVQ training in food preparation and hygiene. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: There is a suitable complaints policy in the home and a system for recording complaints and the outcomes. One complaint has been reported and suitably dealt with in the past year. Letters of thanks are kept. Residents said there are no barriers to raising concerns with the management. The manager and most of the staff have attended the local ‘No Secrets’ course provided by the department for adult social care. The deputy manager has undertaken the trainers’ course and will provide in house training. Staff said they found the training very useful. There is a copy of the local inter-agency procedures in the home and the home has a suitable policy. There have been no abuse issues at the home. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is comfortable, clean and free from offensive odours making it a pleasant place for residents to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, interviews with residents, staff and manager. The home is warm, homely, comfortable and clean with no offensive odours. Maintenance and refurbishment is ongoing; some paintwork that has been scuffed by wheelchairs and so on has not been re-painted due to the imminent move to the new premises. A new Parker bath has been provided in a downstairs bathroom. The grounds are kept neat and tidy and are accessible to residents. The pond has been filled in and now contains plants.
Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 18 Relevant policies and procedures are in place for infection control and staff receive training in this subject. There are appropriate hand-washing facilities for staff in all areas and alcohol hand cleansing gel is also available. There are disposable plastic aprons and disposable gloves. Individual hoist slings are provided for residents and washed as required. Each room has a sheet that details when it was last cleaned and by whom. The laundry rooms are small but staff cope well they are looking forward to moving to the large facility in the new home. Residents said the laundry service is very good. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels generally meet the needs of residents and staff morale is good. Residents are in safe hands and they benefit from the 95 of care staff that are trained or in the process of training to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, and interviews with residents, relatives, staff and manager. The registered manager said there are no vacancies at present and agency staff have not been used for two years. Staffing levels were thought to be satisfactory by residents, visitors and staff. Residents and visitors said that staff are very caring and considerate and they go out of their way to help. Residents commented that the staff are their extended family and they have a laugh, even in the middle of the night. Overseas staff have settled in well, one said he is having English lessons to improve his communication. One resident said, “The Ukrainians are so kind and very caring”. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 20 New care staff undertake an induction programme that includes the skills for care induction standards and leads on to the NVQ 2 course, in care. 55 of care staff are qualified to at least NVQ level 2 in care and a further 40 are undertaking NVQ training. The home operates an equal opportunities policy. Recruitment files inspected contain the documents required by legislation. There were no interview records seen. Staff are issued with terms and conditions of employment and a relevant job description. A staff handbook is being compiled. Relevant employment checks are made. The registered manager said that staff are all treated equally. Staff have received substantial training in the past year and records are maintained; copies of certificates gained are held in staff files. There are details of training courses on the staff notice board and staff said they are supported well with training. Statutory training is undertaken during working hours and records are maintained. A matrix was recommended to help the manager ensure that all staff attend training according to legislation, the secretary said she would do this next week. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. The home handles residents’ money if they wish and ensures that their financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health, safety and welfare of residents, visitors and staff. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, staff and the manager. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 22 The registered manager is a first level registered nurse who has been competently managing this home since 1994. She has achieved the Higher Diploma in the Management of Care Services and recently completed an aromatherapy course. She is a member of the Liverpool Care Pathway, Central Cornwall, Steering Group. She said she keeps herself up to date with current nursing issues relevant to the residents living in the home. Recent training includes management updates, the Liverpool Care Pathway and end of life programme. She is a moving and handling trainer and a First Aider. Staff said she manages the home very well and is very approachable. A quality assurance survey is undertaken annually. The registered manager said that questionnaires were sent to the residents last month, the relatives will be surveyed in June and the staff later in the year. Survey results in the past have been positive. The registered manager said she visits each resident on a daily basis. Staff meetings take place and a residents / relative discussion group has commenced. There is a biannual management meeting to review quality in the home. Minutes are produced for all meetings and show staff involvement and actions taken. The Investors In People award (IIP) is up for review in June 2007. Informal audits take place and the registered provider inspects the home every month and sends a report to the Commission. Money is held for several residents, six control their own money with the assistance of their relatives. Lockable facilities are provided in the bedrooms. Money is held securely in individual plastic wallets. Appropriate records are maintained and receipts are kept. The management endeavour to ensure that working practices are safe. Relevant service checks take place as required and are up to date. Staff receive statutory training regularly. All of the nurses have undertaken first aid training. Accident reporting complies with data protection; there are very few accidents in the home. Health and safety risk assessments have been undertaken and so has a fire risk assessment. Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Penlee House DS0000046984.V324043.R01.S.doc Version 5.2 Page 25 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
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