Inspection on 21/03/06 for The Penant

This inspection was carried out on 21st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Penant 24/05/07

The Penant 17/11/06

The Penant 23/12/05

The Penant 05/11/04

The Penant 09/07/04

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

CARE HOME ADULTS 18-65 The Penant 7-9 Harold Road Clacton on Sea Essex CO15 6AJ Lead Inspector Neal Cranmer Unannounced Inspection 21st March 2006 09:30 The Penant DS0000054579.V262377.R01.S.doc Version 5.1 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 The Penant DS0000054579.V262377.R01.S.doc Version 5.1 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. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Penant Address 7-9 Harold Road Clacton on Sea Essex CO15 6AJ 01255 475688 01255 475306 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) The Regard Partnership Limited Mrs Elizabeth Anne Barfield Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (3) of places The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 10 persons) Three named persons over the age of 65 years who require care by reason of a learning disability The total number of service users accommodated in the home must not exceed 10 persons 23rd December 2005 Date of last inspection Brief Description of the Service: The Penant comprises of two Victorian dwellings joined by a connecting door, located close to the sea front at Clacton on Sea and the amenities the area has to offer. The home is managed by one registered manager and accommodates six people with a learning disability. The accommodation offers single rooms all of which, bar one, have en-suite facilities. There are adequate communal and bathing facilities. The front garden is mainly laid as a hard standing for vehicle parking, with a small-bordered area. The rear garden is enclosed and is also mainly laid as a patio area with some small-bordered areas. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in March 2006, lasting 4.75 hours. The inspection process included discussion with two service users, the registered manager and briefly two members of staff. Tour of the premises included observation of service users’ bedrooms, bathing and toilet facilities, as well as communal living areas and gardens. During the course of the inspection a range of documentary evidence was sampled. Fifteen of the forty-three standards were inspected. Of these eight were met, five were minor shortfalls, with the remainder being major shortfalls. What the service does well: What has improved since the last inspection? What they could do better: The service’s Service Users Guide continues to require further development to make it available to service users in a format that is suitable for their needs. This piece of work has commenced and continues to be ongoing. The home needs to ensure that its practices in respect of handling service users’ money on their behalf are adequate to ensure the financial security of service users, whilst at the same time safeguarding staff who are involved in handling/managing money belonging to service users. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 6 The service’s laundry facilities continue to meet the most basic of needs at the home. The service needs to ensure that its staff are appropriately trained and competent. This relates to the need to ensure that 50 of the staff team are qualified to NVQ Level 2 or better. The registered person must ensure that all new starters to the home receive a formal induction that meets with Skills for Care requirements. The registered manager has yet to achieve their NVQ Level 4 in management, although this has now been commenced. 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. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 7 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 The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 8 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 2. The registered person has yet to provide a Service Users Guide that is available in a format which is suitable to the needs of the service users. The home has a comprehensive pre-admission needs assessment to be used with future referrals made to the home. EVIDENCE: Although the registered manager assured the inspector that the Service Users Guide was being developed into a user-friendly format, as required from the previous inspection, the evidence to support this claim was unavailable. Therefore, the requirement from the previous inspection remains. The home has a comprehensive pre-admission needs assessment which included an initial interview visit record and personal profile summary. This was then followed up by a part two moving in and introduction for admission report. The assessment covered the following areas: • • • • • • General health Learning disability diagnosis Prescribed medication Personal care Communication needs Mobility DS0000054579.V262377.R01.S.doc Version 5.1 Page 9 The Penant • • Personal relationships Work, occupation and leisure The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 10 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): 7. Service users are supported to make decisions about their day-to-day lives to the best of their individual abilities. However, clear procedures need to be developed which ensure the financial security of service users, whilst at the same time ensuring that staff are also protected. EVIDENCE: None of the service users residing at the home are able to manage their own finances, although all have their own bank accounts with a cash card attached to the account. The home’s staff support service users to access their finances via usage of the card. Although the audit trail of money transactions was generally good, and gave no rise for any immediate concerns, the registered manager was advised to develop a policy to support the practice, with a clear rationale and breakdown of safety checks in place. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 11 Appointees for the service users’ benefits are corporate and some discussion took place around the need to ensure that money belonging to service users was not paid into any account, that maybe business related (the registered manager/provider was referred to Regulation 20 of the Care Homes Regulations). Money and records held in the home on behalf of service users were sampled and were found to be correct and in order. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 12 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): 12, 16 and 17. Service users are supported to take part in activities that are age and peer appropriate. The daily routine at the home is designed to assist service users maximise their independence. Service users were seen to have unrestricted access to the home and gardens. Service users are provided with a healthy diet. Meals were evidenced to be provided three times daily, at least one of which was seen to be cooked. EVIDENCE: The needs of the service users are such that none are able to partake in any form of paid or voluntary employment. Sampling of service users’ activity plans evidenced that one service user attends the local college. Staff support service users to access their benefits and manage their financial affairs. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 13 Observation of interactions between staff and service users indicated that the daily routines of the home are designed to promote independence; service users were seen to have unrestricted access to all areas of the home. Staff were heard to refer to service users by their preferred terms of address, in respectful and considerate tones. Staff were heard and seen to interact with service users and not exclusively with each other. All service users’ rooms were able to be locked from the inside should the service users choose to do so, although override devices were available for use by staff in the case of an emergency taking place. The home operates four-weekly rotational menus which evidenced that three meals are provided daily, at least one of which was seen to be cooked. The menus seen were varied and nutritious. Records were seen of the home recording meals consumed by service users. Food stocks sampled on the day of the inspection were seen to be adequate. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 14 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): 19 and 20. Evidence was provided that service users’ physical health care needs are well met, although records pertaining to these could be maintained better to ensure ease of access. The home’s practice pertaining to service users’ medication was good. Records were seen to be well kept and all staff had received training in this area. EVIDENCE: All service users are registered with a general practitioner. Health records sampled indicated involvement/access to a range of healthcare professionals as follows: • • • • • • General practitioner Chiropodist Community nurses Dentists Social Workers Opticians Although records were generally well kept, it is recommended that these could be laid out better to make them more readily accessible. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 15 All medication is dispensed via a measured dosage system or named containers. The home does not stock any controlled medications. Discussion with the registered manager confirmed that all staff have received training in the safe administration of medicines. Medications are stored in a wall mounted locked cabinet. Evidence was seen of a homely remedies record sheet for each service user which was seen to have been signed off by each service user’s general practitioner. Situated on the inside of the cabinet door was a copy of the home’s protocol for PRN medication (as required medication). This was alongside a copy of the organisation’s Medication Administration Policy. The home’s medication records were sampled and found to be in order. Each service user’s medication record was seen to include a profile of the service user with a photograph. Medication is returned to pharmacy via a returns book. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 16 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): 23. The home’s practice in relation to adult protection issues was generally deemed to be good. EVIDENCE: Since the previous inspection the home has had one referral made in respect of an adult protection issue. Discussion with the registered manager indicated that the referral process had been appropriately managed, ensuring all relevant agencies were appropriately notified. All appropriate actions were taken to ensure that the needs of the service user and others involved in the referral were safeguarded. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 17 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): 28 and 30. Shared space at the home was adequate to meet the needs of the service users. Although on the day of the inspection the home was clean, tidy and free from any offensive odours, the laundry facility at the home continues to barely meet the Standard in terms of having all of the necessary equipment available. In the context of the overall appearance of the home this continues to be the area that lets it down. EVIDENCE: Shared space at the home continues to be proportionate to the needs of the service users. The requirement from the last inspection remains in respect of home’s laundry facility which, whilst meeting basic needs, continues to be in a generally poor state of repair and lets the home down in terms of its ability to comply with the environmental standards. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 18 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. Service users are supported by a team of staff who know them well. However, the home to date continues to just fall short of the requirement for at least 50 of the team to be qualified at NVQ Level 2 or better. The home’s recruitment practice records sampled on the day of the inspection were found to be in order. No specific training has taken place at the home since the previous inspection. The home has a structured induction process available, however the record of the most recent employee to the home evidenced that this had not yet been carried out. EVIDENCE: The home employs ten care staff, two of whom are qualified at NVQ Level 2. In addition, a further four members of the care team have commenced the award. The home does not employ any staff under the age of eighteen. Three staff files were sampled in respect of the home’s recruitment practices; all the documentary evidence required under Regulation 19, Schedule 2 of the Care Homes Regulations was seen to be in place. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 19 Since the previous inspection no training has taken place at the home, although evidence was provided in staff files of the following training being scheduled for the near future: • • • • Appointed persons first aid Manual Handling Adult protection Food hygiene The organisation has its own training department which provides in-house training. Training for staff is identified during discussions in one-to-one supervision sessions. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 20 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 and 42. Service users are supported by a team of staff who themselves are supported by a registered manager who has a significant number of years’ experience of working in the care sector. Although the manager is not yet qualified at NVQ Level 4 in management, evidence was presented that they have now commenced the award. The home’s safe working records sampled on the day of the inspection were seen to be current and in order. EVIDENCE: The registered manager has a significant number of year’s experience of working in the care sector. However, they are not yet qualified at NVQ Level 4 in management, although evidence was provided which confirmed that the registered manager has now been enrolled and commenced the award. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 21 The home’s safe working practices were sampled through the viewing of the following safety certificates: • • • • • • • • • • • Record of fire extinguisher checks Certificate of water calibration Gas safety record Emergency lighting certificate Fire detection alarm system report Electrical installation certificate Record of water temperature checks Record of fire alarm tests Emergency lighting test record Record of fire drills Fire extinguishers and hose reel visual test The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 22 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 2 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 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 3 x 2 X X X X 3 x The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose and Service Users Guide meets with requirements. This relates to the need for both to be provided in a format that is accessible to service users. The previous timescales of January 2005, and 31/03/06 were not met. The registered person must ensure that monies belonging to service users are not paid into any other account other than one in the name of the service user. Timescale for action 30/06/06 2. YA7 20 (a &b) 30/06/06 3. YA30YA28 23 (2b) The responsible person must 30/06/06 ensure that the home is kept in a good state of repair, externally as well as internally. This relates specifically to the condition of the laundry facilities based in outbuildings at the rear of the property. The previous timescale was not met. The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 24 4. YA32 18 (a) 5. YA35 18(i) The registered person must ensure that at all times suitably qualified, competent and experienced staff are working in the care home. This relates specifically to the need to ensure that staff are NVQ Level 2 qualified or better. The registered person must ensure that all new starters to the home are inducted, in line with Skills for Care requirements. 30/06/06 30/06/06 The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA37 Good Practice Recommendations It is recommended that the registered manager complete their NVQ Level 4 in management at their earliest convenience. It is recommended that health care records pertaining to service users’ healthcare needs be kept more clearly and concisely, in a format that is easily accessible. 2. YA19 The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Penant DS0000054579.V262377.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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