Inspection on 23/12/05 for The Penant

This inspection was carried out on 23rd December 2005.

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 4 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 21/03/06

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 Draft Unannounced Inspection 23rd December 2005 09:30 The Penant DS0000054579.V262300.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.V262300.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.V262300.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.V262300.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 5th November 2004 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.V262300.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 carried out over one day in December 2005, lasting 5.5 hours. The inspection included discussion with the registered manager and two members of staff as well as some very basic communication with two service users, due to their limited communication skills. However, despite the difficulties in communication, observation of the service users indicated that they were happy, relaxed and at ease in their environment. The inspection included a tour of the premises, which had recently under gone complete refurbishment, observation of service users’ rooms, toilet and bathing facilities, as well as communal areas and gardens. Nineteen of the forty three standards were inspected, of which thirteen were met, four were minor shortfalls, the remaining two being major shortfalls, resulting in four requirements and two recommendations. What the service does well: What has improved since the last inspection? The accommodation at the home when taken over by the current organisation was in a generally very poor state of repair. Complete refurbishment to the interior has taken place and the accommodation now provided is to a very good standard. However, significant work remains to address the outbuildings to the rear of the property and, in particular, the home’s laundry facilities which are currently letting the home down. However, the organisation must be congratulated on the work done to date. Service users who were able to express a view on their accommodation indicated by nodding and smiling that they were very happy with the changes that had been made. The home now has in place a mechanism for reviewing the quality of its service provision. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 6 The home has now developed a pre-admission assessment to be used before determining its suitability to met the needs of service users referred to the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Penant DS0000054579.V262300.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.V262300.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, 2 and 5. Prospective service users and/or their representatives are provided with the necessary information to enable them to make an informed choice about the home’s capacity to meet their needs, although the format requires reviewing to ensure it is applicable to meet the needs of the service users it is designed for. The home’s pre-admission needs assessment was sufficiently detailed to provide the necessary information. Service users’ contracts of residency were detailed in informing the rights and responsibilities of all parties. EVIDENCE: Both the home’s Statement of Purpose and Service Users Guide were sampled and were in order, apart from the need for them to be made available in a format suitable to the needs of the service users. Two pre-admission assessments were sampled and were seen to cover all the areas recommended under National Minimum Standard 2. Contracts of residency sampled detailed what was included within the tariff of charges, rooms to be occupied by the service users, as well as any notice period required to be given by either party. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 9 The Penant DS0000054579.V262300.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): 6 and 9. Care plans and risk assessments were well detailed, containing all the relevant information necessary to enable service users’ needs to be met. EVIDENCE: Two care plans were sampled, both of which were derived from the home’s own pre-admission assessment of need. They included clear guidance to staff as to the level of intervention required by service users and were seen to have dates set for evaluations. Risk assessments were clear and concise in identifying and laying out the risk, as well as the necessary management plan to be followed to reduce the level of risk to its minimum. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 11 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): 15. Evidence would suggest that service users are supported to maintain links with their families and friends. EVIDENCE: The home has an open door policy on the receiving of visitors. The home’s visitors’ book was sampled which evidenced that service users’ relatives were in periodic contact. The registered manager spoke of service users being free to receive visitors in the privacy of their own rooms, or in the lounge, whichever was their preferred choice. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 12 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. Health care records require further development to ensure they are clear and concise. EVIDENCE: All service users are registered with a General Practitioner. Service users’ care plans sampled contained a section for recording interventions from health care professionals as well as a single sheet which included records of interventions from: • • • Dentists Speech and Language Therapists Opticians. A weight monitoring form was included, although there was no evidence of service users’ weight having been monitored. Although there was some evidence of records being maintained, these require further development. It was further recommended that single record sheets are maintained in respect of each health care professional to aid recording. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 13 The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home’s complaints and adult protection policies and procedures were deemed to be robust in terms of protecting service users from the risk of harm or abuse. EVIDENCE: The home has a corporately developed complaints policy which was deemed to meet with statutory requirements. The home maintains a log for recording the receiving of any complaints. At the time of the inspection no complaints had been received by either the home or the Commission for Social Care Inspection. The home’s adult protection and whistle blowing policies were also corporately developed and were also deemed to comply with statutory requirements. Discussion with the registered manager indicated that all staff have received training in the protection of vulnerable adults; this was ratified during discussion with staff. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,27,28,29 and 30. The home is fit for its stated purpose, being comfortable and safe for use by service users. Service users’ bedrooms were seen to be equipped to suit their individual needs and lifestyles, and to promote their independence. All service users’ rooms bar one have en-suite facilities. The remaining toilet and bathing facilities at the home are adequate to meet the needs of the service users. Shared space available at the home was deemed to be adequate to meet the needs of the service users. The home is equipped with a range of aids and adaptations to enable service users maximise their independence. Although on the day of the inspection the home was clean and tidy and free from any unpleasant odours, the home’s laundry facilities are in a poor state of repair and require urgent attention. EVIDENCE: The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 16 The home was deemed to be fit for its stated purpose and was in keeping with the local community. The home was on the whole safe, accessible, comfortable, light and airy, and on the day of the inspection was clear of any foul or unpleasant odours. The home is close to local amenities and is within close walking distance of the town centre. Furnishings and fittings at the home were of a good quality and were domestic in nature. The home complies with the individual room space requirements of National Minimum Standard 25. Service users’ rooms were seen to be equipped to the appropriate standard. Bedding, curtains and floor coverings were of a good quality and there was much evidence of service users’ own personal possessions. All service users bar one have en-suite facilities; the service user who does not has access directly outside their room to a bathroom and toilet. Shared space at the home is proportionate to the number of service users and staff on duty. Kitchen facilities are domestic in nature and were more than adequate to meet the home’s needs. Facilities are available to accommodate staff sleeping in. Laundry facilities at the home, whilst meeting most basic needs, are generally in a poor state of repair and let the home down significantly in its ability to achieve all the environmental standards. The home is fitted with a range of aid and adaptations to enable service users to maximise their independence, i.e.: • • • • Hi-Lo bath Hand grab rails Call systems Stair rails. As stated previously, the home’s laundry facilities at the home, whilst meeting the most basic of need in terms of having the required equipment, are in a poor state of repair, being situated in outbuildings to the rear of the property. Whilst this remains the case the home will continue to fail to meet the required environmental standards. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 17 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): 34 and 36. The home’s recruitment processes continue to require further development before they fully comply with statutory requirements. Evidence suggests that formal supervision is taking place at the frequency recommended. EVIDENCE: Three staff files were sampled in respect of the home’s recruitment practices. Two were found to comply with Regulation 19, Schedule 2 of the Care Homes Regulations; the other contained no identity photograph or health declaration. One contained a Criminal Records Bureau check on which there was evidence of a police caution in 2004. This was explored further with the registered manager who was able to explain the actions taken by the organisation’s representatives prior to their reaching their decision to appoint. The actions taken were felt to have been appropriate in terms of ensuring service users’ safety. Discussion with the registered manager and staff indicated that formal supervision is being provided every six to eight weeks; this was further evidenced during the sampling of staff files. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43. The registered manager is not yet qualified in management at N.V.Q level 4, although they are about to commence the award. The home has a corporately developed process for reviewing the quality of its service provision. The home has a business plan for the period up to March 2006 and contained nothing to raise any concern for the home’s ongoing financial viability. EVIDENCE: The registered manager is a registered nurse for people with learning disabilities and, therefore, has many years’ experience working in the care sector. However, the manager is not currently qualified at N.V.Q level 4 in management, although a letter was presented confirming their commencement of the award in January 2006. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 19 The home’s quality assurance is sampled via questionnaires that are disseminated from the organisation’s head office. Responses are then collated into an annual satisfaction survey which is organisation specific. The home has a business plan for the period April 2005 to March 2006. It contained nothing to indicate any concern for the organisation’s ongoing financial viability. Indeed ,in the last year the home has, as mentioned elsewhere within this report, undergone a complete interior refurbishment. The home’s public liability insurance was seen to be displayed and was current. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 20 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 3 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 3 25 3 26 3 27 3 28 1 29 3 30 1 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 x x 2 x 3 x x x 3 The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 21 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 Timescale for action 31/03/06 2. YA28YA30 23 (2b) 3. YA34 19, Schedule 2 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 timescale set of January 2005 was not meet. 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 registered person must not 31/03/06 employ staff at the care home unless they have obtained all the documents specified under Regulation 19, Schedule 2 of the Care Homes Regulations. The previous timescale set of January 2005 was not meet. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA37 YA19 Good Practice Recommendations It is recommended that the registered manager completes their N.V.Q 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. The Penant DS0000054579.V262300.R01.S.doc Version 5.1 Page 23 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.V262300.R01.S.doc Version 5.1 Page 24 - 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. 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