Care Home: Penerley Lodge

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What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Penerley Lodge 36/40 Penerley Road Catford London SE6 2LQ Lead Inspector Ms Rehema Russell Unannounced Inspection 10:00 14 October 2008 th 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 Penerley Lodge DS0000025637.V371440.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. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penerley Lodge Address 36/40 Penerley Road Catford London SE6 2LQ 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) 020 8695 6029 penerly@priemerecarehomes.co.uk Mr H A Cole Mrs Maureen P Cole Mrs. Pauleen Wickes Care Home 27 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 27 elderly persons of whom up to 2 may have dementia 13th September 2007 Date of last inspection Brief Description of the Service: Penerley Lodge provides accommodation and care for 27 older men and women who are physically frail, up to 2 of whom may have dementia. The home was formed by combining three formerly private Victorian houses and is located in a quiet residential road in Catford. It is within 10 minutes walk of a main shopping centre, which is also accessible by buses available a few minutes walk from the home. The main shopping area has good transport links to other areas of London by both bus and rail. There is a large forecourt in front of the home with space for several cars to park and nearby on-street parking is available. The home has a large conservatory, which also has a smoking room and private meeting room, and the garden has a decking area, raised flowerbeds, lawn and a landscaped area to the side. Prospective service users and their relatives are given a copy of the Statement of Purpose and are given further verbal information about the home during their trial visit. The front page of the most recent CSCI inspection report is advertised on the notice board and a copy made available at request from the home’s office. Fees vary according to whether rooms are private/en-suite or paid by local authorities. There is an additional charge for hairdressing. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place for 2 hours during the afternoon of 9th September 2007 and for one day on 14th October 2007. Both visits were unannounced. During both visits the inspector spent most of the time in the lounge of the home where there is a desk area in the corner where care files and records can be accessed, and staff and residents spoken with. In this way the inspector was able to observe the interactions between residents and staff and the atmosphere in the home. The inspector also looked at some documentation in the office, communal areas and some bedrooms and spoke with the manager and several members of staff and residents, some in private. Although the home is registered for 27 people, it is currently undertaking building works and therefore has a reduced capacity of 23 places. All were occupied at the time of the inspection, with 6 people on a waiting list. The building works consist of converting one-third of the home plus the adjacent house acquired into a unit for elderly people with dementia. What the service does well: Service user quotes included: • “quite nice here” • “staff are very nice” • “Pauline is very fair”(manager) • food is “reasonable” • “the food is good” • “I’m happy that I’m here” • “They’re good people in here” • “I love them” • “They’re very friendly, make you feel welcome, always given tea when I visit” • “They’re very good” The atmosphere at the home was very relaxed and homely, open, friendly and family like. In addition: • • Potential residents are thoroughly assessed before admission so that the home can be sure they will be able to meet the resident’s needs The home ensures that residents benefit from the full range of healthcare facilities and that their privacy and dignity is respected. DS0000025637.V371440.R01.S.doc Version 5.2 Page 6 Penerley Lodge • • • • • • • There is a full timetable of activities, tailored to residents’ preferences and capabilities Residents choices are supported, relatives and friends are encouraged to visit the home and are made welcome, and the food provided is well cooked and presented. Care plans and risk assessments are regularly reviewed. The home provides good communal and garden facilities. All bedrooms are well decorated and have good furniture and fittings. Recruitment procedures are thorough so that residents are safeguarded from harm. There are good staffing levels and all care staff are qualified. What has improved since the last inspection? What they could do better: Four requirements and three recommendations have been made following this inspection: • • • • The Registered Person must ensure that information required by regulation is given in the Statement of Purpose, and in the Service User Guide The Registered Person must ensure that refurbishment results in sufficient and suitable communal bathroom facilities. The Registered Person must establish an effective quality assurance system which includes monthly Regulation 26 reports. The three recommendations relate to information missing from the service user guide, the consideration of regular administration support at the home, and the annual publication of residents’ views. Please contact the provider for advice of actions taken in response to this Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 7 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. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 8 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 Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 9 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): 1, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information given to residents is comprehensive but does not meet legislation in regard to contract and fees information. A thorough assessment procedure is carried out prior to the admission of all residents. The home does not admit residents for intermediate or rehabilitative care EVIDENCE: The inspector was given a copy of the Statement of Purpose, which was checked when this report was being written. At the previous inspection of 13th September 2007 there were several omissions and inaccuracies in this document, the majority of which the Proprietor has amended. However there are two areas that still require amendment: Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 10 Under “Details of Staff Numbers and Staff Trainng” the author has omitted to list the number of care assistants employed at the home. • Under “Fire Safety” the author states that a fire exercise is carried out weekly and a full fire drill monthly, but fire records only show fourmonthly fire drills. See Requirement 1. At the previous inspection of 13th September 2007 the inspector was given a copy of the information booklet given to each resident on admission to the home which the home uses as equivalent to the Service Users Guide. However the inspector did not collect a copy at this inspection. After the previous inspection, three requirements were made in regard to this document and the Proprietor must check these have been implemented and send a copy to the Commission for perusal. The information omitted that the document must contain were: • • • Regulation 5 (b), relating to accommodation fees, Regulation 5 (c), relating to contracts, and The amendment to Paragraph (1) of Regulation 5 that came into force in July 2006 requiring information, including “whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user.” This information was given to registered persons via the London Provider Newsletter of July 2006. • The booklet should also include a summary of service users’ views of the home. See Requirement 2 and Recommendation 1. Documentation on care files evidenced that a thorough admission procedure is carried out. There is an admission sheet signed by manager and service user, the placing authority’s care management assessment/continuing care assessment and a full and thorough health and social care assessment carried out by the home prior to admission. In addition there are further assessments in regard to continence, mobility, falls, nutrition, body chart, personal inventory list and other relevant consents (e.g. resuscitation, funeral plans). All assessments were signed and dated and reviewed monthly for the first three months following admission. The home does not admit residents for intermediate or rehabilitation care, and therefore Standard 6 is not applicable. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 11 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, 10, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and care needs are set out in an individual plan of care. Residents’ health care needs are met and the storage and administration of medication is satisfactory. Service users are treated with respect and their privacy upheld EVIDENCE: Three care plans were examined in detail and sections of several more were seen. All were in order with all relevant documentation signed. Since the previous inspection of September 2007 the manager has devised a care plan template and all care files have been reorganised accordingly. The template is excellent and has made the care files easy to keep in order, read and understand. Care plans contained all relevant information, plus relatives’ consent for any behavioural modifications (e.g. restriction of cigarettes to a specific number per hour), charts for district nurse visits and multidisciplinary team visits (dentist, physiotherapist, optician etc) and evidence of mental health reviews as appropriate. By 2 months after admission each resident has Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 12 a full care plan under the headings of Communication, Moods and Behaviour, Personal Hygiene and Eating & Drinking. All were reviewed monthly, and in additional there are daily comments (reports) on each resident twice per day after. Verbal and documentary evidence indicated that residents’ healthcare needs are fully met. Staff said that the home has a good relationship with the general practitioner, who visits whenever requested. Residents’ health needs are fully documented e.g. attendance at AA meetings, district nurse visits, GP visits. Staff were not satisfied that a resident with an ulcer was receiving only one visit from the district nurse per week and so they took photographic evidence of the ulcer and managed to obtain twice weekly district nurse visits. The GP had also been notified and kept fully informed. There are currently only two residents with diabetes, controlled with diet and tablets, and no residents requiring liquidised food. All medication, with the exception of one only, is now dispensed via blister packs (monitored dosage). A tablet count was taken and was found to be correct. The medication book has a list of staff signatures at the front and a picture of each service user in front of their medication sheet so that there is no possibility of mistaken identity. Each sheet also has the resident’s name, room number, date of admission, keyworker, GP, social worker and allergies. All staff have had medication training, and no gaps were found in medication administration records. The daily temperature of the fridge where insulin, penicillin and eye drops are kept is recorded and no problems were found. Observation, verbal evidence from staff and residents and documentary evidence on files indicated that residents’ privacy and dignity is respected and upheld. For example, there is written agreement that at one service user’s request, he is only bathed by male workers; staff said that they shut the lounge door if a resident wishes to make a private phone call using the telephone in the hallway; all clothes are labelled; double rooms have been converted to singles so that there are only 2 double bedrooms in total now; residents are always seen by healthcare professionals in their own rooms; conservatory doors are closed should a visitor request privacy with their relative (alternatively there are two small rooms available for use); staff take care to encourage residents with mental health problems to dress appropriately for community living. The manager was observed to respect dignity and privacy in several ways, including refusing to speak with a resident about a personal matter in the lounge and taking the resident to a private area where they could speak together. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 13 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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Daily routines are flexible to suit residents’ preferences and capacities and residents are encouraged and supported to maintain contact with family and friends. Residents are assisted to exercise choice and control over their lives and receive a balanced and nutritious diet in pleasant surroundings. EVIDENCE: Although there are set times for breakfast, lunch and dinner, evidence was given from residents and staff that these routines are flexible. For example, residents can have breakfast early if they wish and one resident regularly has a late breakfast after 10 am. Since the previous inspection of September 2007 the Proprietor had employed a full time activities co-ordinator who works full time from Monday to Friday and provides a full 2 week activities programme displayed in the conservatory. This includes: bingo, individual talks with residents, reminiscence, puzzles, quizzes, games, colouring, making hats, cooking, crocheting, knitting. The inspector was told that at least half of the residents join in with the various activities. On the second day of the inspection several residents were enjoying a game of bingo, complete with prizes which they told the inspector they were excited to receive. The activities Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 14 co-ordinator is organising a Christmas fete and last year organised a residents & relatives Christmas party with a Magic Man, singing entertainments, raffle, dancing and buffet. Previous service users relatives are also invited and some still make cakes for the raffle. From observation and verbal evidence form residents it was clear that they can choose freely whether or not to join in with activities – they are encouraged to do so but their choice is respected. The activities co-ordinator does not work on Saturdays but the inspector was told that carers do singing and reminiscence on this day with residents. Sunday is a rest day. The activities co-ordinator also runs a mobile shop once a week from which residents can buy sweets, crisps, drinks and toiletries and takes some residents out for walks. Two residents currently attend day centres, and 2 others have been referred. Framed pictures of residents have been hung around lounge, which makes it very welcoming and homely. As mentioned above, 2 residents attend day centres weekly and 2 others have been referred. Several residents are taken to church each Wednesday via Dial A Ride and a priest visits once weekly to give communion to those wishing to receive it. Residents spoken with confirmed that they have regular visitors at the home and that visitors are made welcome by being offered tea. Visitors can be seen in the lounge, or entertained in residents’ own bedrooms or the visitor’s room off the conservatory if more privacy is wanted. There are no set times for visiting but the home requests a phone call for visits after 7 pm for reasons of safety. There was verbal and documentary evidence that residents’ autonomy and choice is encouraged and respected wherever appropriate. Two residents were recently moved to the ground floor due to building works in one part of the home and the unreliability of the stair lift, but both residents, and relatives where possible, were fully consulted and notes recorded in their care plans. There is a list of advocates on notice board and in each care plan, and the latter also has a list of the preferred toiletries of the individual resident. Residents are given choice in regard to what they wear, what they eat (there are menus on each table with 2 meal choices, and other provision if neither choice is suitable) and how they spend their day. Since the previous inspection the Manager asked each resident for their food likes and changed the menu accordingly, e.g. to include liver & bacon, faggots, belly of pork strips, spam fritters, corn beef hash etc., and the assistant chef can provide Caribbean food for the one black resident at the home. During the inspection residents were observed to be moving around the home at will, choosing which room they wished to be in, with some sitting and chatting with staff. Lunch is taken in conservatory with nicely laid out tables with printed menus and matching napkins. As noted above, there is a choice of two cooked meals at lunchtime, or if a resident doesn’t want either choice, staff will provide a sandwich/jacket potato/pie/pizza etc. The assistant chef, who is of Caribbean origin, sometimes cooks Caribbean food for the one black resident in the Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 15 home. On the day of the inspection the choices were lamb & potato bake with French beans and swede or macaroni cheese. For dessert there was banana custard, yoghurts or fresh fruit salad. Supper was quiche and tomatoes or sandwiches, with cheesecake and biscuits. After lunch, one service users came out of the conservatory with his drink, happily singing to himself. Staff prepare evening supper e.g. hot dogs, cheese on toast, soup (made previously by the cook) and sandwiches. If a resident is peckish at night, staff will make sandwiches and a drink. Hot drinks are given between 7.30 and 8pm each evening. The cook works Monday to Friday from 7.30am to 2pm, making breakfast and lunch and preparing cakes for tea and food for the evening meal. An assistant works 3 weekdays per week and is the main cook at weekends. Most of the meals are home made, including the cakes for tea, which were delicious. Residents confirmed that the food was good and they enjoyed it. Penerley Lodge DS0000025637.V371440.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are listened and responded to and service users are protected from abuse. EVIDENCE: The home has a clearly written complaints procedure, accessible in the Statement of Purpose. No complaints have been received by the home or the Commission since the previous inspection of 13th September 2007, and there have been no adult protection issues. All staff have been trained in adult protection and during the inspection the inspector observed staff dealing with verbal and physical aggression in a calm and appropriate manner. Penerley Lodge DS0000025637.V371440.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, 20, 21, 22, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained but there are problems with the physical standards in regard to the lack of a passenger lift, insufficient bathroom facilities, and a small kitchen with insufficient storage facilities. However planning permission has been obtained for a refurbishment programme, during which the Proprietors have undertaken to remedy these defects. Bedrooms are decorated and fitted to a good standard however, and there are comfortable, accessible, attractive and homely communal facilities. The home was found to be generally clean and hygienic throughout. EVIDENCE: The premises currently consists of three houses, numbers 36, 38 & 40, that have been combined to form one home. Numbers 38 & 40 are semi-detached and have the communal areas and refurbished bedrooms. Number 36, called Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 18 Hazeldene, is in the process of being merged with the newly acquired house no. 34 to form a unit for people with dementia. Planning permission to build a passenger lift shaft between the two semi detached houses (i.e. between nos. 38 & 40 and nos. 34 & 36) to replace the current two stair lifts has been refused but the Proprietor has plans for a lift that does not require the construction of a shaft. Various alterations and refurbishments have been carried out over the past three years and are still in the process of being carried out. Staff have been careful to ensure the safety of residents while works are being carried out but it has meant that the home is currently not fully suitable for its stated purpose nor fully accessible. The home has two indoor communal areas, which are both attractive and homely and on the ground floor. There is also a landscaped and well maintained back garden which is easily accessible from the communal areas. This provides residents with a choice of where to spend their time. The first communal area, the main lounge, is a large well furnished room which has a television and video area near to the kitchen hatch, and an area where service users can sit away from the television. It has been redecorated with washable paint and in the colour scheme used through the home, blue and cream. One corner of the room has a desk where healthcare workers can undertake paperwork whilst still observing residents. At the previous inspection of September 2007 the inspector was told that the Proprietor intended to get a large flat screen television to improve visibility for residents, and this would be welcome. The second communal area is a large conservatory which leads off from the main lounge. It is large and well lit with comfortable chairs, good quality furniture and fittings and attractive décor. Two separate rooms have been built within the conservatory, one being a smoking room and the other a private visitors/meeting room. Residents were observed to use these communal areas at will. A new barbecue and new wooden garden furniture with umbrellas for shade have been obtained for the garden. There are no communal bathroom facilities on the first floor although there are a total of 15 bedrooms on this floor, 3 of which are en-suite (toilet, washbasin and shower facility). There are three communal toilets upstairs. All residents therefore use the two communal bathrooms on the ground floor. Unfortunately, neither bathroom has natural light or natural ventilation. There are 8 bedrooms on the ground floor, 2 of which are double bedrooms and 2 of which are en-suite. Due to the current refurbishment works the home is supporting 23 residents only and as 5 of these have en-suite facilities in their bedrooms, the number of bathrooms is less of a problem. However, the Proprietor must ensure that there are sufficient bathrooms with adequate facilities for the whole home by the time the refurbishment works are complete. See Requirement 3. Only one person currently uses wheelchair, but they can walk with a zimmer frame and the wheelchair is only used when they become very confused. Access to the first floor remains via stair lifts but the Proprietors intend to Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 19 install a lift during the refurbishment works. One resident needed to be moved to a downstairs bedroom because of the breakdown of one stair lift, but full consultation and agreement took place and was recorded in the care plan. A number of bedrooms were seen and were found to be in good condition, well decorated and with good quality furniture and fittings, and all are personalised. The home was observed to be clean and hygienic throughout. Both the laundry room and the kitchen are small for the size of the home but both are due to be modernised and expanded when the refurbishment takes place. The dry food storage cupboards were seen and were both in good order, clean and well organised. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff and residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policies and practices and staff are trained and competent to do their jobs. EVIDENCE: There is sufficient staff cover for the number of residents at the home. During weekdays there is a manager, senior healthcare assistant and 5 healthcare assistants each day with two waking staff at night. At weekends there are 4 healthcare assistants during the day. The staff complement consists of a manager, 4 senior healthcare assistants, 12 healthcare assistants and 5 night staff. There is no deputy or administration assistant, which is unusual for a home of this size. It is recommended that the Proprietors consider providing administration assistance for the manager at the home. See Recommendation 2. All care staff have a minimum of NVQ Level 2 qualification, and so the home has exceeded the 2005 training target. Several care workers are currently undertaking NVQ Level 3. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 21 The inspector checked the files of the two employees employed since the previous inspection of 13th September 2007. No problems were found, the files had all the relevant information required and were in good order. Evidence was seen of new staff receiving induction, including all basic training such as fire safety, food hygiene and manual handling. Within six months of employment they also undertake training in abuse, dementia, health & safety, and dying, death & bereavement. Further training undertaken includes care plan training and medication provided by the Pharmacy. The inspector was told that all relevant staff have been put forward to refresh their 1st aid training, and new staff to undertake it. In the week previous to this inspection all 4 senior care staff had undertaken dementia training, provided in house by the manager and with a test paper at the end of the course. Seniors spoken with said the training had been enjoyable and informative and had helped their understanding of certain residents’ behaviour. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent and experienced to run the home and provides a positive ethos, leadership and management approach. There is no established quality assurance system and no evidence of required monthly Regulation 26 reports, although this is an outstanding requirement. Residents’ financial interests are safeguarded. The health, safety and welfare of service users is promoted. EVIDENCE: The Registered Manager has many years experience of working in and managing the care home. She is taking NVQ Level 4 in Care & Management and after finishing this intends to obtain the Registered Manager’s Award. She is familiar with the conditions/diseases associated with old age, has an open and caring attitude towards residents and is familiar with each resident’s Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 23 individual characteristics, preferences and needs. Residents and staff told the inspector that she was very approachable, very caring and fair. It was evident that both staff and residents felt at ease in her company and able to speak openly with her. She has made many improvements in the organisation and running of the home over the past 2-3 years, including improving documentation and staff training, amongst others. She has an open, honest and friendly relationship with the Commission and facilitates inspections well. The home does not have an established quality assurance system, and although this has been a repeated requirement, there was no evidence of Regulation 26 monthly reports carried out by the Proprietor or representative as required by the Care Standards Act (Regulation 26 (3)). See Requirement 4. At time of this inspection the Manager had just sent out quality assurance questionnaires to every resident’s relatives. A similar form had been sent out last year but with a response from only 4 relatives. They had been generally happy with the home but mentioned concerns about activities (there is now a full time activities co-ordinator). For service users, the inspector was told that staff sat down with each one individually and got very good results – 95 were happy at the home and had no complaints. Some residents did not realise that they could ask for tea if they woke up during the night. The inspector was told that it was explained to them that Penerley was their home and they could have drinks at night just as they would be able to in their own homes. Now night staff routinely offer teas and biscuits to anyone who wakes at night. A summary of service users’ views should be published annually. See Recommendation 3, which was also cited after the inspection of 13th September 2007. The inspector was told that the system of managing/safeguarding residents’ monies had not changed since the previous inspection. The home does not administer or manage any service user monies. Residents’ personal monies are handled exclusively by themselves or their relatives, or by solicitors and social workers where there are no relatives. Relatives/solicitors pay a lump sum to the Registered Person’s head office and anything a resident purchases, such as hairdressing or items from the mobile shop, is financed from petty cash, notified to head office and entered on invoices which relatives/social workers receive monthly. The following health & safety documentation/items were checked and found to be in order: • Fire drills – records showed that a fire drill is carried out every 4 months. The date, time, list of participants and duration of the drill is recorded, which is good practice. DS0000025637.V371440.R01.S.doc Version 5.2 Page 24 Penerley Lodge • • • • • • • • • • Fire alarm and detector systems (call points), checked weekly in rotation Emergency lighting, checked weekly Fire Extinguishers, serviced on 6.12.07 Fire risk assessment by City Fire Group, dated 13.3.07 Weekly checks of water temperatures in bedrooms and bathrooms 2-3 weekly checks of all alarm call bells Monthly wheelchair checks Hazardous waste collection COSHH data sheet Gas safety certificate 9.7.08 Penerley Lodge DS0000025637.V371440.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 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 1 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 1 X 3 X X 3 Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 Requirement Timescale for action 31/03/09 2. OP1 5 3 OP21 23 (2)(j) 4. OP33 24 & 26(3) The registered person must ensure that the information in the Statement of Purpose is clear and factually correct. The registered person must 31/03/09 ensure that all of the information required by regulation is provided in the information given to residents/service user guide. The Registered Person must 31/03/10 ensure that there are sufficient bathroom facilities to meet residents needs in regard to the number and location of assisted bathrooms that are to be provided for general use in the home after refurbishment. The registered person must 31/03/09 establish and maintain an effective quality assurance system, including Regulation 26 visits and reports. Previous timescales not met. Continued failure to meet this requirement will result in enforcement action being considered. Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations The Registered Provider should ensure that all of the information recommended under National Minimum Standards 1.2 is provided in the information given to residents/service user guide. The Registered Provider should consider providing regular administration assistance at the home. The results of surveys of residents’ views should be published annually. 2 3. OP27 OP33 Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Penerley Lodge DS0000025637.V371440.R01.S.doc Version 5.2 Page 29 - 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. 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