Care Home: Penlee

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What the care home does well This is a family run home with a friendly atmosphere. Residents’ relatives and staff all appreciate the day-to-day input of Dr. and Mrs Gupta. Outcomes for the residents are positive in the main. For example five residents spoken with said, “the home is nice, the staff are kind and caring.” A good rapport between staff and residents was observed. The staff work hard to ensure the well-being and comfort of the residents’ and treat them with respect and kindness. Meals are varied, healthy and nicely presented offering choice and variety. Residents feel that if they had something to complain about they would speak to a member of staff. Penlee provides a homely and comfortable environment for residents. It is decorated and furnished to a good standard and there are some homely touches. There is a relaxed atmosphere and relatives tell us they are always made to feel welcome. What has improved since the last inspection? The home have worked hard since the last inspection to meet the requirements made. Care plans have been reviewed and their format changed to provide a more comprehensive and clear way of communicating the care needs of residents, and actions that are being taken to address them. Staff have received training in care plan use and writing, and we are told they are more widely used to inform practice. They continue to need attention to improve the information recorded as gaps in necessary information were observed during the inspection. Risk assessments are now well completed with clearly stated actions to minimise risk for the safety of the resident. Staff have received training in manual handling and safeguarding and satisfactory practice in these areas was observed. As mentioned above safe recruitment practices are now being undertaken to protect residents. The management have revised their approach to training and staff have undertaken a variety of mandatory and specialist training since the last inspection. A system for recording and ensuring staff attend, together with the Penlee DS0000020337.V377962.R01.S.doc Version 5.2 provision of practical sessions has been implemented, to ensure staff have the skills and knowledge to meet residents needs. Record keeping and communication of needs and how they are to be met has improved, however there is room for further improvement for the safety and well being of residents. All fire doors inspected closed flush to frame for the safety and protection of residents. What the care home could do better: The service needs to continue to work hard to maintain improvements made for the safety and well being of residents. Activities provision remains limited and a number of comments received told us residents would like and benefit from better activity provision. The service continues to work outside of the regulations without a Registered Manager. The provision of such would enhance the service provision. Record keeping although improved needs further attention to detail to ensure all key information regarding residents health and well being, and how their needs can be met are clearly communicated to all staff. Key inspection report CARE HOMES FOR OLDER PEOPLE Penlee 21 Uphill Road North Weston Super Mare North Somerset BS23 4NG Lead Inspector Patricia Hellier Key Unannounced Inspection 12th November 2009 10:00 DS0000020337.V377962.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Penlee DS0000020337.V377962.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Penlee DS0000020337.V377962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Penlee Address 21 Uphill Road North Weston Super Mare North Somerset BS23 4NG 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) 01934 632552 01934 412711 penlee@freeuk.com Dr Harmandar Singh Gupta Mrs Diljeet Kaur Gupta Manager post vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Penlee DS0000020337.V377962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 29 persons requiring nursing care Staffing Notice dated 23/04/02 applies. Manager must be a RN on part 1 or 12 of the NMC Register The provision of one interim care bed for service users 50 years and over. 8th May 2009 Date of last inspection Brief Description of the Service: Penlee is a Victorian building renovated in 1992 situated along from the main sea front and overlooking the Weston Golf Club. It provides nursing care for up to 29 older people. The building and décor is of a good standard providing a comfortable and homely environment. Accommodation is provided over three floors with a passenger lift giving easy access to all floors. There are twenty-three single rooms, and three that may be shared. Eighteen of these have en-suite facilities and all have a call bell system. Communal space is provided in a lounge and dining room in the main building, and a conservatory. This looks out onto an enclosed garden with a feature fountain. Provision is made within the home for some activities and outings, which also enable close links with the local community to be maintained. All local facilities are within easy walking distance but some are closed in winter. The enclosed garden allows for good weather activities outside. Garden furniture is provided. Dr and Mrs Gupta have owned Penlee for many years. They are very involved in the day-to-day running of the home. They make information available through a brochure about the home that incorporates key information from the Statement of Purpose and Service User Guide. CQC reports are displayed in the entrance to the home and available for all to read. The fess range from £545 - £650 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and some transport. This information was provided in September 2008. Penlee DS0000020337.V377962.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 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection took place over 6 hours on one day. Manager, Ms Pauline Rodman was present throughout. The Registered Before the inspection we reviewed all regulatory activity undertaken since the last inspection, and all information we have received in that period. This informed our focus on the key standards. The last two inspection reports were reviewed, as there has been a Random Inspection to follow-up on issues raised at the last Key inspection and to check compliance with the Statutory Requirement Notice issued in respect of safe recruitment practices. At this inspection the home was seen to be compliant with this requirement. The completed Annual Quality Assurance Assessment (AQAA) form, from the provider was also reviewed. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We (The Commission) also reviewed all correspondence and regulatory activity since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included discussions with eight residents, two relatives, and seven staff. Practices were observed and documents relating to care, and health and safety were reviewed. Of the two resident surveys returned, both were satisfied with the care they receive and said the home is clean and fresh. Comments from residents were “I am very happy they do all they can”. No areas of concern were raised. The staff surveys returned told us the home has a “friendly atmosphere between staff and residents”. “Since the last inspection there is better communication between staff”. A concern raised was the need for “improved leadership from the management for the running of the home”. All residents and relatives spoken with told us that the home was good and the staff very kind. Comments received were “it is homely and comfortable”; “my relative is happy and settled”. Penlee DS0000020337.V377962.R01.S.doc Version 5.2 Page 6 What the service does well: This is a family run home with a friendly atmosphere. Residents’ relatives and staff all appreciate the day-to-day input of Dr. and Mrs Gupta. Outcomes for the residents are positive in the main. For example five residents spoken with said, “the home is nice, the staff are kind and caring.” A good rapport between staff and residents was observed. The staff work hard to ensure the well-being and comfort of the residents’ and treat them with respect and kindness. Meals are varied, healthy and nicely presented offering choice and variety. Residents feel that if they had something to complain about they would speak to a member of staff. Penlee provides a homely and comfortable environment for residents. It is decorated and furnished to a good standard and there are some homely touches. There is a relaxed atmosphere and relatives tell us they are always made to feel welcome. What has improved since the last inspection? The home have worked hard since the last inspection to meet the requirements made. Care plans have been reviewed and their format changed to provide a more comprehensive and clear way of communicating the care needs of residents, and actions that are being taken to address them. Staff have received training in care plan use and writing, and we are told they are more widely used to inform practice. They continue to need attention to improve the information recorded as gaps in necessary information were observed during the inspection. Risk assessments are now well completed with clearly stated actions to minimise risk for the safety of the resident. Staff have received training in manual handling and safeguarding and satisfactory practice in these areas was observed. As mentioned above safe recruitment practices are now being undertaken to protect residents. The management have revised their approach to training and staff have undertaken a variety of mandatory and specialist training since the last inspection. A system for recording and ensuring staff attend, together with the Penlee DS0000020337.V377962.R01.S.doc Version 5.2 Page 7 provision of practical sessions has been implemented, to ensure staff have the skills and knowledge to meet residents needs. Record keeping and communication of needs and how they are to be met has improved, however there is room for further improvement for the safety and well being of residents. All fire doors inspected closed flush to frame for the safety and protection of residents. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Penlee DS0000020337.V377962.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 Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s assessment process, while person centred in the main, is not clearly completed to show how the home is able to meet residents’ needs. EVIDENCE: As there had been no new residents admitted to the home since the last inspection, we were not able to review the assessment process to ensure it contains all necessary information on which to ensure the home can meet the resident’s needs. This requirement will be carried forward and inspected at the next Key inspection. The documentation has been revised since the last inspection and the service now have a written format for ensuring prospective residents, relatives or professionals know the outcome of the assessment and why. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 10 People said they had been offered the opportunity to visit the home before moving in on a permanent basis. The manager told us people are welcome to stay in the home on a trial period, to ensure they settle into the home and are happy with the service provided. In the recent Quality Monitoring surveys to residents’ and relatives about care provision in the home the following was reported by the manager “We have looked at the results of the survey and it has been noted that the area in which we have scored poorly surrounds the admission process with many of you (or you’re relatives) not having received enough information regarding the home prior to admission. We plan to overcome this by introducing a more in depth pre-admission form which will enable us to ensure that we can meet the needs of future service users prior to admission.” Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents care needs are documented in a person centred manner, and staff are aware of these needs and how to meet them. The system in place for the management of medicines is satisfactory and provides all the safeguards necessary for the protection of residents. People are treated with dignity and respect. EVIDENCE: Care provision for residents at Penlee has improved since the last inspection, and staff demonstrated awareness of the individual needs of residents and how best to meet them, for their health and well being. Staff interviewed were able to identify the care needs of residents spoken about, and did talk about greater involvement in the care plan recording and use to inform their care provision. Two care plans were inspected and while they contained more information than previously there were still gaps in key information necessary to provide wholly person centred care. The manager acknowledged they were aware of this and Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 12 is working with the staff to complete the information. We discussed the need to ensure this information is recorded on admission or soon after to ensure residents are provided with appropriate person centred care to meet their needs. It was evident that the manager and staff have put in a lot of work to provide well informed care plans. The Key Worker system has been reviewed and all members of staff are now providing greater input to the care plans, which should help with consistency of information. Residents spoken with told us they are happy at the home and felt their needs are being met. Two members of staff interviewed were able to describe the resident’s needs and appropriate action to meet those needs. All care plans contained information about the individual’s personal details, their next of kin, likes and dislikes and risk assessments. In one care plan there was a good practice entry where information regarding an assessment for Depravation of Liberty was recorded and signed. All care plans were signed and dated by staff, and the resident or their relatives evidencing their involvement with care provision. In one care plan there was no information about the next of kin and the section of the care plan regarding social interests/hobbies stated “not applicable”. In the same care plan the section about expressing sexuality (appearance / behaviour) had been left blank. These gaps in information prevent the staff from providing full person centred care to meet the resident’s needs. Staff should obtain and record clear information about the individual to ensure they can appropriately meet their needs. A second care plan contained good information about physical needs and how to meet them. A specific record has been commenced for monitoring the skin of those at risk of developing pressure sores; this contained good information in the one seen and cross referenced well to the actions in the care plan, ensuring a consistent approach to care provision. The information was not signed for accountability purposes and this is required. The two care plans inspected showed there are clear follow up actions noted in regard of specific issues to ensure the resident’s needs are being met. Risk assessments are undertaken and issues identified. These identified needs are translated to the care plans to ensure staff are fully informed of resident’s needs, to ensure their safety while promoting independence. Both residents spoken with told us “the staff are very nice and kind”. One resident told us “they are always there for you”; while another resident told us “they look after my needs”. The residents and visitors with whom we spoke said that they were satisfied with the standards of care and felt the staff are good and do their best. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 13 Relatives felt they are kept well informed of any significant issues, and that their involvement is welcomed. Another relative told us that assistance with personal care “is sensitively and discreetly given” for the comfort and well being of the individual. Staff when interviewed were able to describe all the needs of the residents being case tracked, and demonstrated a person centred approach to care. Evidence was seen of regular visits by the chiropodist and optician, and residents being taken to other appointments as needed, to ensure their health and well being is maintained. Care records showed evidence of resident and relative involvement, and had been reviewed monthly to keep information up to date. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed, offered and responded to. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with eight of the residents confirmed a satisfactory standard of personal care. Two residents said, “it’s homely” another resident said, “people are very kind”. The Medication Administration Record (MAR) sheets had been well completed with no gaps. Hand transcriptions were seen on these sheets and had been signed, as recommended by two people, for accountability and protection purposes to ensure the right dose of medication was recorded. The interactions of the care staff observed demonstrated respect for individuals and their right to privacy. Residents spoken to say, “the staff are very thoughtful and kind and treat you very well”. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Staff interviewed said, “We are all one happy family here”. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ benefit from menus and sometimes routines, that are flexible to meet their needs. Social activities are limited, but residents’ right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcomes relatives and visitors. EVIDENCE: Many residents and relatives commented on the atmosphere of the home. One person described it as informal and homely, and residents’ felt that their visitors are also helped to feel relaxed and at home. When asked about activities we were told “we sing sometimes” and another said “I just sit here”. Two relatives spoken with and responses from relatives in two surveys received told us “there is need for more activities”; “more one to one stimulation would be good for Mum”. There were no notices about activities seen, but inspection of the activities records showed staff have been trying to be more involved in providing activities for residents’ both in groups and on a one to one basis. Records Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 15 showed provision of games, walks and tea parties as well as time spent with individuals reading stories or reminiscing. During the inspection a number of residents were seen just sitting in the conservatory. No other activities were observed to be offered to residents, although we did see a member of staff having a conversation once with a resident in the conservatory. Resident’s social and recreational needs are not being fully met. We saw evidence that the home have tried to recruit an activities person but were let down at the last minute. The manager told us she is aware of the problem and with the provider is actively seeking to recruit to the post to ensure provision, to meet residents’ needs. People who use the service told us they can see their visitors at any time, helping them to feel this is their home. Relatives spoken with told us they feel “welcomed” when they come, and that “there is a warm, caring feel to the place”. The dining room is homely and tables well presented providing an atmosphere that is conducive to an enjoyable meal. All residents said they liked the meals, and relatives felt a good and balanced diet is provided. Menus inspected verified this as did the meal on the day of inspection. The cook works hard to ensure residents’ choices and preferences are met and choice is always offered at every meal. During the inspection residents’ were seen with access to cold drinks at all times, with tea and coffee being offered at the usual times. Since the last inspection staff have received Food Handling and Hygiene training to ensure they have the skills and knowledge for the protection of residents from poor practices and potential infection. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are confident they are listened to and their requests acted upon. Staff have a clear understanding about how to safeguard residents from abuse. EVIDENCE: The home has a comprehensive complaints procedure and all residents have a copy of it. There have been no complaints since the last inspection. Residents stated that if they were not happy about anything they would speak to the manager or provider. Three residents said that the provider and staff are very approachable and they would always raise any niggles with them. The two relatives spoken with felt their concerns were listened to and acted upon. Bed rails and recliner chairs were observed in use for residents; and consent for the use of these had been obtained from either the resident or through a best interests meeting as recommend under the Mental Capacity Act 2005. Evidence of the latter was seen in one care plan but not in another. This practice must be consistently followed to ensure the safety and protection of residents. The manager showed us evidence of her booked place to undertake training in the application of the Mental Capacity Act 2005 for the safety and protection of Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 17 residents. In discussion with the manager she informed us that she would cascade the learning to the staff team through a staff meeting. The home has a copy of the North Somerset ‘No Secrets’ guide and an abbreviated local policy/procedure for the home specifically for responding to allegations of abuse. Since the last inspection staff have received formal training regarding Safeguarding Adults and how to whistle blow should the need arise. Staff when interviewed were aware of the policy and how best to respond to any allegations or incidents, should they occur for the protection of residents. Since the last inspection both the management team and the staff have reviewed their understanding of the reporting and handling of Safeguarding issues and demonstrated clear knowledge of the policy guidelines and how to follow them, should the need arise, for the safety and protection of residents. Staff when interviewed told us they felt “everyone is pulling together more”; “there is better communication and leadership now”. All felt they would feel confident to whistle blow should the need arise. All residents said, “The staff are very kind and take time”. “I can’t fault them”. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. Satisfactory Infection Control practices are followed. EVIDENCE: The home is nicely decorated and well maintained with a welcoming atmosphere, and made comfortable with homely communal spaces. All rooms are provided with vanity units or en suite facilities. Residents’ rooms are personalised and comfortable. The home was clean and free from offensive odours throughout. The laundry facilities were organised to minimise potential cross infection. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 19 Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Dispenser soap and paper towels have been provided in communal areas, thus providing good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from staffing levels that are adequate to meet their needs and are protected by robust recruitment practices. Residents benefit from staff that are trained and competent to do their jobs. EVIDENCE: The staffing rotas for the two weeks prior to the inspection were reviewed. Staffing levels appear to provide sufficient care staff to meet residents’ needs. A good team of ancillary staff supports them. Residents reported, “staff don’t always have time to stop and chat”. Staff approached residents with directness, openness and consideration. Each of the residents with whom we spoke said, “the staff are very good”. Relatives spoken with told us they found the staff “welcoming and friendly”. In discussion with the manager she informed us she felt that staffing levels were more than adequate to meet the needs of residents. Three staff when interviewed told us there are enough staff to meet the needs of residents. Staff interviewed said they are kept busy, but still have time to chat with the residents. Person centred interactions were observed with staff taking care to Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 21 ensure the residents needs and wishes had been met, before moving on to their next activity. Call bells were answered promptly during the inspection. A few of the staff team employed at the home are from overseas. Residents and staff said, “we are all one family”. One comment received told us language difficulties can be a problem and lead to different understandings and practice. The manager told us this has been addressed with staff through discussions and sample care records, to ensure there was no misunderstanding of residents needs for their wellbeing. Since the last inspection a Random Inspection was undertaken in August to ensure the home is complying with the Statutory Requirement made to ensure their recruitment practice protects residents’ from potential harm. The outcome of the inspection was the home had met this requirement within the stated timescale. All staff said “team work has improved since the last inspection and they are all now working together better”. . They also told us there is much more awareness of the need to use equipment, and properly: also “we are all much more involved and there is better communication which is better for the residents”. Comments from residents, and observations of practice during the inspection, verified this. Since the last inspection staff have been provided with the mandatory training required. Evidence of this was seen in the training database inspected. Staff when spoken to confirmed they had undertaken the training and demonstrated good knowledge and understanding in the areas of Manual Handling, food hygiene, fire precautions, infection control and safeguarding adults, thus ensuring that residents are cared for by competent and knowledgeable staff. They have also undertaken some specialist training e.g. dementia awareness and equality and diversity which we were told was very helpful and has enhanced their care provision for the residents. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has satisfactory management systems to check the facilities and quality of services provided, to ensure the home is run in the best interests of residents and for their safety. EVIDENCE: Dr and Mrs Gupta have a number of year’s experience of caring for the elderly and running Penlee. The manager has been in post for 18 months; however she is not yet registered with the Commission so we are unable to fully comment on her suitability to manage the home. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 23 Dr and Mrs Gupta are around daily in the home and support the manager in running the home. They together with the manager seek to give leadership, guidance and direction to staff to ensure they are knowledgeable and competent to meet the needs of people who use the service. We are told that since the last inspection the manager has “developed a back bone and leadership ability”. “The manager was lack a daisical but has improved a lot”. “The home would benefit from improved leadership from the management”. People who use the service and relatives feel the manager is approachable, available and seeks to ensure their needs are met. Three residents spoken with told us the manager is kind and approachable. Two relatives spoken with told us they are confident in her ability to ensure my relative gets the right care now. My relative seems content enough here” Since the last inspection the provider has employed a consultancy firm to assist the manager in understanding and implementing management systems and practices, to ensure the home is run in the best interests of the residents. Evidence was seen of the hard work put in by the staff to ensure the requirements from the last inspection have been met. They now need to continue to work hard to maintain improvements made for the safety and well being of residents. A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents and relatives. Evidence was seen of recent audits of aspects of service provision. Of particular note was the Care provision audit which showed that a number of people were unhappy with the admission and initial care planning of their relatives. The manager told us that she is working to ensure improvement in this area. The home has now developed its systems in order to complete the Quality Assurance processes. The manager now produces an analysis of responses received and writes a report demonstrating how feedback has informed the running and development of the home. See reference to this in the Choice of Home section of this report. Personal records in the home are stored securely and used in accordance with the Data Protection Act 1998. While record keeping has improved since the last inspection a number of records e.g. the care plans, did not have full, accurately maintained and up to date information to ensure good and safe care provision for the protection of residents. This is required for the safety and well being of the residents. Records inspected showed evidence of regular safety and fire checks being carried out. Staff spoken to confirmed they have received fire instruction and Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 24 drills had taken place. All fire doors throughout the home were seen to be shutting flush to frame to protect residents. Penlee DS0000020337.V377962.R01.S.doc Version 5.3 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 X X 1 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 3 X X X 2 3 Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 26 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 OP3 Regulation 14 Requirement The registered person must ensure that a full assessment of needs is undertaken and recorded. To ensure the home can meet the prospective residents’ needs. The registered person must having regard to the needs and wishes of residents provide recreational activities and facilitate them to engage in social activities The registered provider must appoint a person to manage the home and ensure they are registered with the commission for the safety and protection of residents. This relates to the lack of action from the provider and manager to initiate the registration process. An immediate requirement was issued Previous timescale of 31/08/09 not met Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 27 Timescale for action 01/01/10 2. OP12 16.2 01/01/10 3. OP31 8&9 01/01/10 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 OP7 Good Practice Recommendations The registered person must ensure that all care plans contain full and accurate information to ensure residents needs can be met in an appropriate manner for their health and well being. To ensure that all written records are maintained up to date with full relevant information for the benefit of residents’ care. 2. OP37 Penlee DS0000020337.V377962.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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