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Inspection on 05/01/10 for Pedros

Also see our care home review for Pedros for more information

This is the latest available inspection report for this service, carried out on 5th January 2010.

it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Pedros The quality rating for this care home is: The rating was made on: two star good service 2 8 1 1 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Jo Mohammed Date of this annual service review: 2 4 1 1 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: Hastings Road Telham Battle East Sussex TN33 0SH 01424775675 01424751641 Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : learning disability Conditions of registration: Hastings and Rother Primary Care Trust Number of places (if applicable): Under 65 Over 65 5 0 The maximum number of service users to be accommodated is 5. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Pedros is an adapted bungalow situated on the main road between Hastings and Battle. Access to bus and rail routes are nearby. The home is registered to accommodate five adults with learning disabilities and challenging behaviour. Accommodation consists of five bedrooms, four of which have en-suite facilities. A fifth residents bedroom would have use of a bathroom close to their room. Communal areas comprise of a lounge, kitchen, kitchenette, bathroom facilities, two laundry rooms, a conservatory and garden. There is under floor heating throughout and all Annual Service Review Page 2 of 7 A new Responsible Individual. 2 8 1 1 2 0 0 8 facilities are at ground floor level. Off road parking is available at the front of the home. In April 2008, Hastings and Rother Primary Care Trust became the registered providers for this service taking over from Kent & Medway NHS and Social Care Partnership Trust. The Hastings and Rother Primary Care Trust manages nine other homes within the Hastings, St Leonards and Rother area. Further information about the services Pedros provides including current fees and Care Quality Commission [CQC] inspection reports can be obtained directly from the home. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? -We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: -The Annual Quality Assurance Assessment [AQAA] that was sent to us by the service. 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. -Information we have about how the service has managed any complaints. -What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. -The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. -Relevant information from other organisations. -What other people have told us about the service. What has this told us about the service? The Annual Quality Assurance Assessment [AQAA] that we took our information from is dated 8th October 2009. This provided good information. In the summary section and other parts of the Annual Quality Assurance Assessment [AQAA] the home identifies what they do well as actively listening to service users views. Providing competent, professional, person-centered support to service users with severe learning disabilities and challenging behaviours. They identify service users physical, emotional and mental health needs are addressed promptly with input from the multidisciplinary team.That service users have a varied and healthy lifestyle with a lot of community presence and strong emphasis on participation. They build links with families, friends, the local community and embrace change. The home recognises the service must continually evolve in its outlook and the support provided. Guidelines and risk assessments are reviewed and updated every six months or sooner. They identify having holistic and person-centered goals in place for each service user. The home identify having a number of recent vulnerable adult alerts and the staff team being professional, demonstrating awareness of reporting and responding to these matters via the appropriate channels and that there has been a reduction in the number of adult protection alerts over the last year. They identify using quality assurance documentation and undertaking audits. Providing safe and appropriate support from a competent and qualified staff team who are clear about their roles and responsibilities. They aim to provide and identify minimum staffing levels at all times. Annual Service Review Page 4 of 7 The Annual Quality Assurance Assessment [AQAA] identifies how the home has improved over the last twelve months by rolling out a new format in respect of how service users person centred folders are compiled, presented making them easier for staff to understand. They say they continue to recognise service users choices in their lifestyles and make changes accordingly by including this information in individual folders. They say they respond to the changing needs of service users promptly and professionally. That there is a staff training matrix in place and staff vacancies have been filled. They continue to follow up with the housing association regarding the completion of works required in the home. They identify how they have made the following changes as a result of listening to the views of service users by replacing the fixed weekly planners with a flexible planner. Preferred activities are said to be in place enabling service users to be more involved in the decision making process. The home is currently working with the Speech and Language team to further enhance communication levels with service users. Service users have had individual communication assessments and the recommendations from these are awaited so that the home can act upon this information. They intend to ensure staff receive training in intensive interaction and Makaton. They identify what they could do better and how they are going to do this by being more vigilant with staff supervisions ensuring they occur on time and have regular team meetings. The Manager is to take over the majority of staff supervisions to ensure the team are supported. They intend to use the complaints format more effectively in respect of works that need to be completed by the housing association. The homes future plans over the next twelve months is such that any planned new admissions will follow a comprehensive assessment with greater emphasis given to the environment, peer group and having a contingency plan in place. They intend to work with the Commissioners and the housing association to put in place an easy read contract for service users and to paint the interior of the home in washable paint and replace the carpets with lino. In respect of equality and diversity the home identifies they listen to the views of service users and meet their requests as far as possible. Three of the service users attend religious services. Equality and diversity training is now in place for all staff members. They identify how they have tried to reduce any barriers to improvement by using agency staff in filling staffing deficits. Ensure the management team have enough management time to carry out and complete all relevant assessments and paperwork. They identify having a successful recruitment campaign with active involvement from Managers and service users. They say the Managers of the homes run by the Primary Care Trust have been re-empowered and work supernumerary in order to enhance service delivery. It is said the budget has been adjusted to accurately reflect a more realistic cost of running the service. They identify giving a service that provides value for money by keeping under review service users challenging behaviours ensuring guidelines, risk assessments, support plans and analysis of behaviours are in place with the aim to teach more appropriate skills in place of certain behaviours. This process is described as demanding in terms of staff skills, management time, assessments and observations. Despite service users Annual Service Review Page 5 of 7 level of challenging behaviour and support required, it is said that high levels of community presence and choice over lifestyles is promoted. That service users families and professionals associated with the home provide positive feedback. The home was last inspected in November 2008 when a key inspection was conducted. Four requirements and two recommendations were made at the inspection. Following the inspection, the home voluntarily provided and produced a detailed response and action plan in respect of how these requirements and recommendations were going to be addressed. Some reference to these and current progress is also evidenced in the AQAA showing how the home are working towards meeting these requirements. The AQAA identifies twelve staff have obtained their National Vocational Qualification [NVQ] in care at level 2 or above and five staff are working towards NVQ level 3. Eighteen staff have completed the Skills For Care induction training. The AQAA indicates maintenance of equipment, health, safety checks and recruitment matters are in order. It was noted there is no date to show when the last certificate for the premises electrical circuit was issued. The data section of the AQAA indicates a number of the homes policies and procedures were last reviewed prior to 2008 including a mixture of much earlier dates. Information taken from the AQAA identifies the Primary Care Trusts policies and legislation are promoted and these are in the process of being reviewed, updated and will be re-issued to the home. The home has identified in the AQAA that over the last twelve months they have not received any complaints and made two safeguarding referrals that have led to safeguarding investigations. From the information held by the Care Quality Commission [CQC] there have been three safeguarding investigations; two of which were referred back to the service to investigate. The other safeguarding investigation is ongoing relating to the death of a service user in May 2009. The Care Quality Commission [CQC] has not directly received any concerns or complaints from other parties. The home appropriately reports notifications about significant occurrences to the Care Quality Commission [CQC]. What are we going to do as a result of this annual service review? We consider the quality rating of the home remains the same since the last key inspection. We will do a key inspection by November 2010 to review our assessment of the home. However, we reserve the right to re-visit this decision if additional information is brought to our attention. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: 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 copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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