Inspection on 21/03/06 for 16 Pendean Court

This inspection was carried out on 21st March 2006.

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

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

Other inspections for this house

16 Pendean Court 02/08/06

16 Pendean Court 15/02/05

16 Pendean Court 08/09/04

16 Pendean Court 03/03/04

Similar services:

5 Seafield Road

Honeybourne House

Longrun House

Bodley Community Care Support Centre

Thomas Pocklington Trust

Chantry Gardens

Penkelly House

25-27a Alexandra Road

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Pendean Court (16) 16 Pendean Court Liskeard Cornwall PL14 6DZ Lead Inspector Mike Stokes Unannounced Inspection 21st March 2006 10:30 Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pendean Court (16) Address 16 Pendean Court Liskeard Cornwall PL14 6DZ 01579 340201 01579 344410 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Royal National Institute for Deaf People Care Home 8 Category(ies) of Sensory impairment (8) registration, with number of places Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Some service users may have an additional Physical Disability (PD) or Learning Disability (LD) 18th September 2005 Date of last inspection Brief Description of the Service: The Royal National Institute For Deaf People are registered in respect of Pendean Court to provide accommodation and personal care for up to 8 adults with a sensory impairment. Pendean Court is a detached building with well-maintained grounds, situated in a residential area of Liskeard. The home is close to local shops, community facilities and public transport. The care home is purpose built with all service users bedrooms and shared communal facilities provided on the ground floor. The home provides level access to assist service users that may have a physical disability and specialist aids and adaptations are provided throughout the building. Service users use a vibrating pager system and flashing lights provide visual alarms for fire precautions and doorbells, minicom telephone systems, mobility aids, hoists and adjustable sinks in bedrooms are provided. The landlord of the building is Habinteg Housing Association and a programme of general maintenance is provided. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection to review the standards of care provided at the home. I arrived at 10.30 am and the inspection finished at 4.30pm. I was assisted by the RNID Service Manager to discuss developments, review records held in the home, meet service users, staff and inspect the homes facilities. I have also had access to written responses from 2 relatives, 2 service users and a community project worker involved with the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. The RNID is providing information and detailed pre admission procedures to ensure that appropriate admissions are made at Pendean Court. EVIDENCE: Pendean Court is registered to accommodate 8 service users and the service manager stated that the RNID is reducing this maximum occupation to 7 service users. There are currently 5 service users living at the home and 2 referrals have been received as part of the pre admission procedure. Pendean Court is a specialised facility and service users may travel from other local authorities to access this service. The RNID policy and management manuals provide detailed assessment procedures to ensure that liaison regarding complex care needs is required to facilitate appropriate admissions. Records show that visits to the service users home and introductory visits to Pendean Court have been arranged to complete a detailed assessment and assist with the planned admission process. The RNID Placement Agreement is made involving the funding authority and was seen on a service users file. A discussion occurred to ensure copies of the service users Tenancy Agreements are on file to complete information available to service users and their advocates. Service users have received their guide in an appropriate format assisted by their key workers. The service manager stated that due to improvements to the facilities and various changes occurring at the home a revised statement of purpose and guide would be provided by the RNID. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 8. All service users have been involved in recent assessments of need and reviews of care with funding authority care managers, advocates and localised specialist support services to ensure appropriate services are provided. EVIDENCE: Various complaints were received in 2005 regarding the welfare of service users and these resulted in ‘Protection Of Vulnerable Adults’ procedures being organised. This directly led to each service user receiving an assessment of need and reviews of care that have involved their funding authority representatives, advocates and other localised specialist support services. A service user that had lived in the home for many years has recently been assessed as requiring nursing care and has transferred to an RNID facility. The records for 2 service users were inspected. The records involve various components that include a care plan with reasons for care, a method of approach to meet these needs and risk assessments. The contact sheets also provide an important communication record of staff daily and weekly observations and relevant events. A discussion occurred regarding the progress of these procedures as part of the agreed action plan and the service manager agreed that the system used will be reviewed to update all plans and presented in a format that will provide for the inclusion of the service users. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14 and 17. Service users are consulted to record their preferences regarding the various areas of their lifestyle. EVIDENCE: Service users were observed to relax in each other’s company in the communal areas and individually in the privacy of their own rooms. Service users have appropriate locks on the door to their rooms and support staff use a flashing light system to inform the service user that they are outside. One service user can access community facilities independently in an electric wheelchair and other service users require support to access community facilities with the homes transport that has a tail lift facility to accommodate wheelchair users. The support staff and records confirmed that service users enjoy a range of activities including Duchy College, shopping, Liskeard Sports Centre, Echo club, trips to places of interest, contact with relatives and holidays. A bedroom has been converted to an art and activity room and a service user was seen to enjoy the use of this area with support staff. Service users participate in cleaning their rooms and domestic routines at the home. The support staff are expected to use signing at all times to include service users in communication and meetings are organised to include service Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 10 users, with the aid of symbols and pictures in deciding the menus and preferred activities. A dietician advises regarding health and nutritional issues. A service user has provided a written response to the homes recent survey and being supported by the RNID, states’ I like help and self more, I like help with learn skills and independence’. A written response from a relative regarding the same survey stated, ‘the staff encourage the residents to live as independently as possible and to develop a wide range of skills and abilities. There is a good atmosphere as the staff and residents work together to manage the practical side of daily living’. A written response from a community project worker regarding the same survey stated, ‘ The achievement and enjoyment of activities by each service user has been strengthened by the support and commitment of staff’. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The RNID have provided a senior manager to review all procedures at the home. This service manager has provided formal supervision to all staff and a comprehensive training schedule has been implemented as part of an agreed improvement plan. EVIDENCE: The service users have been involved in comprehensive assessment and review procedures with specialist support staff to ensure appropriate services are provided. Service users are registered with local Surgeries and have access to community nursing services and regular health care support and checks. The service manager is experienced in consulting with the care managers, consultant psychiatrist, physiotherapists, occupational and speech therapists as required by various service users. The medication policy, storage and procedures have been reviewed and are administered appropriately. The preferences of service users regarding support with personal care and outcomes are recorded in plans of care and will be available to on going review meetings with local authority representatives. A specialist communication strategy has successfully been implemented to assist staff in offering a service user with choices regarding personal care issues. The service manager has clarified staff roles and responsibilities in formal and informal meetings at the home to reinforce the need for a consistent approach in providing for the welfare of service users. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The RNID have provided appropriate information and responded effectively to complaints received by participating in multi disciplinary investigations and the implementation of an improvement plan. EVIDENCE: The RNID provide appropriate policies and procedures that are discussed with staff at induction and appraisal reviews. Service users and relatives receive information in the service users guide and a copy of the complaints procedure is displayed in the home. 5 separate complaints were received from support staff during 2005 regarding numerous issues involving the welfare of service users. These complaints were the subject of numerous multi disciplinary protection meetings, staff interviews and investigations that were concluded in February 2006. During this period I conducted unannounced monitoring visits at various times of the day and including weekends. On the last inspection visit 18th September 2005 it was necessary to issue an Immediate Requirement Notice regarding concerns for staffing issues, fire precautions and inadequate communication of care needs. The RNID have complied with these, conducted detailed investigations and produced a comprehensive review of services that include procedures and practise issues for service user welfare, environmental improvements, staff support and development issues and a restructuring of the management team. The RNID have agreed with the previous registered manager to become the deputy manager and a new appointment as manager has been completed. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The RNID have done a substantial refurbishment as part of its development plan; it is providing a safe and comfortable home for service users. EVIDENCE: A tour of the facilities occurred and a service user expressed approval of her room that had been redecorated. The service manager stated that redecoration of bedrooms occurs with the full consultation of the service user regarding colour schemes and design. The RNID has recently refurbished the entrance lobby, all corridor areas and communal lounge space through painting, carpeting throughout and new furniture. All service user bedrooms are spacious, personalised, offering single accommodation with en-suite facilities. All areas in the home offer level access and appropriate aids and adaptations are provided. The assessments regarding moving and handling regarding service users mobility and assisted bathing has been completed. The managers office has been moved from the first floor to provide access to service users on the ground floor. The vacated area on the first floor is now a staff room, training area and the staff sleeping in facility is adjacent. The conservatory area has new furniture and offers a quiet area for service users and visitors to the home. The laundry room is also refurbished and new tumble and washing machines provided. The plan includes future development of the kitchen and garden areas to enhance services and facilities. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36. The RNID has implemented an effective action plan to ensure that competent and supervised staff are providing for the welfare of service users. EVIDENCE: The recent investigations regarding the complaints received identified tensions and grievances within the staff group. The RNID service manager has provided staff meetings, appraisals and supervision to ensure that support staff understand all local and national policy in relation to the aims of the home, their responsibilities and conflict management procedures. The records of staff appraisals and supervision are detailed with action plans included. The minutes of staff meetings show details of effective communication that concentrate on organisational issues and the positive outcomes for service users. The improvement plan included a comprehensive staff-training schedule that has been complied with. The training records include core elements involving fire precautions, first aid, moving and handling, health and safety and food hygiene. Staff have completed NVQ level 2 and above and 3 NVQ assessors are available. A discussion occurred regarding the introduction of the 12-week induction procedures and a schedule of arranged training has been provided as part of the on going improvement plan. The plan includes British Sign Language that has been identified as a priority to ensure that carers have the opportunity to communicate effectively with service users. Appropriate staffing levels and rotas are provided. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 15 The records of staff recruitment procedures and staff training profiles were inspected and the service manager agreed that these would be reviewed and updated. A written response from another relative regarding the RNID survey stated, ‘I would like to state the facilities are excellent, the rooms are adequate and spacious. The staff are very friendly and kind, they are always willing to help my daughter. We are happy to know that in the future Pendean Court would be incredibly supportive towards her’. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. The RNID has provided effective senior management to give leadership and direction to this facility. The application to register a new manager should be submitted to this Commission. EVIDENCE: A new manager with appropriate experience and qualifications as an NVQ assessor, the NVQ level 4 and Registered Managers Award has been recruited and will receive an induction to the RNID. The application to register with this Commission should be submitted at the earliest opportunity. The service manager continues to provide line management and has managed the improvement plan effectively and completed detailed monthly reports on the conduct of the home. The development of quality assessment procedures is recommended. The RNID has provided for the provision of moving and handling training, a written fire precautions risk assessment, the regulation of water temperature and risk of Legionella, the provision of mixing valves on hot water outlets to prevent scalding, the evidence of portable appliance test and 5 year wiring checks. Habinteg Housing Association provide various repairs and maintenance of boilers and other electrical equipment. Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 2 X X 3 x Pendean Court (16) DS0000009208.V263281.R01.S.doc Version 5.1 Page 18 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA6 Good Practice Recommendations The registered person should review the statement of purpose and service user guide to reflect recent changes. The registered person should review and develop individual plans for treatment and rehabilitation, describing the services and facilities to be provided and how these will meet current, changing needs, aspirations and goals. The registered person should review the recruitment records available for inspection in the home. The registered person should review the staff training profiles to demonstrate individual records. The registered person should submit the application to register a manager with this Commission at the earliest opportunity. The registered person should develop effective quality assurance and quality monitoring systems that are based on seeking the views of service users and stakeholders, to measure success in achieving the aims, objectives and the statement of purpose of the home. DS0000009208.V263281.R01.S.doc Version 5.1 Page 19 3. 4. 5. 6. YA34 YA35 YA37 YA39 Pendean Court (16) Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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