CARE HOME ADULTS 18-65
Pendarves (3) 3 Pendarves Road Camborne Cornwall TR14 7QB Lead Inspector
Lynda Kirtland Key Unannounced Inspection 5th June 2007 09:15 Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 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 Pendarves (3) DS0000009115.V340470.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 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. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Pendarves (3) Address 3 Pendarves Road Camborne Cornwall TR14 7QB 01209 610827 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) mail@dcact.org Spectrum vacant post Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: 3 Pendarves Road is a home providing accommodation and personal care for up to three adults with a learning disability. The registered provider is Spectrum, an organisation that provides specialist services for people with autistic spectrum disorders. Spectrum employs a manager and a team of staff to run the home on a day-to-day basis. External, on-call managers are available to provide specialist input, support and advice where necessary. The home is located in the town of Camborne, within easy reach of all the town’s facilities. There are shops within walking distance of the home and the home has a vehicle to provide transport for service users who require access to resources in the wider community. The home is a two-storey building, set in its own grounds. All of the bedrooms are large single rooms. One has its own lounge and bathroom. There is a shared bathroom on the first floor. The home has a lockable office on the first floor, which also provides accommodation for staff to sleep in. Downstairs there is a communal kitchen, large lounge, smaller lounge, which is currently serving as a storage area and a communal kitchen/dining room. There is a separate laundry area in which service users are able to do their own laundry. The home does not provide specific facilities for people with physical disabilities, but could be adapted for this, if necessary. Fees are £1500 per week, which excludes variable charges for service users’ personal items, off-site entertainment, dry cleaning, private chiropody and alcoholic beverages. Inspection reports are made available to service users if they wish to see them. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on 5 June 2007 and lasted for approximately five hours. The purpose of the inspection was to ensure that service users’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that service users’ placements in the home result in good outcomes for them. Information received from and about the home since the previous inspection has also been taken into consideration in making judgements about the quality of outcomes for the service users living there. The inspection included meeting with two of the service users currently living at Pendarves Road. Members of staff were interviewed and there were opportunities to directly observe aspects of service users’ daily lives in the home and staff interaction with them. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the home’s manager. The principle method of inspection was “case tracking”. This involves interviews with service users; staff caring for them and examination of records relating to their care. This provides a useful impression of how the home is working for service users overall. Two service users were case tracked in detail at this inspection. Pendarves Road is registered to provide care and accommodation for up to three service users, however they currently provide this service to two residents. The home’s manager, Gemma Morris has been in this post for two months. She is applying to be the registered manager and is in the process of submitting her application to the commission. It is acknowledged that there have been management changes in the home, hence this inspection has identified positive areas of care but there are some areas of improvement needed. What the service does well:
Service users’ initial admissions were on the basis of detailed assessments; to make sure Pendarves Road would meet their needs. Residents’ care needs are clearly set out in individual care plans, which are regularly reviewed with them and their representatives so that they are aware of the goals of their placements in the home. Residents are encouraged to make choices about things that are important to them such as what activities they do during the day, meals and what time to get up in the morning, which was observed during the inspection. Staff support
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 6 them to take managed risks so that they develop their skills and independence safely. Residents confirmed that they enjoy a good quality of life in that staff take them out and help them to access a range of activities in and out of the home that are culturally and age appropriate. They are supported to maintain valued relationships with their families, can make telephone calls to them in private. Residents are given information about their rights and responsibilities as residents, including their rights to consult with advocates outside of the home, if they wish. They are provided with healthy, home prepared meals that are culturally appropriate and account for their individual tastes and preferences. Residents look smartly and appropriately dressed and staff support them to take care of their personal needs as independently as they can. Staff help them to access specialist healthcare services as necessary so that they maintain good physical and mental health. Residents said in the main they felt able to raise any concerns they have with staff and there is a key worker system in place so that they can talk to a nominated person, if they prefer. There is a formal complaints procedure, but there have not been any formal complaints made since the previous inspection. The home was clean and tidy throughout at the time of the inspection and provides service users with a safe and comfortable place to live, in a convenient community setting. Safety equipment is regularly tested and checked to make sure the home is safe for them to live in. The inspector was welcomed to the home in a friendly manner by staff and service users. All were aware of the reason of the inspection. What has improved since the last inspection?
Since the previous inspection the home has improved in the following areas: Purchase of a medication cupboard means medication is stored more safely. This unit should be attached to the wall. Residents and staff confirmed that the staff team are more stable leading to more consistency of care for residents in the home. Residents said that ‘ the staff team are getting better’. The homes manager believes that the majority of care staff have achieved NCQ level 2 or above, although documentation to evidence this was not reviewed. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 7 What they could do better:
The home’s manager has been in post for two months and stated she was unaware if the previous inspection requirements had been addressed. Therefore they have been re notified. These were in relation to: service users need improved information about the costs of their placements in the home and their personal finances so that they are fully informed about their decisions to live there: More staff need to be trained in the safe handling of medicines and so that service users will be better protected from medication errors: staffing at night needs to be reviewed. Other areas of improvement that were identified at this inspection were: Evidence that consultation with service users in gaining their views in who will live or work at the home should be gained. The home manager raised that there has been some difficult in respect of promoting infection control with food. The home’s manager is considering purchasing a residents’ fridge, which will contain snacks and drinks so that residents can have access to this at all, times. Residents said they ‘liked’ this idea and thought it could prevent disagreements in the home. The commission recommend that the home’s manager undertakes a risk assessment and that all avenues are explored before the decision of locking away any food is taken. MAR sheets must be completed on a daily bases to evidence accountability for the administration of medication. The authorisation of PRN medication by an on call manager who does not know the service user should be reviewed to ensure this system is safe. Training in this process should be provided. The kitchen / dining areas need to be reviewed. The residents commented, echoed by staff, that the kitchen area has limited space, which causes a difficulty when preparing food. The trellising which divides the kitchen/ dining area is unattractive and residents and staff both commented that this felt like a ‘barrier’. There is lack of storage space in the kitchen that is outdated and the ding area is sparsely furnished not making them attractive or comfortable areas to cook or dine in. The home’s manger agreed to collate information as to the training that staff had received and how she would address any gaps in essential training. In addition there must be a further review of the risks attached to the employment of a lone worker in the home at night so that residents and staff are not placed at risk. Escorting residents on a one to one base also needs to be updated giving consideration in particular to gender issues. Some issues were raised regarding staff attitude that the homes manager agreed to investigate and inform the commission of her findings. Staff should have copies of the General Social Care Council’s Code of Practice. Supervision of staff needs to commence so that work practice and training issues can be discussed.
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 8 An application by the home’s manager to be considered for the registered manager post must be sent to the Commission without delay. An environmental health inspection should be arranged. A review of the home’s fire assessment taking into account the new legislation should occur. The inspector would like to thanks residents and staff for their assistance during this inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 9 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 Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed and re-assessed, when necessary to ensure that the home can continue to properly provide for their health, personal and social care needs, including their individual and diverse needs. Service users need to be provided with improved information about the terms of their placements in the home, though, so that they are fully informed about their decision to live there. EVIDENCE: A resident had been admitted to the home under an emergency placement. The resident confirmed that due to this he did not visit the home before his admission, but was provided with information about the home. The resident felt ‘satisfied’ with the admission process and commented that staff had been ‘supportive and helped me settle in well’. From documentation-inspected assessments from other professionals were sent to Pendarves Road in order to assist them with their admission assessment process. The residents did comment that it would have been ‘nice’ to meet each other properly before admission, and commented that they felt they had no choice as to who would live at the home as ‘that is Spectrums decision’, ‘it’s a done deal’. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 11 The previous inspection required that residents are provided with information on their fees as this was not present in their individual service users’ guides, which also function as contracts, neither is there clear information on their welfare benefits and personal contributions to the costs of their placements in the home. This requirement has still not been addressed and is therefore re notified to the home. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ care plans address their personal, health and social care needs so that they are aware of the goals of their placements in the home and appropriately address needs relating to their ages, religion and cultural backgrounds, disabilities, sex and sexual orientation. Service users are provided with opportunities to make decisions about things that are important to them and supported to take managed risks so that they develop their skills and independence. EVIDENCE: A resident confirmed that they attend care plan reviews on a regular basis and that their relatives and a social worker are invited to attend reviews. They felt involved in the process and that their views are listened too. Care plan formats are detailed and include specific headings related to residents’ personal, health and social care needs including their individual and diverse needs. Residents, staff and the home’s manager were able to provide examples of how service users are enabled to make choices about things that are important to them including the activities they participate in, when they get up in the
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 13 mornings and go to bed at night and menu planning. Residents care plans contain consideration of their abilities to make decisions for themselves. Residents confirmed they can choose the level of privacy they wish to enjoy in their private accommodation. Residents are able to take managed risks, backed up with written risk assessments and risk management plans, particularly with regard to their engagement in higher risk activities. These set out how staff support residents to take managed risks in order to develop their skills and confidence. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff assist service users to access a range of age, peer and culturally appropriate activities in and out of the home and to maintain appropriate contact with their families so that they enjoy a good quality of life. Their rights and responsibilities are set out clearly for them so that they are well informed about what is expected of them as residents of the home. They are provided with a healthy diet so that they stay well and enjoy their meals. EVIDENCE: Residents gave examples of activities they enjoy taking part in, during interviews held with them at the time of the inspection. Copies of their activity rotas are held on the notice board in the kitchen and their daily care records confirm that they take part in a range of activities in accordance with their individual care plans. Staff confirmed that they help service users to access a range of local community facilities, which their records confirmed. Residents said that they
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 15 enjoy going on trips out of the home and went out on a trip in the afternoon of the inspection. Appropriate transport is provided for them. Residents said they are able to contact their families by telephone in private and that visiting is encouraged. The home’s service users’ guide clearly sets out what residents can expect and what is expected of them in return. It is provided to them in a suitable format so that they can understand it. They are also informed of their rights to access independent advocates if they wish. Residents said that they like the food provided to them at the home and confirmed they are involved in the menu planning. One did query the portions of food provided and this was discussed with the homes manager who is addressing this. Residents were observed accessing the kitchen and are able to prepare their own breakfasts and lunches. They help to plan the main evening meals, which are suitably varied, home prepared and appropriate to service users’ cultural backgrounds and preferences. The manager explained that there has been a difficulty in open access to food especially in the fridge and concerns of infection control. Due to this she is considering purchasing a fridge that can be accessible for residents for snacks and drinks at all times, which in the commissions discussion with residents they said they ‘liked’ this idea. It is hoped by the use of a residents’ fridge this will reduce the infection control risks. The manager wishes to lock the main fridge and the Commission advised that this is risk assessed and that all avenues need to be explored before this decision can be taken. The manager will risk assess this and consult with the Commission as to the action they are wanting to take. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are appropriately supported with their personal care and to access the healthcare services they need so that they can live comfortably and appropriately in a community setting. Further improvements are needed to protect them from medication errors. EVIDENCE: Residents are able to access bathrooms in private and staff guide, support and assist them as necessary, to help them maintain their independence and dignity. Staff have clear written guidance on how residents need and want support, so that they provide assistance appropriately. Residents said they felt staff are sensitive and supportive when undertaking personal care. Residents’ healthcare needs are considered as part of the care planning process and regularly reviewed. Residents confirmed by documentation showed that they access external healthcare providers, including specialists, when they need to. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 17 Since the previous inspection the home has purchased a suitable medication cabinet. This needs to be attached to the wall. Residents do not currently self-administer medication, one said they would like to try this which the homes manager was informed of. The homes manager needs to undertake appropriate risk assessments and ensure that suitable lockable facilities are available before, if assessed as appropriate this can be commenced. Spectrum has a medication policy that was present in the home along with the Royal pharmaceutical guidelines. BNF guidelines were dated 2000 and need to be updated. Since October 2006 the commission has been made aware of three medication errors. In inspecting the medication cabinet it was evident that some improvements are needed to ensure that medication errors do not occur. The MAR sheets must be completed on a daily bases, if a resident refuses medication this must be documented as this shows the homes accountability in offering the medication. It was difficult to undertake an audit of medicines as the MAR sheets did not record the number of tablets it had received and therefore a tablet count of tablets which were not in blister packs was difficult to do. In addition one resident did not have an up to date MAR sheet so there was no records of any medication being administered to this individual. It is of concern that when PRN medication is to be administered outside of 9-5 hours that the manager on call is asked to authorise this. This manager may not know the resident, as they do not manage that particular home for example. Spectrum needs to review if this system is appropriate. Due to this and the concerns around medication errors in Spectrum homes the Commission will discuss with Spectrum management team the quality of the medication training for staff and its accreditation. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Service users have opportunities to make their views known and complaints are taken seriously. There are sound systems in place to protect them from abuse so that they can feel safe in the home. EVIDENCE: Residents confirmed they can make their views known to staff. There is a key worker system in place so that they can discuss any concerns with a nominated individual if they prefer. They are invited to contribute to their care plan reviews and can access the home’s formal complaints procedure if they feel they need to. There have not been any formal complaints since the previous inspection. One resident said that he would like staff to listen to their views more and act on them and would like to see more of Spectrums management team. This was raised with the homes manager who will discuss this with the individual. Written procedures to guide staff on how to protect service users from abuse, neglect and self-harm are posted on the wall in the office, including the local multi-agency procedures. The home’s manager said that she has applied and is on the waiting list for local multi-agency training. In the meantime, most care staff have undertaken internal training with Spectrum. Staff records show they are recruited on the basis that they are suitable to work with vulnerable adults in a care setting and the required checks are made before they commence work in the home. Residents said they manage their own finances. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home’s environment is generally well maintained so service users have a safe, comfortable environment in which they can develop their skills and independence. However improvements are needed to the kitchen/ dining area and a bathroom. The kitchen area has limited space for service users to be able to use this area with staff support safely. The dining area is sparse and not homely, a bathroom needs to be updated to make it more attractive to use. There are systems in place to protect service users from risks due to cross-infection. EVIDENCE: Residents commented that on the whole they are pleased with the furnishings and décor of the home. They were particularly pleased with their bedrooms which they said they had personalised (not inspected) and the communal lounge area, which was attractively furnished. This was also apparent during an inspection of the premises. Residents did comment, as did staff, that there is limited space in the kitchen to be able to prepare foods. The trellising which divides the kitchen/dining area
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 20 was felt to be a ‘barrier’ and the dining area was sparsely furnished. The kitchen units are dated and the kitchen has no drawers for storage. Residents commented that they ‘didn’t like the dining room’. One bathroom was also dated. These areas need to be reviewed. The home was clean and tidy throughout at the time of the inspection and staff have written guidance on maintaining good hygiene in the home. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of qualified staff so that service users can have confidence in their competence and skills. Staffing numbers at night need to be reviewed so that lone care staff and service users are not put at risk. Staff training needs to be reviewed and any gaps in training identified and addressed. The home’s recruitment policies and practices are fair, safe and effective so that service users can be assured that staff are suitable to work in a care setting but they lack regular, formal supervision. EVIDENCE: Since the previous inspection staffing at the home has been more stable thus allowing more consistency for residents. One resident commented that the ‘staff team are getting better’ and felt ‘happier’ that the staff are now more consistent. One resident did comment that they did not get a say in who worked at the home and felt this was Spectrum management’s decision. This was confirmed by the home manager who stated that Spectrum appoint staff, who then have a trial period working at the home from which their appropriateness is assessed.
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 22 The home’s manager confirmed there is a current full time vacancy for one carer. Therefore she has been on shift more and away from management duties. However she felt that she cold undertake her management duties comfortably whilst the home has one service user vacancy. This must be reviewed when the service user vacancy is filled. There is a minimum of two staff on duty during the day/evening on a 5 week rolling rota. Care staff undertakes all personal care duties plus with residents assistance cleaning and cooking tasks. At night one member of staff sleeps in. The home has a lone nighttime working policy. From discussion with staff, reading care plans, and incident sheets the Commission required that the staffing levels on lone working be reviewed urgently. Staff need to ensure that residents are safe at all times and that staff are also protected from possible allegations and take into account gender issues. Resident on the whole were satisfied with the care that they receive from staff. Some issues were raised regarding individuals attitude, which was raised with the homes manager who agreed to investigate this further. At the beginning of the inspection the manager stated that she had not been authorised to enter Spectrums staffing database and therefore was reliant on staff informing her of what training they had/not received. During the inspection authorisation was agreed. The homes manager agreed to prepare an over view of the teams staff training needs and how she would address any gaps in training. The home’s manager said that staff had told her that 3 care staff had a NVQ at a minimum of level 2. She also confirmed that formal supervision has not yet occurred. The home’s staff recruitment records indicate that staff are appointed on the basis of written application forms and equal opportunities interviews. Appropriate checks are made of their suitability to work with vulnerable adults in a care setting. Staff do not have copies of the General Social Care Councils Code of practice and these should be gained. Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home’s manager must apply to the Commission to be registered so that an assessment of her fitness to provide this role is assessed. The home is mainly well managed for the benefit of service users. There are formal and informal systems in place to ensure that service users’ views are accounted for in the day-to-day running and ongoing development of the home. There are systems in place to protect service users from avoidable harm and injury. EVIDENCE: Gemma Morris, the current manager has been in post for 2 months. It is of concern that Spectrum have again changed the management of the home and not applied to the Commission for registration when a new manager is appointed. Ms Morris said she is completing her CRB and will then forward her registered manager application to the commission. In the interim she must forward relevant documentation to demonstrate that she fit for purpose to manage the home to the commission.
Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 24 Residents were complimentary about Ms Morris management style. She is currently completing her NVQ level 3 and is commencing her NVQ 4. She has worked at other Spectrum homes and therefore experience in working in this specialist area. The manager has not undertaken a Quality assurance process yet due to her recent arrival. She was unaware of the whereabouts of the previous quality assurance survey. However it is noted that resident’s views are taken into account in their care plan reviews and on an individual bases. Staff views are discussed at team meetings. Regulation 26 visits also show a level of quality assurance process in the home. The home’s fire safety records were completed and up-to-date. There are records of regular tests and checks of safety equipment and procedures in the home to ensure service users’ safety. It is advised that the homes fire risk assessment is reviewed in line with the new legislation. The home’s manager was unaware, and unable to find documentation as to when the last environmental heath inspection occurred. It is recommended that this be arranged. Pendarves (3) DS0000009115.V340470.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 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 X 2 3 3 X 4 2 5 2 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 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X X 3 Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 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 YA5 Regulation 5(1)(bb) Timescale for action Service users must be informed 31/07/07 of their total fees payable and the method of their payment so that they can make an informed decision to live in the home. This requirement is renotified from 21/09/06 It is of concern to the Commission that this requirement has not been met within the required timescale. Further time has been provided to the new manager to fully comply. Staff must undergo training in 31/10/07 the safe handling of medicines so that service users are better protected from medication errors. This requirement is renotified from 01/06/06 and 21/09/06 It is of concern to the Commission that this requirement has not been met within the required timescale. Further time has been provided to the new manager to fully comply. Requirement 2. YA20 13(2) Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 27 3. YA20 13(2) MAR sheets must be completed on a daily basis to evidence accountability for the administration of medication. The kitchen and dining areas must be reviewed to ensure that they are appropriate for service users use. Staff must be provided with essential training so that they are safe to work with service users, with particular reference to training in emergency aid. 30/06/07 4 YA28 216 (2)(h)(g) 23(2)(b) 18(1)(c) 31/10/07 5 YA33 31/10/07 6. YA33 18(1)(a) There must be a review of the 30/07/07 risks attached to the employment of a lone worker in the home at night so that service users are not placed at risk. This requirement is re-notified from 21/09/06 It is of concern to the Commission that this requirement has not been met within the required timescale. Further time has been provided to the new manager to fully comply. The home’s manager must investigate into concerns raised regarding staff attitude and send her findings to the Commission. The home’s manager application for the registered manager post must be sent to the Commission without delay. 30/07/07 7 YA22 22 8 YA37 8(1)(2) 15/07/07 Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 28 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 YA36 YA5 Good Practice Recommendations Staff should be provided with regular, recorded individual supervision and more regularly held staff meetings. Service users should be given clearer information in their individual contracts about their welfare rights, including how their benefits and any contributions they make are calculated, so that they can make fully informed decisions about their placements in the home. The accessibility of food should be risk assessed ensuring that the promotion of infection control is considered alongside the rights of Service users to access food at any time. Evidence that consultation with service users in gaining their views in who will live or work at the home should be gained. The medicine cabinet should be fixed to the wall An updated copy of the BNF guide should be gained. The authorisation of PRN medication by an on call manager who does not know the Service user should be reviewed to ensure this system is safe. Training in this process should be provided. Specific concerns raised by a Service user regarding staff attitude should be investigated. Staff should have copies of the General Social Care Council’s Code of Practice. An environmental health inspection of the premises should be arranged. A review of the home’s fire assessment taking into account the new legislation should occur 3 YA17 4 5. 6. 7. YA4 YA34 YA20 YA20 YA20 8 9 10 11 YA22 YA34 YA43 YA43 Pendarves (3) DS0000009115.V340470.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon & Cornwall Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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
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