CARE HOME ADULTS 18-65
Pendarves (3) 3 Pendarves Road Camborne Cornwall TR14 7QB Lead Inspector
Lowenna Harty Announced Inspection 6th December 2005 09:30 Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 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.V258975.R01.S.doc Version 5.0 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.V258975.R01.S.doc Version 5.0 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) andy.williams@dcact.eu.com Spectrum Andrew Williams Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd June 2005 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. 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. There is an additional, smaller bedroom on the first floor. Downstairs there is a communal kitchen and large lounge. There is an additional lounge, which is currently serving as a bedroom on the ground floor. The home has a communal kitchen with dining area. It is set in its own grounds. 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. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on 6 December 2005 and lasted for approximately four and a half 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. The inspection focused on an inspection of the premises, examination of care, safety and employment records and discussion with the home’s manager. There were opportunities to observe the daily life of the home and staff interaction with the service users. Two of the service users were interviewed. The third was out at their college placement and declined to be interviewed. Service users were very informative about their lives in the home and their concerns. Their comments have contributed to the overall inspection report and have been very useful. The home provides a good standard of care to the service users placed there, subject to specific improvements, which were identified in the course of the inspection. There is evidence of ongoing work to address these. What the service does well:
There are currently three service users residing in the home and no new admissions have taken place since the previous inspection. They were all admitted on the basis of detailed, professional assessments, to confirm that the home would be suitable to meet their needs. Service users are helped to make decisions about their lives and have detailed written care plans, which they help to develop, which consider their abilities to make decisions for themselves and goals they need to achieve to increase their independence. Service users are provided with a range of healthy, home prepared meals. They are encouraged to take part in household shopping, menu planning and food preparation to develop their skills and independence. They prepare their own breakfasts and lunches and have access to snacks and drinks between meals.
Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 6 The home’s manager is experienced and competently manages the day-to-day running of the home. He is currently undertaking training to gain formal qualifications needed to manage a care home effectively. What has improved since the last inspection? There are now records of house meetings held with service users, so that they can discuss problems and contribute to household decisions about matters affecting them on a day-to-day basis. Service now have a greater choice of main meals as there is a stock of home prepared meal alternatives in the home’s freezer, which service users can have if they do not want the main menu choice. Spectrum has introduced improve systems and procedures for managing service users’ medications so that they are better protected from harm due to medication errors. The new procedures allow for service users to manage all or part of their medicines for themselves and one service user has made great progress in doing this, which is valuable in helping them to develop their skills, confidence and independence. There have been some improvements to make the home more attractive and comfortable for service users. A window restrictor in one of the rooms has been painted white, so that it appears less obtrusive and essential plumbing work has been carried out to repair a leaking tap. Spectrum has submitted an application for the home’s manager to be registered with the Commission, which is currently being processed. There is improved evidence that Spectrum’s senior managers are regularly visiting the home to review the quality of the care provided there, and more reports of these visits have been sent to the Commission for external review. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 7 What they could do better:
Written risk assessments, which form part of the care planning process, need to be up-to-date, accurate and agreed with service users, particularly where they contain restrictions necessary to protect service users or others, so that service users are fully involved and consulted on the best ways to manage risks. Service users said that they are not fully aware of their rights to access the home’s records, which contain personal information about them. They must be informed of their rights and helped to exercise them in accordance with the Data Protection Act 1998. Whilst service users were mainly satisfied with the food provided to them, they should be allowed greater choice over the portion sizes for their main evening meals. Staff need to undergo training in the safe handling of medicines and the new procedures for managing medicines in the home so that they are better able to prevent service users from being harmed by medication errors. The revised written procedures to guide them in their practice need to be made available to them at all times. Specific improvements are needed to make the home more comfortable and attractive for service users. The outside of the home still needs to be painted and pot holes in the main drive need to be filled in. Spectrum has already taken steps to repair a sash window frame in a service user’s bedroom and needs to ensure the work is carried out. Service users should be provided with either a private telephone line or mobile telephone facilities to ensure that their private calls are not interrupted by the office telephone. Staff have good access to the home’s manager and senior Spectrum managers for consultation on a day-to-day basis, but they should be provided with more regular formal supervision sessions and team meetings, with records kept, to review their practice and training needs for the benefit of service users. The home’s annual development plan should be shared with service users and their representatives so that they are given feedback on their contributions and are able to make comments about the ongoing improvement of the service. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 8 Spectrum should ensure that reports of senior managers’ visits to the home are sent regularly, each month, to the Commission so that service users can be confident that there is external monitoring of the services provided to them at the home. 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. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 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.V258975.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Admission to the home is based on a detailed assessment to ensure that it will be suitable to meet service users’ needs. EVIDENCE: There have been no new admissions to the home since the previous inspection and there were no current vacancies at the time of this inspection. There is detailed initial assessment information on each of the current service users’ files to inform staff in the ongoing care planning process. The home’s statement of purpose states that admission is on the basis of an assessment. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 11 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): 7 Service users are assisted to make decisions about their lives although improvements are needed to enable them to participate more fully. EVIDENCE: Service users have detailed written care plans, which set out all their personal, health and social care needs and relevant factors concerning their religious, cultural and ethnic backgrounds. Service users participate in drawing these up and are invited to sign them as evidence of their agreement with them. Their care plans consider their decision-making abilities. Service users also have detailed written risk assessments, which set out any necessary restrictions for the protection of service users and strategies for staff to help them to manage risks. These need to be up-to-date, accurate and signed by service users as evidence of their agreement. There are now records of house meetings held with service users, when they are consulted on household matters, which affect them on a day-to-day basis. Service users made specific suggestions for improvement in the course of the interviews held with them during the inspection. These comments have been incorporated into the inspection report. The inspector noted that service users do not appear to be fully aware of their
Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 12 rights to access their personal records under the Data Protection Act 1998. They must be informed of their rights in this respect. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 13 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): 17 Service users have a choice of healthy meals although they should be given more choice about portion sizes. EVIDENCE: There are records of service users’ dietary needs and food preferences on their personal files. Menu plans show that they are provided with home prepared meals and they are encouraged to participate in household shopping, menu planning and food preparation. They are encouraged to eat healthily and take regular exercise to remain physically well. There is now a stock of frozen prepared meals as alternatives to the main menu, should they prefer to have something different. Service users make their own breakfasts and lunches and are able to access drinks and snacks. Service users mainly expressed satisfaction with the food, but should be provided with greater choice over their portion sizes for their main meals. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 14 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): 20 The home’s management of service users’ medicines has improved although further improvements are needed to protect them from harm due to medication errors EVIDENCE: Spectrum has introduced new medication procedures and systems in the home, which allow for service users to take control over all or some aspects of their medication, depending on their individual risk assessments and one service user has been enabled to do this. Record keeping in respect of medication administered to service users has improved. The home’s manager has undertaken training in the safe handling of medicines, but staff require training in the new systems and safe handling of medicines to protect service users from medication errors. The home’s revised medication procedures were not readily available at the time of the inspection and they need to be available to guide and inform staff at all times. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 15 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): 23 Service users need improved protection from abuse, neglect and self-harm. EVIDENCE: Service users indicated that they are mainly well cared for and safe in the home, during interviews held in the course of the inspection. There is evidence now that staff working with them are recruited on the basis that they are suitable to work with vulnerable adults in a care setting. Spectrum’s internal procedures for the protection of vulnerable adults from abuse need to be reviewed and updated so that staff are guided by the latest best practice. Copies of the multi-agency procedures for the local authority and service users’ placing authorities need to be held in the home for staff to cross-reference them, should the need arise. The home’s manager should attend local multiagency training in the protection of vulnerable adults from abuse and ensure that all staff are aware of their duties and responsibilities in this respect. Written procedures for the handling and management of service users’ personal finances need to be reviewed and updated to ensure that there is clear guidance for staff and a satisfactory audit trail for service user’s money. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 16 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 The home is generally well maintained, comfortable and homely but specific improvements are needed to satisfy service users that it is suitable for them. EVIDENCE: Service users live in a domestic-style building in a residential area, with good access to local community facilities. It was clean, tidy and warn at the time of the inspection. It is generally well furnished and decorated and there is evidence of ongoing maintenance to ensure that repairs are completed as necessary. The outside of the building has been jet washed, but it still needs to be painted and the home’s driveway needs repairs as there are several potholes in it. An immediate requirement was issued at the time of the inspection for a sash window frame in a service user’s bedroom to be repaired and Spectrum has taken steps to address this. Service users have access to a telephone on which they can make calls in private, but the line is shared with the home’s office. They should have either a private line or the option of the use of a mobile telephone to ensure that their private calls are not interrupted. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 17 Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 18 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): 36 Staff should be provided with more formal supervision so that their care practices are regularly monitored, reviewed and improved. EVIDENCE: There is some evidence, from supervision records that staff undergo formal 1:1 meetings with the home’s manager to discuss their care practices and training needs, but these need to be held more regularly and should be at least every 6-8 weeks. There are records of some team meetings, but not of regularly held meetings. They should be more frequent so that staff are well informed about service users’ needs Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 19 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, 39 & 43 The home is well run for the benefit of service users living there, but the manager needs to register with the Commission so that service users can be confident he is fit to undertake this role. Systems for reviewing and improving the quality of care need to be improved so that service users can be more confident that the home is run in their best interests. There needs to be more accountable management of the home and service. EVIDENCE: The home’s current manager is experienced in working in a care setting and has submitted an application to the Commission to be registered as manger. He undertakes regular training to update his knowledge and skills and is in the process of undergoing training to obtain formal qualifications needed to effectively run a care home. Service users are consulted formally and informally on the quality of the services provided to them and they indicated that they are mainly satisfied,
Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 20 although they mentioned specific concerns. The home’s manager has drawn up an annual development plan for the home, but this needs to be shared with service users and their representatives. Spectrum is a registered company and a charity and sends copies of its annual report to the Commission each year. Senior managers from the organisation visit the home regularly and now sent copies of reports of these visits to the Commission more often, but they should do so every month, so that service users can be confident that there is some external oversight of the home’s management of their interests. The current manager has now submitted an application to the Commission to be registered as manager for the home, which is being processed. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Pendarves (3) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X 2 DS0000009115.V258975.R01.S.doc Version 5.0 Page 22 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. 1. 2. Standard YA7 YA7 Regulation 12(2) 12(2) Requirement Service users’ risk assessments must be up-to-date, accurate and formally agreed with them. Service users must be informed of and enabled to exercise their rights to access their personal records in accordance with the Data Protection Act 1998. Staff must undergo training in the safe handling of medicines. The home’s written procedures to guide staff on medication management must be available to them at all times. There must be robust systems in place to ensure that service users are protected from abuse, neglect and self-harm, in line with current best practice. A broken sash window must be repaired and repainted. Timescale for action 01/04/06 01/04/06 3. 4. YA20 YA20 13(2) 13(2) 01/06/06 01/01/06 5. YA23 13(6) 01/04/06 6. YA24 23(2)(b) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 23 No. 1. 2. 3. 4. Refer to Standard YA17 YA23 YA23 YA23 Good Practice Recommendations Service users should be given greater choice about the portion sizes of their main meals. The home’s written procedures for the protection of vulnerable adults from abuse should be reviewed and updated. Staff should be provided with access to local multi-agency training on the protection of vulnerable adults from abuse. The home’s written procedures for the handling of service users’ money should be reviewed and updated to provide clear guidance for staff and a satisfactory audit trail in respect of service users’ personal money. The outside of the building should be re-painted. The home’s driveway should be repaired. Service users should be provided with improved facilities to make telephone calls in private, without the risk of interruption by the office telephone. Staff should be provided with regular, recorded individual supervision and more regularly held staff meetings. Service users and their representatives should be provided with copies and consulted on the home’s annual development plan. Copies of monitoring reports on the home from Spectrum’s senior managers should be sent to the Commission regularly, each month. 5. 6. 7. 8. 9. 10. YA24 YA24 YA24 YA36 YA39 YA43 Pendarves (3) DS0000009115.V258975.R01.S.doc Version 5.0 Page 24 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
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