Inspection on 04/10/05 for 89 Pavenhill

This inspection was carried out on 4th October 2005.

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

89 Pavenhill 21/03/07

89 Pavenhill 16/03/06

89 Pavenhill 22/03/05

89 Pavenhill 24/11/04

89 Pavenhill 19/03/04

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

CARE HOME ADULTS 18-65 Pavenhill (89) 89 Pavenhill Purton Wiltshire SN5 9DA Lead Inspector Pauline Lintern Unannounced Inspection 4 October 2005 th Pavenhill (89) DS0000028555.V253757.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 Pavenhill (89) DS0000028555.V253757.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. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pavenhill (89) Address 89 Pavenhill Purton Wiltshire SN5 9DA 01793 771373 01793 771373 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) White Horse Care Trust Mrs Karen Brogan Care Home 3 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (3) of places Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 3 Only the named, female service user with a learning disability referred to in the application dated 10 February 2004 may be under the age of 65 years 22/03/05 Date of last inspection Brief Description of the Service: 89, Pavenhill is one of 14 care homes that are run by The White Horse Care Trust. The home offers accommodation and personal care to two people with learning disabilities. The building is a detached bungalow in Purton. There are two bedrooms, a lounge with dining area and a garden to the front and rear of the property. There is a shower room with toilet and another toilet is available close to the kitchen area. The service users receive personal care and support throughout the day from a permanent staff team. There is at least one member of staff on duty throughout the day, one in the evening and one sleeping in. The philosophy of care emphasises the importance of an ordinary, domestic type home environment and the involvement of people with a learning disability within the wider community. Each service user is offered a range of daytime and leisure activities and is well known in the local community. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: This is an excellent service and at the time of the inspection all of the standards set by the National Minimum standards were being met. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 6 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. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 7 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 Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 8 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, 4 and 5 All prospective service users have their needs assessed to ensure that the home can provide a suitable service. There is an opportunity for prospective service users to “test drive” the home prior to accepting a placement. Each service user has a contract of terms and conditions with the home. EVIDENCE: Since the last inspection the home has had no new admissions. When sampling the care plans the inspector observed full assessments that had been carried out prior to admission. There was evidence of involvement in that process by external agencies and other professionals. One service user had the opportunity to visit the home and stay for the weekend to ensure that she was happy. The care plan included a consent form for staff to administer medication and a profile of the individuals likes and dislikes. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 9 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, 8 and 9 Service users are encouraged to make choices about their life and how they wish to live it. Service users participate in any decisions to make changes to their individual plan where possible. Staff members encourage service users to be actively involved in all aspects of life in their home. Independence is promoted whilst ensuring that all risks are minimised where possible EVIDENCE: During the inspection staff members were observed offering choices. One service user was encouraged to choose her clothes for the day, whilst being gently reminded that it was colder outside than it looked. One lady chose to have her breakfast in bed on the morning of the inspection. Two care plans were inspected and both contained detailed information. There was evidence that one service user had attended her last review meeting and had been involved in any changes made. The care plans included a summary of medical input. Regular visits to the GP, mobility reports, audiology, dental, podiatry and opticians were all recorded. One service user had a communication profile which identified her preferred method of communicating. Service users have the opportunity to attend the Residents consultation meeting within the home. Minutes from this meeting showed that one Service user had been consulted on all aspects of life within the home. The care plans Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 10 include behavioural guidelines where appropriate. There is evidence that care plans are reviewed regularly. The home has risk assessments in place to enable service users to lead independent lives, whilst minimising any potential risks where possible. There is evidence that all risk assessments are regularly reviewed and dated. The home has a key worker system in place. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 11 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, 13, 14, 15, 16 and 17 This home clearly empowers service users to take an active part in the local community. Service users have to opportunity to access appropriate leisure activities of their choice. Both of the service users have limited contact with family members, however they receive many visitors from the local neighbourhood. Staff members make provision for the service users to have equal rights and opportunities. The home provides a well-balanced menu. EVIDENCE: One service user said that she had attended a course called “Learning to choose staff”. The certificate was on her bedroom wall to show that she had successfully completed the course. The home supports service users to access the local community. One the day of the inspection one service user was going shopping in the morning and later in the day attending a local craft club. The service user said that she had attended a local tea dance with a staff member. The service user showed photographs of a recent holiday to a farm in Poole, which both people went on. Another holiday to Weston-super-Mare has been planned for one service user with one staff member accompanying her. One service user who enjoys music attends a Music Alive Session weekly; the sessions are timetabled within her care plan. Both service users have a Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 12 tracking form which monitors daily living skills and activities attended each month. Both service users attend a day centre on a Wednesday where they often play Bingo and have the opportunity to have their dinner with people at the centre. Each service users cultural needs and spiritual needs are clearly detailed within their plan. There are records, which show that one service user has received regular communion within the home. One service user stated that she had recently had her hair done within the home. The home has its own vehicle to enable staff to support individuals into the wider community. Staff have taken advantage of the local “Blue Badge Scheme” which entitles people to special local parking facilities. This provides easier access for the service users. One service user said that she enjoyed making rugs and showed an example. She stated that she enjoys TV especially “ the soaps”. She confirmed that she decides what she wishes to do. This lady added that she was looking forward to Christmas as they always had a lovely time and she enjoyed decorating the tree and having friends around. Staff members encourage service users to participate in local events such as the yearly carnival. The home has won prizes for its decorated window, which the service users say they enjoy doing. Records showed that one service user had agreed that she would no longer load and unload the dishwasher, but would continue with other household tasks which she enjoys. These include preparing food, clearing away after lunch and tidying the kitchen area. Meals are taken in the lounge area, at the dining table. The menus were inspected and showed to be nutritional and varied. One service user said that she was involved in deciding what food they had and said she thought that the food was “very good”. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 13 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, 20 and 21 Service users are being provided with good personal care and support. EVIDENCE: Care plans examined detailed the amount of support required for service users in relation to their personal care needs. One staff confirmed that one service user liked to do her own personal care with slight supervision from the staff. During the inspection both service users were going through their morning shower routines. The staff member assisting them treated both people respectfully and ensured their privacy at all times. One service user said that she preferred to take a shower as she felt safer than having to get into a bath. Both service users have received an “OK Health Check” this year. A record of this is in the individual’s files. There is evidence of input from the District Nurse. All blood tests are recorded and all medication is reviewed with the GP on a regular basis. There are guidelines in place for the administration of” when required” medication. One service user has recently attended a breastscreening unit with staff support. The recordings off all medical appointments are detailed within the individual’s file. Service users weight is monitored. One staff reported that this has helped to reduce one service users sugar levels resulting in an improvement in her diabetes. All medication records were accurate on examination. The home uses Drug stock sheets to monitor usage. Each service user has a medication box that is Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 14 securely locked away. Risk assessments, policies and procedures are in place to protect service users when dealing with medicines where possible. The Trust has a well-developed policy on death and dying which tells staff what to do if a death occurs. One service user has stated certain hymns she dislikes and would not wish to be used at her funeral. Pavenhill (89) DS0000028555.V253757.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): 22 and 23 The staff team work closely with the service users and are available to listen to any concerns they may have. EVIDENCE: There have been no complaints about this service since the last inspection. The home has a sound complaints policy and procedure. During the inspection staff confirmed that they had seen the Wiltshire and Swindon Guidance leaflet “No Secrets” and were fully aware of the procedure for reporting suspected abuse. The service also has a “whistle blowing” policy in place. One service user confirmed that she would inform the staff team if she was not happy or had concerns. The commission has received comment cards from family members, which confirm that they have been told of the homes complaints procedure. Pavenhill (89) DS0000028555.V253757.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): 25, 26, 29 and 30 The home provides a very high standard of accommodation that is a real home to the people living there. EVIDENCE: The inspection started early in the morning and on entry the house appeared clean and tidy. There were no offensive odours. Staff were observed cleaning the home at the time of the inspection. Both bedrooms were seen and were personalised to each individual. One service user said that she had liked the colour of her bedroom. All furnishings matched and the rooms had a nice fresh feel to them. Personal items such as photos and toys were displayed. One service user said that she “felt safe and did not want to ever move from the home”. A staff member said that the two service users had recently swapped bedrooms to allow for their changing needs. This swap was after consultation and full agreement of the people involved. All radiators in the home have safety covers to prevent accidents to service users. The home has a maintenance log and there is evidence of work being carried out. Both service users use wheelchairs when going out. Records show the wheelchairs are regularly serviced and maintained. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 17 There is a small garden to the rear of the bungalow and a small conservatory area to the side where service users can sit if they wish. Pavenhill (89) DS0000028555.V253757.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): 32, 34, 35 and 36 The staff are well supported by the Trust. The staff team are competent and receive regular training. The homes recruitment policy protects service users were possible. EVIDENCE: There is at least one member of staff on duty throughout the day from the core staff team, one in the evening and one sleeping in. Regular bank staff provide extra support for activities when needed. The home runs an on-call system for support and guidance if required. Staff reported that they felt well supported by the area manager and the Trust in general. One staff member seen during the inspection has just completed her NVQ level 2 in care. One other staff member has her NVQ level 3 in care. Staff reported that they are regularly supervised and receive a yearly appraisal. All records of supervision are treated confidentially in line with Data Protection Act. The inspector observed records and certificates of training received for staff. These included mandatory training such as manual handling, fire safety, first aid and basic food hygiene. There was evidence of refresher training taking place. Other training provided is Abuse awareness, nutrition, drug awareness and induction. One service user said that she “got on well with all the staff team and the bank staff” Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 19 Staff attend regular team meetings. The minutes of the last meeting (Sept 1st 05) showed that both service users needs were discussed in detail along with Health and Safety and any issues within the team. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 20 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 and 42 This home provides a good level of care to service users. The staff team work well together and the needs of the service users are their main concern. EVIDENCE: One well-qualified, competent staff member is acting up as Deputy Manager. She said that she was well supported by the area manager and the Trust. The area manager makes weekly visits to the home and will stay for the whole day. There is documentation showing that service users who are able to express their views have the opportunity to do so. The health, safety and welfare of service users are promoted and protected by the systems in place. There are records of all Fire systems tests (2.10.05) and drills (2.10.05), Emergency lighting tests (1.10.05), 3 monthly fire routines ( 19.7.05) Fire inspection report (14.5.05) and Gas safety Certificate (1.2.05). All electrical equipment has had a PAT test. All required policies and procedures are in place to safeguard the service users as much as possible. The home holds data on all hazardous materials (COSHH), which are all securely locked away. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 21 Accidents are recorded appropriately and stored in line with the Data Protection Act 1998. Fridge and Freezer temperatures are recorded daily Assessment of risk is being managed well and includes good supporting documentation. Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 22 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 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 4 4 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x 4 3 x x 3 4 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pavenhill (89) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x DS0000028555.V253757.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Refer to Standard Good Practice Recommendations Pavenhill (89) DS0000028555.V253757.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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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