Inspection on 10/05/05 for Pauline Burnet House

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pauline Burnet House 07/08/07

Pauline Burnet House 07/08/06

Pauline Burnet House 31/01/06

Pauline Burnet House 08/12/04

Pauline Burnet House 27/07/04

Similar services:

Coopers Mill Ltd

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Paradise Lodge

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Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Pauline Burnett House 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF Lead Inspector Don Traylen Announced 10 May 2005 @ 10:00 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 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 Stationary 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. Pauline Burnett House Version 1.10 Page 3 SERVICE INFORMATION Name of service Pauline Burnet House Address 1 Pippin Drive Chesterton Cambridge CB4 1TF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01223 424946 01223 420485 Cambridge Mencap to be appointed Care Home (CRH) 7 Category(ies) of Care Home only registration, with number Learning Disability (LD), 7 places, both sex of places Physical Disability (PD), 7 places, both sex Pauline Burnett House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08-12-2005 Brief Description of the Service: Pauline Burnett is a purpose built care home that opened in 1992 and is registered to provide for seven people with learning disabilities and physical disabilities. The Cambridge Housing Society owns the building and care is provided by Cambridge Mencap, Edmund House Group of Homes. The building is of the same domestic style as the surrounding houses. It is built on two floors, is spacious and well equipped with aids and adaptations for service users. The home has seven bedrooms, an open plan kitchen, a dining area, and a large lounge and is comfortably furnished. A garden is accessed through French doors from the kitchen dining area. The managers office and the separate staff sleep-in room are located on the upper floor of the home. Pauline Burnett House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection commenced at 10 am on the 10th May 2005. A further inspection visit to the home was conducted on the 12th May at 5.45 pm for 2 hours. During the two inspections all of the service users were seen and a total of 8 staff were spoken to. The Commission did not receive any comment cards from service users or relatives that had been sent to the home. The organisation appointed a new manager who took responsibility from the previous acting manager when he left on the 28th January 2005. What the service does well: What has improved since the last inspection? What they could do better: It is of concern that staff reported they felt bullied by the manager. The manager of the home must provide leadership by example and direction and should motivate and support care staff. The management of the home should support staff so they feel valued and consider the recent resignations and movement of staff from the home so that the quality of care to service users is not affected. Staff must be enabled to report or Whistle Blow their concerns to the organisation. The organisation should welcome complaints to help evaluate their service. Pauline Burnett House Version 1.10 Page 6 The written records must be improved in their presentation and be kept under review. The Statement of Purpose and the Staff roster and training analysis matrix could be maintained in a clearer and tidy format so that they can be read and understood and remain as a record of the organisation’s business. A Quality Assurance system must be effectively applied. The information collected by the home about the comments made by service users, staff, relatives, or professionals, should be collated and analysed so that it can be used to inform potential improvements to the service. Staff should be included in the discussions and decisions that affect improvements. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pauline Burnett House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Pauline Burnett House Version 1.10 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 standard(s) 1,2,3,4, The admission process is a carefully considered process arranged between the commissioning professionals and the home to ensure the service meets the individual needs of service users. EVIDENCE: The Statement of Purpose provided by the manager on the day of inspection was not current and was in need of additional information such as the managers name, the address of the home, a complaints procedure that contains the CSCI details and page numbers. The manager was advised to refer to the National Minimum Standards for care homes for Younger Adults and The Care Homes Regulations 2001 to seek the required information. It is recommended that The Statement of Purpose should contain a reference to how staff are enabled to Whistle Blow on poor practice. The Service User Guide was not available at the time of inspection. However, the Commission had previously received this document on the 15th March 2005, which was in large print and contained symbol format but did not contain a summary of the complaints procedure. It is required that the registered provider ensures that the Statement of Purpose and Service User Guide are kept under review. Five of the service users have lived at the home for over seven years and two service users have lived at the home since mid 2004. Assessment information Pauline Burnett House Version 1.10 Page 9 and care planning detail contained in the service users’ files has been conducted through the LDP and with the involvement of the home. Previous inspections have ascertained the comprehensive and exacting preparations that are applied to admit service users. A comprehensive assessment provided through the Learning Disability Partnership (LDP) has been provided for each of the service users. The home has a history of consultation and working with the Learning Disability Partnership that ensures referrals are made for specialist health interventions when necessary. The home’s capacity to meet service users’ needs was shown by the effective communication skills of the care staff who were observed interacting with service users with differing and complex needs. Pauline Burnett House Version 1.10 Page 10 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 standard(s) 6,7,8,9, Service users express their choices and preferences to staff who support them to take calculated risks in pursuit of their chosen activities. EVIDENCE: The previous report for the inspection described the extensive content of the Care Plans and the involvement of key workers. Two Care Plans were read during this inspection. Not all service users have the capacity to understand their plan of care. The Care Plans were well presented well-maintained and recorded service users extensive needs. A main file with extensive risk assessments and pre-admission information about each service user is kept as well as the active plan of care. For the service users who have their day care commissioned and provided by separate day staff, their daily care is recorded separately and in addition to the home’s Care Plan. Care Plans contained records called “my week” and “my file”, where eating and drinking preferences, sleeping, medication and family involvement and day care have been recorded. It was stated that one service user who chose not to attend a Day Centre was informed by the manager that he could not go out with his carer on that day. Pauline Burnett House Version 1.10 Page 11 It is recommended that consultation with service users in the routine and greater aspects of their lives should be carefully considered and established as a quality assurance mechanism for care planning. It should also be established whether staff may advocate on their behalf if necessary, as their job descriptions state. Pauline Burnett House Version 1.10 Page 12 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 standard(s) 11,12,13,14,15,16, Service users participate in a full and busy lifestyle that ensures that they have opportunities to use facilities in the local community. Service users’ rights are respected by care staff who have demonstrated they will advocate on their behalf. EVIDENCE: Personal development and the continuation of leisure activities and participation in peer appropriate community activities is central to the care planning for each service user. Each service user has an individual plan of care that indicates the leisure activities within their day care and in their chosen activities and holidays. Visits to families are a regular arrangement for at least three of the service users. The LDP who commission care also arrange some of the daytime socio- developmental care through Day Centres such as “Horizons” and “Owl” and social firms offering gardening, woodwork and art therapies. Staff have initiated service users’ meeting. Staff expressed their concerns that the manager has not respected service users’ rights on one occasion when one service user declined to attend his regular day centre and when another service user was reported to have been kept waiting outside of the house. Pauline Burnett House Version 1.10 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 standard(s) 18,19,20 Service users’ wellbeing is maintained with consideration and attention given to their individual health and social needs. EVIDENCE: No service user manages their medication. The procedure for administering medication taken in blister packs from the manager’s office is a dedicated task that needs time to manage. The process should be risk assessed because of the need for one member of staff to execute this role without interruption. Care Plans relate to health and social care and to the individual style of support and approaches provided by staff for each service user. Methods of monitoring and reporting physical needs and personal support are noted on a daily basis by staff and are recorded in daily notes. Pauline Burnett House Version 1.10 Page 14 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 standard(s) 22.23 Service users are not at risk, but adequate arrangements for advocacy and staff training in preventing abuse are not ensured. EVIDENCE: Training plans revealed that not all staff have received training in the protection of vulnerable adults. Training must be provided to all staff and must be part of the induction training offered to new staff. Comments made in the report on “Lifestyle” (Standards 11-17) have reported that staff stated that the manager does not show respect to service users. If staff advocate on behalf of service users and raise concerns, these concerns should be considered as the concerns of the service users and therefore the recommendation made in relation to this should be implemented as soon as possible. The above evidence and the atmosphere reported to exist between staff and the manager does not ensure the protection of service users. Pauline Burnett House Version 1.10 Page 15 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 standard(s) 24,25,26,27,28,29,30, Service users are provided with a spacious and comfortable environment. EVIDENCE: The toilet adjacent to the main entrance was in need of cleaning. The handle of the toilet cistern was loose and in need of repair. The remainder of the home was kept clean and tidy. Four service users, two of whom have severe physical needs, share the downstairs specialist bathroom. Five service users rooms had been personalised with their possessions. The facilities in the home remain unchanged since the inspection report of the 18/12/2002 that considered them to be appropriate for the service users’ needs. Pauline Burnett House Version 1.10 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36, Service users are provided appropriate and person-centred care despite the low morale felt by staff. EVIDENCE: Staff reported their lack of confidence in the manager’s ability to support them in their role. Staff also expressed feelings of intimidation by the manager. One member of staff reported the managers’ attitude felt like “bullying”. Service users have not been affected by the low staff morale, but the evidence suggest they are not gaining any benefits from an unhappy staff team. Two staff have resigned since the last inspection in December 2004. Staff reported that recent staffing re-arrangements have caused some deterioration of staff morale. From the discussions with staff it is recommended that senior management consult with staff about their concerns as soon as possible. Staff confirmed their training is appropriate and they can make enquiries about additional training. Two staff have achieved level 2 NVQ awards. It was discussed with one care worker that particular internet websites provide valuable information and that the home should have access to the internet to help inform staff of current affairs and legislation relevant to their work. Pauline Burnett House Version 1.10 Page 17 The seven service users have a variety of complex needs and are assessed for high dependency needs. Two service users have severe physical and learning disabilities that determine they each have two care staff at all times. Four service users use wheelchairs and six need prompting and assisting at meal times. All service users have specialist communication needs. Therefore a minimum of four staff is needed when seven service user are at home. The manager stated that four staff are always on duty when the seven service users are at home. However, one member of staff stated that there have been occasions when only three service users have been on duty. Two requirements have been made in relation to Standards 33 and 35. Pauline Burnett House Version 1.10 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40 Service users and staff are not benefiting from the leadership and management of the home. There is a risk that the quality of care to service users will be adversely affected. EVIDENCE: Staff reported they considered the manager’s attitude was not conducive to promote good relationships. All staff spoken to stated they felt morale within the home was low and that staff are leaving because of the manager’s approach. The staff roster for May 2005 was read. The roster had been altered and was difficult to interpret. Staff names were not recorded in full, their job title had not been indicated, times of shifts did not indicate am or pm and there was not a code to signify the use of letters One member of staff could not clarify who was working at any time according to the staff roster. The manager stated she had collected comments made by service users, relatives and staff, but had not scrutinised or analysed these comments. The inspector and the manager discussed that a quality assurance system involves collating and analysing comments in addition to using other methods to Pauline Burnett House Version 1.10 Page 19 determine how the service might improve. SCORING OF OUTCOMES Pauline Burnett House Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 3 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 2 x Standard No 31 32 33 34 35 36 Score 3 3 2 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 1 2 2 x x x Pauline Burnett House Version 1.10 Page 21 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 1 Regulation 6 and Schedule 1 Requirement The Statement of Purpose and the Service User Guide must be kept under review and ammended copies must be sent to the CSCI (timescale of 01/05/05 not met) Four staff must be on duty when seven service users are at home. All staff must receive training in the protection of vulnerable adults. Arrangements must be made for all staff to acheive the NVQ level 2 award in care and Learning Disability Award Framework (LDAF) accredited training. The registered manager or the acting manager must establish satisfactory working and professional relationship with staff. The home must establish and maintain a system to produce a quality assurance report that includes the views of service users. Timescale for action 01/08/05 2. 3. 4. 33 35 35 18(1)(a)) 13(6) 19(5)(b) 01/07/05 01/08/05 01/08/05 5. 38 6. 39 12(5)(a) & 9(2)(b)(i) & 18(2) 24 01/08/05 01/09/05 Pauline Burnett House Version 1.10 Page 22 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 6 8 & 14 &16 & 18 Good Practice Recommendations The Statement of Purpose should make reference to the companys Whistle Blowing policy. It is recommended that the inclusion of service users in relation to their lifestyle planning should be established through a quality assurance mechanism and should include care staff who are allowed to advocate on behalf of service users, as their job descriptions state. The home should have an internet connection to help inform staff of current affairs and legilsation relevant to their work. A risk assessment should be carried out on the procedures for administering medication in relation to the practical issues of time, attention and service users needs 3. 4. 32 20 Pauline Burnett House Version 1.10 Page 23 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Pauline Burnett House Version 1.10 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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