Inspection on 31/01/06 for Pauline Burnet House

This inspection was carried out on 31st January 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pauline Burnet House 07/08/07

Pauline Burnet House 07/08/06

Pauline Burnet House 10/05/05

Pauline Burnet House 08/12/04

Pauline Burnet House 27/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

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 Burnet House 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF Lead Inspector Don Traylen Unannounced Inspection 31st January 2006 10:00 Pauline Burnet House DS0000015101.V260326.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 Pauline Burnet House DS0000015101.V260326.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. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pauline Burnet House Address 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF 01223 424946 01223 420485 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) Cambridge Mencap Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 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 Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by two inspectors on the 31 January at 10 am and was completed at 12:10. The acting manager was present during the inspection. Three service users and five members of staff were at the home for part of the inspection before leaving to participate in heir regular physical and social activities. What the service does well: What has improved since the last inspection? 5 of the 6 Requirements made in the last inspection report for the 10/05/2005 have been met and the remaining requirement to establish and maintain a system to produce an annual quality assurance report is being addressed. The overall atmosphere is one where staff have stated they are happier and are enthusiastic. They stated they felt supported by the acting manager who has been appointed after the previously appointed acting manager left the service. The acting manager is the organisation’s Community Housing Manager and has sufficient and appropriate experience relevant to her temporary role of acting manager. An additional full time member of staff and a deputy manager have been appointed since the last inspection. The organisation has also increased their number of ‘relief’ staff able to be utilised when necessary. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 6 The various files and records maintained in the home’s office were tidy, clearly titled and accessible. An internet facility is now accessible to all staff and progress on recording Care Plans and other documents as ‘Word’ documents is evolving. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pauline Burnet House DS0000015101.V260326.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 Pauline Burnet House DS0000015101.V260326.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): 1, Prospective service users are carefully considered prior to offering a placement and service users are offered sufficient information before agreeing to move to the home. EVIDENCE: Standards 2,3,4, and 5 have been satisfactorily and consistently met at previous inspections. The Statement of Purpose has been reviewed and updated and should include the date of review. The Service User Guide has been updated to include pictorial details of the home and service users, who have been consulted in this initiative. Pauline Burnet House DS0000015101.V260326.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): 7,8, Service users are consulted about the plans for their daily social and physical education. EVIDENCE: During the inspection service users were observed to be consulted whether they wished to go horse riding and had been consulted about the recent pictorial presentation of the Service User Guide. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 10 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, Service users benefit from social and physical exercise and are supported to regularly participate in their different interests. EVIDENCE: The last report identified that 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 and that 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. Three service users regularly visit their families. The Learning Disability Partnership 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. Horse riding and ‘carting’ is another popular pursuit enjoyed by some of the service users. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, Service users are generally protected by the policies and procedures for administering medication, despite the finding concerning this Standard. 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. Two signatures were missing from the medication records sheets and the medication was not in the respective service user’s blister pack. An Immediate Requirement was made in respect of these omissions. The last report remarked that, ‘the process should be risk assessed because of the need for one member of staff to execute this role without interruption.’ In addition to the Immediate Requirement, a further Requirement has been made in this report to establish a safe system to assure that medication administration and their records are accurate. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29,30, The home has a full range of equipment to enable staff to meet service users’ needs. EVIDENCE: The facilities in the home remain unchanged since the inspection report of the 18/12/2002 that considered the home was equipped with facilities appropriate to the service users’ needs. Four service users, two of whom have severe physical needs, share the ground floor specialist bathroom. On the day of inspection the home was warm, very clean and fresh and had sufficient natural light. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, Staff recruitment, their training and team work, protects service users. EVIDENCE: Staff have job definitions and stated they have been issued with the General Social Care Council’s code of conduct. The organisation has recently appointed a Training Manager. New staff undertake a full induction programme and on successful completion are expected to undertake an NVQ level 2 award. At the time of inspection, the acting manager stated that six staff have an NVQ 2 award, four were working towards this award and four new staff were completing their induction. The acting manager stated that all staff have undertaken ‘Protecting Vulnerable Adults from Abuse’ training although there have been delays in accessing the Learning Disability Partnership provided training in Protecting Vulnerable Adults from abuse. The acting manager stated that a member of staff will undertake the ‘Training for Trainers’ project so that training in protecting vulnerable adults can be provided to new staff during the early days of their induction process. The acting manager was reminded of the importance of the induction to include more than an awareness of adult abuse and should include the reporting procedures if abuse were suspected. The acting manager stated there are usually four care staff working when 7 service users are at home. A staff rota showed the planning for this arrangement. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 15 Four staff file were read and each file was well presented and neatly maintained. They each contained very detailed information regarding recruitment procedures: CRBs, two references and a detailed application form and interview process were recorded. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,41,43, The home is well managed although further benefits to service users’ welfare could be achieved through regular monitoring of the medication records. EVIDENCE: Whilst the home does not have a registered manager the organisation have appointed a person to be the acting manager of the home and have kept the CSCI fully informed of their intentions. The CSCI is satisfied the home is well managed and run in the best interests of service users and that staff are supported and encouraged by the acting manager. The home must establish a system for monitoring the Medication Administration Record sheets. The need for this has arisen from an omission in these records that was the subject of an Immediate Requirement being made at this inspection. The acting manager informed the two inspectors she would implement a method to ensure quality of these records. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pauline Burnet House Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 X 2 DS0000015101.V260326.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA20 Regulation 17(1)(a) & Sch3 17(1)(a) Sch 3(3)(i) Timescale for action Medication Administration Record 01/02/06 Sheets must at all times be accurately maintained. The home must establish a 01/03/06 quality assurance system to ensure that medication administration and their records are accurate. Requirement 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 Refer to Standard YA35 Good Practice Recommendations The induction programme for new staff should include more than an awareness of adult abuse and should include the reporting procedures to be adopted should abuse be suspected. Pauline Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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 Burnet House DS0000015101.V260326.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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