Inspection on 07/08/06 for Pauline Burnet House

This inspection was carried out on 7th August 2006.

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

Pauline Burnet House 07/08/07

Pauline Burnet House 31/01/06

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 Dragan Cvejic Key Unannounced Inspection 7th August 2006 10:00 Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pauline Burnet House Address 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF 01223 424946 01223 441768 burnethouse@btinternet.com 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 Julie Rayment Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Pauline Burnett is a purpose built care home that opened in 1992 and is registered to provide care 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 manager’s office and the separate staff sleep-in room are located on the upper floor of the home. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home. It was carried out during a weekday and lasted 5 hours. The main methodology used for the inspection was case tracking. Two service users and a potential user, currently going through the admission process, were case tracked. Staff spoken to was a key worker for a case tracked user. The new manager and deputy manager provided information for this report too. A partial tour of the house was carried out to inspect the physical environment. What the service does well: What has improved since the last inspection? Care plans were much improved and easier to understand and follow in the new format, recently introduced that contain a brief summary of needs and how to meet them. A new medication procedure was introduced and included a pharmacist’s advice and continuous support, through auditing and training for staff. Since the last inspection the manager was offered a permanent post and was registered with regulating authorities. The home employed four more staff and offered better care to service users. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 6 A new system for users’ money was introduced to ensure better protection and accuracy. 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.V306690.R01.S.doc Version 5.2 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.V306690.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carried out a full and effective assessment prior to offering place to the potential user to ensure that they could make a clear and informed choice. EVIDENCE: A prospective service user, currently going through the admission procedure, was case tracked to demonstrate the effectiveness of the admission procedure. His previous care plan was obtained from his previous place of living. His trial visits were also used to identify needs and to make sure that all needs would be met if admitted. All these weekly visits were well documented. The prospective user’s relative was significantly involved in the process. The home organised staff training before the moving in date to ensure the needs would be met upon admission. The current service users were consulted during these trial visits on the suitability of the referred user to the existing setup of the home. The prospective user chose the colour of his future room. The home also ensured that existing daily routine elements that the user wanted to continue with were preserved, such as attending college and a transport arrangement for this. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were in control of their lives through care planning, risk taking and decision making processes that encouraged their participation. EVIDENCE: Care plans with a newly introduced summary were good working documents. Service users were involved in care planning, as well as their relatives, for all checked care plans. Care plans were reviewed regularly. Staff commented that the newly introduced summary of care plans and actions agreed was very good to gain main information and to remind all of set goals for each individual. Service users were encouraged to take part and express their needs, wishes and ideas that would lead to creating goals and the ways to achieve them in care plans. Service users preferences were recorded. A new system for handling service users money was introduced, not only to improve accuracy and safety, but to ensure that users control their money themselves. Service users were involved in the day to day running of the home. There was a users’ representative on the recruitment panel. A user was a member of Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 10 “Speaking up Parliament”. A service user helped in creating a questionnaire for users’ satisfaction. Service users were encouraged to take reasonable risk and continue with self development, as they wished. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from social and physical exercise and are supported to regularly participate in their different interests. EVIDENCE: Service users were encouraged to take part in stimulating activities. A new referral to college was ensured during the admission process. Several users attended college. One user was attending a computer course. Users were supported to be active in the community through education at college, through leisure activities (going to the cinema and carting), through being part of community groups, such as “Speaking up”, or having an advocate when there was a need, as well as through their regular contact and home visits to their families. Service users chose their holiday. One user went to Spain with two staff members. Five users spent their holiday in a specialist hotel in Blackpool. Service users kept in close contact with their families. Family members were regularly visiting them and taking part in the home’s organised activities and Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 12 quality assurance review. 3-4 service users spent regular weekends with their relatives outside the home. Service users were offered keys to ensure privacy in their bedrooms and independence if they wished. Staff were observed talking to service users and sharing the preparation of drinks and snacks. Service users were not restricted on where they go within the home. Risk assessments addressed all limits imposed for safety only. The home had a cleaning and cooking rota and encouraged service users to perform simple housekeeping tasks. Service users had breakfast at the time of the site visit and commented that food was good and that they had a choice. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are generally protected by the policies and procedures for administering medication and health care support provided by staff. EVIDENCE: Two service users explained how they chose chiropody service and were helped by staff to arrange chosen chiropodists for them. Two other users stated that their key workers respected their choice on how much help they wanted for specific tasks. One user’s religious custom was recorded in his care plan and staff spoken to were aware of that. The cultural and ethnic balance of users and staff was maintained. Two staff were observed using the hoist to move a user in a safe and comfortable way. The home arranged for epilepsy training for all staff to ensure service users with this condition were safer in case of deterioration. Medication procedure, storage and administration were checked and were safe and appropriate. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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 the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were protected by a clear complaints procedure, whistle blowing policy and by proper staff vetting prior to employment. EVIDENCE: The home has not received any complaints. A concern expressed to registration authority was investigated and found that it was unsubstantiated. However, some elements related to the previous management that were not easy to resolve, were used to check current provisions and ensure that users were protected and that the service was better. The home kept records of complaints and the procedure was displayed and known by service users. The home introduced a new system for handling service users money. Service users were, initially, encouraged to handle their money themselves, or to have their families responsible for their finances. Staff were properly vetted through the company’s recruitment procedure. A service user was on the interview panel. There were no allegations of abuse and no POVA procedures were initiated. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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 the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was comfortable and had a range of equipment to enable staff to meet service users’ needs. EVIDENCE: The purpose built, well equipped home met the needs of service users. Located in a residential area, it still allowed easy access to local communal amenities. The manager explained the assessed need for a proper snooze room to be installed and continued, saying that she had already presented her proposal within the organisation. A service user chose the colour of his room. The home was bright and clean. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were protected by the company’s recruitment procedure and the home’s compliance with it and with whistle blowing policy. EVIDENCE: The staff rota demonstrated that the home employed sufficient staff to meet the needs of service users. Four staff were covering each shift. One waking staff member and another sleep-in ensured that night needs would also be covered. The manager stated that relief staff were used to cover staff absences, rather that agency staff. On rare occasions when agency staff were used, their CRB and POVA disclosures were checked, as well as their training. Staff were clear of their roles, tasks and expectations. The staffing structure balanced users structure and contained male and female workers. The staff member spoken to presented excellent knowledge of users’ needs and goals set in care plans. She confirmed that she felt confident in her role with appropriate training and support through supervision. Four newly recruited staff also meant better response to users’ needs. Induction training was LDAF tailored. The staff atmosphere and open door policy determined staff high motivation and commitment. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 17 Staff documentation and statements confirmed that training offered was appropriate and equipped them with sufficient knowledge and skills to meet users’ needs. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 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 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): 37,38,39,40,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ safety was ensured by policies, training and methods used in the home, but also with working practice. EVIDENCE: The permanent, skilled and experienced manager was appointed since the last inspection. She was properly inducted into the role and confidently took over management of the home. The staff felt relieved by this appointment and ready to expand the scope of their roles by undertaking delegated tasks. They felt encouraged to express their initiative and creativity. The quality assurance process was carried out by the company’s newly appointed quality assurance officer. She planned facilitating reviews for all company’s homes, including this one, one at the time. Questionnaires were ready to go out to families and relatives. The manager was in the process of reviewing policies and procedures. Some procedures, such as money handling and medication were already reviewed and improved. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 19 Safe working practices were in place and ensured both with policies and current working procedures. Staff training on mandatory courses was up to date. A newly introduced induction programme proved to be more effective and both staff and the management were happy with it. A deputy from this home was part of the group that was working on creating new corporate medication procedure. Accidents/incidents were appropriately recorded, analysed and acted upon to reduce reoccurrence. Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 4 3 X 3 X Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 21 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. 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 Pauline Burnet House DS0000015101.V306690.R01.S.doc Version 5.2 Page 22 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. 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