Inspection on 07/08/07 for Pauline Burnet House

This inspection was carried out on 7th August 2007.

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 07/08/06

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 Don Traylen Key Unannounced Inspection 7th August 2007 14:00 Pauline Burnet House DS0000015101.V343046.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.V343046.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.V343046.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.V343046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th August 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 a specialist equipped large bathroom as well as a separate shower room and one other bathroom. The environment has been well maintained and 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. Fees range from £906 to £1266 per week. CSCI reports about the home are available and copies can be obtained from the CSCI website. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Annual Quality Assurance Assessment (AQAA) was completed by the home and returned to the Commission prior to the inspection. One inspector carried out the inspection in the afternoon. All people living at the home were spoken to. The manager was available throughout the inspection and the assistant manager was present for part of the inspection and six care assistants were present at various times throughout the inspection. Care plans were read and six of the seven people living at the home were know from previous inspections and have lived a the home for a number of years. What the service does well: What has improved since the last inspection? A new registered manager has been approved. People individual developmental activities have improved. There are more choices and the funding arrangements have allowed the home to be responsive and to manage these needs. Care plans have improved. They have bee represented in a clearer format and in some parts have bee rewritten in a person centred manner. A recent admission to the home had to carefully planned and prepared. The preparation work had not been undertaken by the previous care provider had to be comprehensively reviewed by Pauline Burnet House and arrangements Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 6 for the provision of the Cambridgeshire Learning Disability Partnership (LDP) support services had to be implemented before admission could be finalised. The laundry room has been supplied with two new high specification washing machines. The gardens have been greatly altered by the removal of many of the overgrown trees that prevented light from reaching the building. Further and extensive work to the grounds is planned by the housing association that owns the property. All agency provided care staff are carefully vetted and checked and inducted and agreed, prior to working at the home. The manager has arranged for all staff file to contain details of recruitment as evidence of appropriate recruitment procedures. 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. The summary of this inspection report can be made available in other formats on request. Pauline Burnet House DS0000015101.V343046.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.V343046.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4, Quality in this outcome area is good. People are very carefully assessed and are always expected to make visits to the home prior to making a decision about moving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six of the seven people lived at the home at the time of the last inspection and have lived at the home for a number of years. These admissions have been inspected at previous inspections. One person who moved into the home since the last inspection had been very carefully assessed and comprehensively risk assessed and a large amount of activity and planning had been undertaken before this person could move into the home. The previous care provider had not supplied the home with adequate detail of need or care plan, or any useful recorded detail of the person’s circumstances and care planning. This meant the home had to be cautious and carefully manage the assessment process and arrange for the LDP to become involved, so that there was a comprehensive assessment conducted and that there were appropriate support networks in place prior to the planned admission. A separate file was maintained for Day care and Day Placements. Pauline Burnet House DS0000015101.V343046.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is good. People are assured of good care planning that is centred on the person. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were read and six of the seven people living at the home were know from previous inspections and have lived a the home for a number of years. The care plan of the person who recently moved into the home was very neatly presented in a good format that was indexed with 10 detailed components of care. Risk assessments for Moving and Handling, Epilepsy management and medication had been conducted. Behavioural charts were kept for the psychologist to read. Contacts included an advocate; guidelines for care were written; visiting care professionals had been recorded and monthly reviews had been carried out. A separate file was maintained for Day care and Day Placements. The manager had introduced this style of care plan and all care plans had been converted to this type. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 10 Meeting for and run by people living at the home are held regularly and had been recorded by staff. Pauline Burnet House DS0000015101.V343046.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, Quality in this outcome area is good. People are given opportunities and provided with appropriate levels of support to pursue their personal development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been an increase in the planned activities and choices that people can make for their daytime social and developmental needs because of the funding now given directly to the home to support people in their personal development needs. On the day of inspection five people living at the home were out at their planned daytime activities, or were enjoying recreational pursuits. One other person was out doing some personal shopping. Each person is always accompanied by at least one personal support worker when out following his or her interests. A programme of educational and social stimulating has been arranged with each person and apart from attending daytime courses some interests followed are horse riding and swimming. One person has recently become involved with the Disability Rights Commission Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 12 and is a local representative for a parliamentary arrangement to represent people with disabilities. She informed me that she has become a very active member of this parliamentary group and recently visited the House of Parliament in an educational and social capacity to understand how such an elected system actually functions. She has also participated in an art and craft class and has been successful in painting and has managed to sell some of her work. People lead and active social and family lifestyle whenever this can be achieved. For instance, one person goes home every weekend; another person’s sister is a frequent visitor to the home; another person sees his parents every Sunday; one person goes home top her parents every 3rd weekend. Two people are going to Cornwall for their holiday; someone else is going to Cyprus and two other people’s holidays were being arranged. The home keeps a full record of daily schedule that are planned and agreed with each person to participate in. Three people stated they were pleased with their lifestyle and one person insisted there was more going on in her life than she had previously experienced. Risks are effectively assessed and managed by planned risk taking balanced with personal safety when people are encouraged and supported to participate in the local and wider community. The needs of one young person who moved to the home recently have been risk assessed and planned and completely new arrangements had been made to support him to develop and provide opportunities that he previously did not have. All of the people returned to the home after 4pm when it was observed that care workers demonstrated respect in their attitude and when talking to each person. Care worker expressed an attitude that was person orientated and were aware of the individual opportunities that people should be supported to enjoy. Pauline Burnet House DS0000015101.V343046.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is good. People are genuinely supported to be independent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An advocate has been arranged for one person who recently moved in to the home and another person is a strong self-advocate and is also supported through a very active and local, independent self-advocacy group for people with leaning disabilities. Another person has a National ‘Mencap’ appointed advocate. The previous ‘Lifestyle’ outcome group showed the emotional needs of people are responded to in a positive manner. The care assistants’ also demonstrated this attitudes and actions demonstrated during the inspection. Health services and specialist learning disabilities services are always available for people and their needs are carefully attended to and monitored. A record of people health related needs and any hospital admissions and treatment is evidence that health care is a priority. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 14 No service use manages their medication. Medication records and administration were assessed and medication stocks counted. Medication that is currently taken from the home by relatives when people stay with them for short periods is recommended to be managed by the families having a separate prescribed medication supply, so that the home do not have to give the relative the entire labelled and prescribed medication supply when people go to their family, or relatives homes. This was discussed in full with the registered manager during the inspection visit. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good. People can be assured that any concerns or complaints are responded to in a manner designed to safeguard them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection three staff were attending training in the prevention of abuse to vulnerable adults (POVA). All staff have received training in the protection of vulnerable adults. The home keeps a reference POVA file that contains relevant information about local and national policy and contacts to report concerns of abuse and other sources and contacts to consult. The organisation has a person nominated to provide POVA training that has been agreed by Cambridgeshire County Council as proficient at giving this training. It is recommended this training is delivered to all new care assistants during their first day of employment or before, to ensure that people are assured of being safeguarded and that it is not left to a later stage to be addressed. A complaints book is maintained. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,29,30, Quality in this outcome area is good. People enjoy and benefit from a good environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was in a good state of repair, was well decorated and appeared well maintained. The home was clean and fresh. A domestic worker responsible for cleaning has recently been appointed. The home is spacious and has two specialist hydrotherapy baths installed in the very large and well-equipped ground floor bathroom. Other equipment includes extensive overhead tracking for hoisting purposes. There is another bathroom on the upper floor, as well as a separate shower room. The manager stated there are plans for the lounge to be redecorated. A new snooker table and small football table been purchased and kept in the large Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 17 communal lounge where various musical instrument are played during the music sessions that are facilitated by a visiting musician. Cambridge Housing Association has provided two modern and very essential and efficient washing machines, through the persistence of the manager. The home is spacious and has specialist hydrotherapy baths installed in the very large and well-equipped ground floor bathroom. There is a bathroom on the upper floor, as well as a separate shower room. Work to the garden has been started and the overgrown trees and hedges have been cut down, thus allowing more natural light into the property. Further tree clearance is being arranged so that more garden space will be opened up. Previous inspections have reported the environment as good and appropriate for people’s needs and this factor is consider when assessing whether the home can manage the needs of people who are being considered to move into the home. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, Quality in this outcome area is good. People living at the home are assured of well-trained care staff to support them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were four care assistants and the manager plus the assistant manger working in the afternoon of the inspection when later in the day all the service users were at home. There is a night care assistant plus one ‘sleep-in’ support worker on the premises every night. New care assistants and a new assistant manager have been appointed. The recently appointed manager has become the registered manager. A domestic worker responsible for cleaning has recently been appointed. All staff are trained in epilepsy and in Protecting Vulnerable Adults from Abuse. Whenever agency staff are used they are vetted and agreed with the agency as only named persons whose employment detail and CRB disclosures and training undertaken have been revealed, prior to them working at the home and must also attend an induction programme organised by the home. Some specific one to one training had been arranged for agency staff and this Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 19 included epilepsy, medication and driver training. This is a new initiative by the registered manager to ensure that people are safeguarding and a method of ensuring that competent staff can meet individual needs. All staff have receive training in, ‘Total Communications’, a recording and writing course. The Learning Disability Partnership training department are used as a valuable source of training provision. Two staff files were read. All staff file had been rearranged and contained full details of recruitment. References had been obtained and a full application form completed CRB had been obtained prior to starting employment in both cases. CRB are re-applied for every three years. Training records are kept in the sane staff files. It was noticed that POVA training was delivered approximately one month after starting. As protecting vulnerable people from abuse is an overarching aspect of ALL care and is a mandatory Skills for Care induction topic (and had been delivered within the induction timeframe), it is recommended that the organisation have some training or awareness training available for new staff on their very first day of employment, or before if this can be arranged. Documented staff meetings are regularly arranged. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42, Quality in this outcome area is good. People living at the home benefit from the leadership set by the manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The overall management of the home has improved under the leadership and example set by the registered manager. The organisation’s quality assurance officer carries out surveys and ensures there is some feedback from people living at the home. Regulation 37 reports and regulation 26 reports have been submitted to the CSCI on an appropriate and regular basis. Hazardous substances were kept in locked cupboards. Record of fire alarm checks and fire servicing agreement were read. The home has a range of policies that address health and safety issues and procedures to follow. Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 Refer to Standard YA20 Good Practice Recommendations Medication that is currently taken from the home by relatives, when people stay with them for short periods, is recommended to be managed by the families having a separate prescribed medication supply, so that the home do not have to give the relative the person’s entire prescribed medication. Training in Adult protection should be delivered to all new care assistants during their very first day of employment or before, to ensure that people are always and continuously assured of being safeguarded and that it is not left to a later stage to be addressed. 2 YA23 Pauline Burnet House DS0000015101.V343046.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V343046.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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