Inspection on 30/11/05 for Peartree House Rehabilitation Centre

This inspection was carried out on 30th November 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peartree House Rehabilitation... 28/09/09

Peartree House Rehabilitation... 22/09/09

Peartree House Rehabilitation... 09/07/09

Peartree House Rehabilitation... 19/03/09

Peartree House Rehabilitation... 20/04/06

Peartree House Rehabilitation... 23/06/05

Peartree House Rehabilitation... 17/11/04

Peartree House Rehabilitation... 11/05/04

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

CARE HOME ADULTS 18-65 Peartree House Rehabilitation Centre 8a Peartree Avenue Bitterne Southampton Hampshire SO19 7JP Lead Inspector Jan Everitt Unannounced Inspection 30th November 2005 09:30 Peartree House Rehabilitation Centre DS0000011441.V254751.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 Peartree House Rehabilitation Centre DS0000011441.V254751.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. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peartree House Rehabilitation Centre Address 8a Peartree Avenue Bitterne Southampton Hampshire SO19 7JP 02380 448168 02380 434260 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) Peartree House Rehabilitation Limited Mrs Marie Kelly Care Home 42 Category(ies) of Physical disability (34), Physical disability over registration, with number 65 years of age (8) of places Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom accommodation and nursing care is provided at any one time shall not exceed 32. The 10 service users who are accommodated in the satellite buildings must be need of personal, emotional and living skills support only. Service users in need of nursing care must be accommodated in the main building only. No more than 8 service users may be accommodated at any one time in the category of PD(E) over the age of 65 years. 23rd June 2005 2. 3. Date of last inspection Brief Description of the Service: Peartree House Rehabilitation Centre consists of a large house, 3 two-bedroom bungalows and four self-contained flats within the perimeter of the grounds. The home is situated on the outskirts of Southampton city and is within easy access of Bitterne village and local amenities. The home is registered with the Commission for Social Care Inspection to accommodate 42 service users of both sexes who have sustained brain injury. The service can accommodate service users between the age of 18 and 65 year, though the home has conditions to their registration so that they can accommodate eight service users over the age of 65 with physical disability. Service users who require only personal, emotional and living skills support and have no nursing needs, are housed in the flats and bungalows with a dedicated team who enable these service users to live an independent life suited to their capabilities. Peartree House employs a multidisciplinary team that comprise of an occupational therapy team, physiotherapists, psychologist, speech and language therapist, a rehabilitation consultant, registered nurses and care staff as well as a full housekeeping staff. The atmosphere at the home was pleasant and the internal décor was well maintained and clean Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Peartree House Rehabilitation took place over an eight-hour period on the 30 November 2005. The inspection was prompted by two recent adult protection issues that were reported to the CSCI. The service predominantly provides a rehabilitation service for young adults with acquired brain injury. At the time of the inspection the home was accommodating 40 service users, 32 of which were in the main house and eight accommodated in the satellite buildings that are provided for more independent living. The deputy manager assisted the inspector throughout the inspection process. The registered manager attended the home for a period of time in the afternoon. Dr Oliver Sargent, the responsible individual, was also present in the home throughout the day. The inspector spent time speaking with service users, care staff, nursing staff, physiotherapist, psychology assistant, speech and language therapist and administration staff. The rehabilitation consultant was also visiting the home for the day and the inspector had the opportunity to discuss issues with him. The general consensus from the multidisciplinary team (MDT) is that the home is providing individual programmes of rehabilitation for those recovering from head injury, which is service user focused to meet their needs and aspirations. Owing to the nature of a number of the service users’ injuries and the service users’ ability to respond and communicate with the inspector, the number of service users from which the inspector could gain views of the service was limited. The inspector spoke to a number of service users during the tour of the building. The inspector observed familiar and friendly interactions between staff and service users and effective teamwork amongst the multidisciplinary team. There were no comment cards received from relatives on this occasion and the inspector did not have the opportunity to speak to relatives as there were none available during this time. The general feeling and atmosphere at the home is positive and welcoming. Service users spoken with reported a high degree of satisfaction with their care and the services delivered in the home. The management team report that the home is very busy and that service users are being discharged from the home at increasing rates to more independent living. Sixteen standards were assessed on this visit of which ten were the key standards to be inspected in the current inspection year of 2005/6. Four standards were found to have minor shortfalls and one with major shortfalls. There was one requirement from the previous inspection report and action had been taken to address the three recommendations made in that report. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? The manager has distributed service user and relative satisfaction surveys as part of the quality control system to identify areas of dissatisfaction and allow service users and relatives the opportunity to give their opinions on the Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 7 effectiveness of the service and suggestions for improvement. The results of this survey are not yet available. The Regulation 26 visit reports undertaken by the responsible individual have been received monthly and are more detailed in their content. The home now employs a part-time speech and language therapist. 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. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 8 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 Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 9 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): These standards were not assessed at this inspection. EVIDENCE: Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, & 9 Service users are aware that planned programmes of care and rehabilitation are in place and that they and their family are invited to participate in planning and reassessing as their condition changes. Service users do make decisions about their lives. Service users are supported to take assessed risks as part of their rehabilitation and independent lifestyle. EVIDENCE: Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 11 The inspector viewed a sample of care plans. All information as stated in Schedule 3 of the Care Home Regulations was documented in the care plans. The care planning system in place is multidisciplinary focused and all records can be documented by any one of the multidisciplinary team (MDT). The inspector noted that identified incidents had not been documented in the care plan daily notes and this could lead to a breakdown of communication between staff. A client care profile forms the basis of the information gathering. A full detailed assessment is also received from the placing authority care manager and, in some cases, a detailed report from the discharging hospital unit. These together with a preadmission assessment by the manager/senior nurse, forms the basis of whether anticipated goals are achievable. The multidisciplinary team undertake assessments and risk assessments and from this gathered information, programmes of rehabilitation are formulated. The rehabilitation programme for service users is based on developing independent living skills; communication, emotional and social skills and reaching identified goals. The system is service user focused, with all disciplines involved in the service user’s rehabilitation programme documentation and evaluating the planned rehabilitation and care programmes in one central service user plan. Care plans are evaluated 6 monthly and the service user and/or family can be involved in this process. A multidisciplinary meeting is held every week during which time a number of service users plans are reviewed and discussed and this results in service users having their care plans reviewed six weekly. The service users do not hold their own plans but are consulted on the plan if possible and appropriate. A number of service users spoken with reported that they were aware of their rehabilitation programmes and the programme was discussed with them when being planned. A service user spoken with, who is about to be discharged from the home, described his rehabilitation in the home and reported that he would not have got ‘this far’ without the input of the team and especially the physiotherapist, for whom he had a high regard. A number of service users are unable to be totally involved with the planning of their care programmes and some choose not to be involved. Service users sign care plans if they wish to and are able to. The inspector evidenced this in some of the care plans viewed. The manager reported that relatives usually have a great deal of involvement at the initial assessment and are invited to be involved with the planning of the programmes of rehabilitation. The home has a key worker system, which can be any one of the multidisciplinary team, and who has a specific involvement with the service user. The service users spoken with could identify their key workers and they understood their role and that it was their key worker they spoke to and related to if there were any specific issues they wished to discuss. Service users can choose their key workers if practical and key workers are changed if there is a request from the service user should the relationship not work. The manager reported that the quality of the care plan reviews is not so good of late and care managers are not attending as often. Service users’ rights to make decisions about their lives were discussed with the deputy manager. Service users can be involved with the decision-making Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 12 about their lives at the review meetings. It is not possible for this to happen for all service users and depends on their cognitive abilities. The inspector observed an example of this. The nurse had negotiated with a service user that he be assisted with his cigarette smoking every hour, and that he was to remind the staff when it was due. He had no sooner finished one cigarette than he was asking for another and had forgotten he had just had a smoke. The nurse explained that service users can make their own decisions but in a case such a short term memory problems those decisions can be forgotten or changed instantly. A number of service users spoken with confirmed that they are able to make decisions about their daily lives. They are able to get up or go to bed as they wish depending on their programmed times for their rehabilitation. Service users do not have their own meetings but can bring any issues to a discussion group, which is held weekly. Families have meetings at the home and any issues they wish to highlight or discuss is written down and presented to the manager for consultation. Risk assessments are undertaken on admission and reviewed. Risks are identified and discussed with the service user/representative. Agreement is sought from the family to put in place strategies to lessen risk. Service users reported to the inspector that they can live within their capabilities and are permitted to move around the area of the home as they wish and that they accept that there are risks involved with their daily living, whilst testing their boundaries. The incident book evidenced that the reported incidents are sometimes the result of service users taking risks. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 13 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): 15 & 16 Service users maintain appropriate relationships with families and friends but the policies that surround sexuality/sexual relationships are not specific to this client group. Service users’ rights are respected and responsibilities acknowledged in their daily living. EVIDENCE: Service users’ privacy is respected and the understanding of the core values of care form part of the staff induction programme. Service users, who need to be seen by the GP, have their consultation in the room in the home that is made available to the doctor on his weekly visit. All service users have their own rooms. A number of the more able service users live in the satellite buildings that consist of two bungalows and four flats. These service users are able to be independent with their living skills and one reported that he only attends the main house for rehabilitation programmes and that he can prepare his own meals. Another service user who lives in the bungalow will attend the house for his lunch and enjoys talking to the other service users. Service users’ do not hold a key to the front door of the house, as it is accessible via a keypad system. All service users are able to hold a key to their room doors if Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 14 they so wish and are able to make that decision. The inspector observed that the staff appeared to have a good relationship and interacted well with the young client group and were familiar with their preferences and needs. One member of staff spoken with had only been working at the home for a few weeks but reported to be really enjoying the job and was gaining a lot of job satisfaction. All areas of the home are accessible to the service users and the main kitchen and staff room are the two areas of the home that is restricted to the service users. Service users who live in the satellite buildings are expected to maintain the cleanliness and tidiness of their private living area. The home has policies in place with regards to drugs, alcohol and smoking and a designated room off of the lounge is set aside for service users who wish to smoke. A number of service users do smoke and the room is used regularly and therefore risk assessments are in place for individual smokers who need supervision with this activity. Staff have a smoking area outside of the building. The home has a policy on relationships in the home, which includes forming sexual relationships. In the light of a recently reported incident, the current active policy was viewed by the inspector and discussed with the manager and it was agreed that this present policy is not appropriate for the client group accommodated in the home and a requirement will be made to review this policy. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 15 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 protected by the home’s policies and procedures for the management of medicines. Service users are able to retain, administer and control their own medication where appropriate. EVIDENCE: The inspector viewed the policies and procedures for the home with regards to the ordering, receiving, administration and disposal of medication. The home has a blister pack system in place and this is contracted with a large distributor in Southampton. The home demonstrated safe systems for the administration of medication. The senior nurse who coordinates the management of the medication reported that the home now has a contract for the disposal of unwanted medication with a waste disposal company who have supplied the appropriate equipment for safe disposal and records of the medication disposed of will be maintained. The inspector viewed the cupboards and medicine trolleys, which were clean and tidy. There was no evidence to suggest over stocking of PRN medication and this indicated an effective ordering system. The drug fridge temperatures were recorded daily and demonstrated safe temperature limits. The home was not administering any controlled drugs and therefore none were present in the home. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 16 At the time of the inspection one service user was self-administrating their own medicines and the appropriate risk assessment and monitoring documents were in place. The nurse reported that they do crush some drugs for the purpose of administration and this takes place with full consent from the service user/relative and the GP, who has signed the agreement to state that it is in the best interests of the service user to receive these drugs and that they are being administered with the full knowledge of the appropriate people. Qualified nurses administer all medicines. The GP visits the home weekly and reviews medications if requested or he sees fit to do so. The inspector discussed with the senior nurse an incident where the transcribing of a medication from one MAR sheet to another had resulted in poor recording of what actual dose had been administered. The nurse showed the inspector the MAR sheet and conceded that although it had been recorded wrongly it was not possible to give more of the medicine, as the stated dose was within the blister pack system. She admitted that this had highlighted a training issue, which had been addressed immediately. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 17 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 Service users feel their views are listened to and acted on. The home has policies and procedures in place for the protection of vulnerable adults but not all staff are aware of the procedures and the implications of their actions with regards to what constitutes abuse. EVIDENCE: The home has a complaints policy in place and this is documented in the Service Users Guide and is to be found in the front reception area of the home. The policy states the CSCI contact number and address. Two complaints have been submitted to the home and the CSCI. One could not be substantiated and the other is still under investigation by the adult protection team. Recent referrals were made under the Adult Protection procedure regarding concerns raised by purchasing authorities about staff practices. Individual care management issues arising from the discussions at a multi-agency meeting are being actioned by individual care managers and the home’s management. The home has a copy of the Hampshire Protection of Vulnerable Adults Policy and the ‘No Secrets’ guidance document issued by the DOH. No staff have been referred to the POVA list to date. The inspector spoke to a trained nurse on duty and she could not describe what her responsibilities would be if abuse was reported to her. She demonstrated poor knowledge of this procedure and the documents that surround the protection of vulnerable adults. In the light of a recent issue when is was stated that a staff member had communicated with a client inappropriately, the incident report quoted that the staff member said she was only ‘joking’ with the service user but this incident was not seen this way by other staff and was reported as being abusive. The urgent training needs of all members of the staff with regard to adult protection and what Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 18 constitutes abuse, has been discussed with the deputy manager. There will be a requirement made from the findings of this inspection The home does manage personal allowances for a number of service users. The inspector viewed the records and observed all monies to be stored individually. All receipts of purchases are kept and a random check of the records and the balance of money recorded matched the actual monies being stored. A record of an inventory of service users possessions held by the home for safekeeping was evidenced in a care plan. The home has its own transport and should a service user request to use it for pleasurable purposes, they pay a contribution to the fuel costs. Carers accompany the service users in the transport to functions. There is no cost incurred if the transport is used for hospital appointments. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 19 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): These standards were not assessed at this inspection. EVIDENCE: Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 20 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, 35 & 36 The clarity and boundaries of the multi-professionals within the team is not always established and therefore service users may not gain the full benefit of their expertise. A competent and qualified staff group supports service users. Staff that have been trained appropriately generally meet the service users’ individual and joint needs. Staff are supported and supervised within their roles. EVIDENCE: Individual staff receive their job descriptions on appointment to the job. The homes policies and procedures are available in a folder in the team office and staff are expected to sign the folder as evidence that they have read them or are aware of them. The home has a key worker system in place and this is written into the job description, which they manager reports are being reviewed. The manager reported that of late there had been some professional disharmony amongst the multidisciplinary team around the coordination of review reports and the responsible individual was in the process of defining professional boundaries without it having any detrimental effect on the rehabilitation programmes in progress. He was monitoring the situation carefully and supervising all of the heads of departments. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 21 The inspector observed that good relationships existed in the home amongst the staff and those spoken with reported enjoying their roles and job satisfaction whilst working with this particular client group. Staff were observed to be in attendance in the lounge area where most of the service users meet during the day. The staff were observed on how they spoke to and communicated with the service users. There was a comfortable atmosphere around the home and staff were very familiar with the service users’ various and complex needs. The home employs occupational therapist, physiotherapists, speech and language therapist, dietician, psychologist, qualified nurses and a team of assistants. The speech and language therapist was spoken with and she said she was quite newly appointed and that she was happy with the recruitment process and enjoyed working at the home in her role. Staff rotas were viewed and this evidenced sufficient staff on duty during the day and night. The home employs a separate catering and housekeeping staff group. Agency staff do attend the home mainly to cover support workers’ role. Various communication systems are in place for service users who are unable to verbally communicate. The clinical psychologist provides training and workshops for all grades of staff on brain injury and methods of communication. The home is committed to training staff. The person employed to coordinate the mandatory health and safety training for all members of staff devises a training plan. The manager reports that there is a training budget in place that adequately covers training needs. The heads of each department are responsible for the individual training of their staff. The home has an induction programme in place and the inspector viewed a sample. The initial induction of two days is with the health and safety coordinator to cover health and safety of the home. The staff member is then supernumerary for a further two weeks to work along side other staff members. The induction period covers all aspects of care and their role in meeting the needs of the service users. The training on abuse and the protection of vulnerable adults was discussed with the manager at which time it was established that staff need further training on this subject. Supervision of staff takes place every two months, and appraisals take place annually. All heads of department have received training about supervision and appraisal. The staff spoken with reported that they feel well supported and the senior nurses are approachable should they request advice or guidance. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 22 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 & 41 The manager is qualified and competent to run the home and is supported by a deputy manager and senior clinical staff. There is a quality control system in place, part of which is based on seeking the views of the service users, and other quality assurance monitoring of systems in the home is undertaken. Service users’ rights and best interests are safeguarded by the policies and procedures of the home, however some incidents are not consistently reported promptly and appropriately. staff. EVIDENCE: The registered manager is a registered nurse and is undertaking the NVQ level 4 in management at the current time. The training matrix seen by the inspector evidenced that the manager continues to attend training sessions in various subjects. The manager’ agrees that her job description sets out her overall responsibilities. The registered manager reported that she depends on Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 23 the deputy manager to manage the day-to-day workings of the home. Given the recent issues at the home, it is imperative that the registered manager be aware of her legal accountability and be more proactive in monitoring what is happening in the home. She must oversee and clarify roles and responsibilities of the team and oversee a review of communication between staff at all levels and representatives of purchasing authorities. At the time of the inspection the service users and relatives/representatives views of the service were in the process of being sought via questionnaires. The home will make available to the CSCI the results of this survey. The manager reports that there is a relatives support group at which time relatives may voice their views and any issues can be discussed with the management of the home and she considers that they have good communication and relationships with the relatives. Staff were observed to communicate freely between themselves and a large amount of information is given at the handover meetings each day that are attended by all disciplines. The inspector observed that some of the service users with communication problems had communication aids available and also the home has an IT suite where service users may use the computers to email their friends and relatives with the assistance of the IT technician employed at the home. Regulation 26 reports are received by the CSCI from the responsible individual that is part of the quality assurance system. The quality of the content of these reports has improved since the last inspection. Service users have access to their records if requested and these are maintained within the nurses’ office which is partitioned off from the main lounge area and very accessible to the service users. The inspector evidenced that incident forms are completed for all incidents that involve service users and records are maintained of the action taken following these incidences. Of these incidences what should and should not be reported to the CSCI via the Regulation 37 forms, was discussed with the deputy manager who demonstrated her lack of knowledge as to the reporting procedure to the CSCI on a Regulation 37 report form. In the light of recent incidents that should have been reported to the CSCI as urgent and were not, this highlighted a training need for the deputy manager and a breakdown of communication from the manager. The visitors’ book was viewed and demonstrated a number of visitors each day recorded. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Peartree House Rehabilitation Centre Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 2 X X DS0000011441.V254751.R01.S.doc Version 5.0 Page 25 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. Standard YA15 Regulation 12(3) Requirement You are required to ensure an appropriate policy is written and implemented to ensure service users’ can develop and maintain intimate person relationships with people of their choice and information and specialist guidance are provided to help the service user make appropriate decisions. You are required to ensure that medication charts reflect the actual dose of medication prescribed by the doctor and that any cancelled medication must be struck through and identified as being withdrawn. You are required to ensure that all staff are trained in the adult protection procedure and the reporting process. You are required to ensure that the deputy manager is trained and can demonstrate knowledge of the adult protection procedure and the appropriateness of what must be reported to Social Service contact team and the CSCI. DS0000011441.V254751.R01.S.doc Timescale for action 31/01/06 2. YA20 13(2) 15/01/06 3. YA23 13(6) 31/01/06 Peartree House Rehabilitation Centre Version 5.0 Page 26 4. YA31 12(5)(a) 5. YA41 37(1) (2) You are required to ensure that the multidisciplinary team and key workers have defined roles and responsibilities. This is to ensure that they work within their roles and parameters of practise as well as working as a team for the wellbeing and safety of the service users, including ensuring effective communication both between themselves and also with care managers and relatives at all times. The registered manager must give notice to the Commission without delay of occurrences in the home that adversely affect the service users. 31/01/06 31/01/06 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 YA6 YA39 Good Practice Recommendations It is strongly recommended that more active communication take place with care managers to attend the review meetings. It is recommended that the home makes available to the CSCI the results of the service users’ and relatives satisfaction survey. Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Peartree House Rehabilitation Centre DS0000011441.V254751.R01.S.doc Version 5.0 Page 28 - 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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