Inspection on 27/09/06 for Pelican Court

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pelican Court 03/10/05

Pelican Court 02/02/05

Pelican Court 08/06/04

Pelican Court 11/12/03

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Pelican Court 6 Pelican Court Wateringbury Maidstone Kent ME18 5RJ Lead Inspector Helen Martin Unannounced Inspection 27th September 2006 2:30 Pelican Court DS0000024003.V307527.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 Pelican Court DS0000024003.V307527.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. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelican Court Address 6 Pelican Court Wateringbury Maidstone Kent ME18 5RJ 01622 817773 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) www.macintyrecharity.org MacIntyre Care Steven Bolton Care Home 9 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care for older people with a learning disability restricted to one person whose date of birth is 19 April 1935. Two people with a learning disability will also have a physical disability. Date of last inspection 03/10/05 Brief Description of the Service: Pelican Court provides services for up to ten adults, including one person who is over 65 years of age, with learning and physical disabilities. The home employs support workers, operating a roster, which gives 24-hour cover. There are no designated staff for catering or domestic duties. The accommodation is arranged over two floors. The ground floor is used to provide accommodation for service users with a higher dependency need (including physical disability); the first floor for those with less dependency needs. The care providers are Macintyre Care, a national organisation for people with learning disabilities. The owners of the premises are Moat Housing, who are responsible for the repair and upkeep of the premises. The accommodation is purpose built. (There is other accommodation close by where supported housing is provided for more independent service users; this is not registered with the CSCI.) The home is located in a village within reach of Maidstone and other towns by public transport. There are shops and village amenities within walking distance. Current fees for the home are £1,041 per week and do not include the cost of hairdressing, chiropody, toiletries, newspapers, holidays and public transport. Full information about the fees payable, the service provided, the home’s Statement of Purpose and the latest inspection report by the CSCI are available from the manager. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 27th September 2006 from 14.30 until 19.00. The visit included talking with the manager, support workers and people who live at the home. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the home and garden was undertaken. The home has given the CSCI a completed pre-inspection questionnaire and this information has been used within this inspection. Postal surveys from residents, their relatives and health and social care professionals could not be included within this inspection as none had been received at the time of writing this report. Pelican Court currently has seven residents with two vacancies. What the service does well: What has improved since the last inspection? The home is better run since the new manager started work in December 2005. Residents know what they should do and what to expect when living in the home because this is now written down. The water from the shower in one Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 6 bathroom is now flowing away properly. If residents take risks or are unhappy about anything, this is now written down and kept up to date by staff. 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. Pelican Court DS0000024003.V307527.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 Pelican Court DS0000024003.V307527.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering moving into this home are able to make an informed choice about whether their needs will be met. They would not however, have information about their individual fees within the statement of terms and conditions. EVIDENCE: Previous inspection identified that prospective residents and their representatives are provided with a statement of purpose and service users guide, containing information to assist them in deciding whether the home is suitable to meet their needs. Residents benefit from an assessment before they move into the home, to ensure that their needs can be met. Local authority documentation was seen for a newer resident. It was said that no residents are currently privately funded. The manager demonstrated an understanding of the range of needs that the home could and could not meet. It was stated that there had been no issues regarding the mental health of one individual since they had been resident within the home. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 9 Prospective residents and their representatives are able to look around the home. Before they moved in, one newer resident visited a few times and had lunch with other residents. Previous inspection identified that all residents had signed tenancy agreements with the housing association that own the premises. Since the last inspection residents have been provided with a statement of terms and conditions about what they can expect in terms of their rights and responsibilities relating to the care provided. The new service agreement is easy to read although it continues not to include the required information about fees. The document does not contain specific information about individual residents’ care plans. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 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, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make their own choices and decisions about their lives. Although they are involved in planning the care and support they receive, this could be better reflected in some documentation. EVIDENCE: Care planning documentation reflects residents’ changing needs and gives staff some guidance about action to be taken to promote their health and welfare. Information is holistic in nature and contains a range of issues. Reviews are undertaken on a regular basis and all information seen was up to date. Files seen are well maintained. Residents are involved in their care planning. They make their own individual personal records, which include their activities, likes, dislikes and steps to obtaining their aspirations and goals; good documentation was seen. The home continues, however, to rely on the Local Authority care plan document, rather than producing their own cohesive plan of care, which would provide clear objectives and staff guidance about how to achieve all the goals identified. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 11 Residents are supported to take risks as part of maximising their independence. This risk assessment process is recorded for hazards, individual needs and activities, such as holidays and trips out. All information seen was reviewed and up to date. Discussion around this issue indicated that people living in the home are given the freedom to make decisions about their lives considering risk management and group living. They are provided with assistance to support their individual choices. A risk assessment for one resident needing bed sides is recorded, although evidence of agreement to this course of action by the resident and/or their representative is not. A regular residents’ meeting is held about decisions such as meals, activities and holidays. Health and safety issues are included within the meetings and residents can watch appropriate videos about fire and adult protection. Residents receive continuity of care by having individual key workers, who meet with them on a monthly one-to-one basis to discuss any issues. Residents’ confidentiality is maintained and their privacy respected, in that personal records are maintained and stored in such a way as to be available solely to appropriate and authorised people. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. Residents enjoy individual lifestyles and are supported to develop their life skills. They have the opportunity to experience a variety of social, educational and recreational activities. Residents would benefit from the full cost of a holiday included in the contract price. EVIDENCE: Residents benefit from opportunities for personal, emotional and social development and are supported towards independent living skills, tailored to their abilities. Residents are treated as individuals and are consulted about their different interests and aspirations, which they record in their personal plans. Activities are provided accordingly. Personal development is enabled through attendance at college, paid employment/voluntary work, day centres, leisure activities and relationships with friends and family. Residents spoken with clearly enjoyed the activities that they were involved with. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 13 Residents are part of the local community. During weekdays residents enjoy attending day centres or college, participating in social events and activities that personally interest them or to further develop their life skills. Staff at the home support their attendance and also provide activities from the home. A wide range of opportunities are available to residents including swimming, visits to a museum, shopping, going to the library, boat trips, cooking, bowling, discos, visits to the coast and places of interest, bingo and snooker. Opportunities are available for residents to undertake paid or voluntary work. Currently one individual works on a farm and another in a garden nursery. Residents are able to see their family and friends as often as they wish. Individuals can visit the home at any reasonable time. One resident described how they visited their family on a regular basis. Residents spend time in the home relaxing, watching television listening to music or undertaking activities that interest them. The home has a pet cat and fish. They also receive guidance with the development of skills within the home with the support of staff. Residents are encouraged with shopping, cooking, cleaning, laundry and household tasks. They enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. Residents are supported to plan holidays and have had the opportunity to go on a trip of their choice, such as Great Yarmouth and a Dr. Who convention in Wales. Residents are usually expected to pay for the cost of their holidays themselves with the exception of food. The funding of staff going away with residents was unclear as, although the service agreement stated that the organisation paid for this, staff said that the resident did. Residents are able to choose their meals and are supported with menu planning. Meals are in accordance with agreed menus, known choices and nutritional needs or preferences. The manager said that staff could support residents who need it with any special diet. Currently one individual has a soft diet and is provided with additional support at mealtimes. One resident spoken with said that they enjoyed the food at the home. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 14 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. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. Residents would be better protected by some improvement to the system for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. They are able to exercise choice regarding this. Staff demonstrated a good understanding of the preferred routines and varying requirements of each individual and detailed guidelines are available. Residents are able to express themselves individually, including their clothing and hairstyles. Residents have access to social and health care professionals, such as GP, district nurse, physiotherapist, optician, dentist, chiropodist and dietician. They are supported with any specialist appointments and/or interventions. One resident attends hydrotherapy on a regular basis and has recently received an assessment from an occupational therapist. Mental health support is available. The manager demonstrated a good understanding of the needs of residents Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 15 and this is reflected in documentation. Staff guidelines are available for residents with specialist needs, such as autism and epilepsy. A procedure is in place for the administration of medication by the home, which aims to protect residents. Storage is secure. Administration records are completed appropriately with the exception of handwritten entries that are not countersigned by a second member of staff as accurate or confirmed in writing by the prescribing GP. Guidelines for the administration of ‘when required’ medication together with a profile of all drugs used are available. There is no signed GP approval for the use of homely remedies. Reference material is available, although the home would benefit from an up to date copy of the Administration of Medication in Care Homes produced by the Royal Pharmaceutical Society. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 16 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. Residents’ views and concerns are listened to and receive appropriate consideration, although they would benefit from a written complaints procedure that was easier to read. Residents are protected from potential abuse, although this was not fully reflected in documentation held within the home. EVIDENCE: Residents are at ease and confident talking with staff who listen to their views and concerns. A regular meeting is held to discuss these. Residents receive continuity of care by having individual key workers, who meet with them on a monthly one-to-one basis to talk about any issues. All meetings are recorded. If residents wish to make a written complaint, postcards are available that are easier to fill in. These can be given or sent to staff, the manager or the area manager. The home is in the process of developing a complaints procedure that is easier for residents to read and draft documentation was seen. Details of complaints and their investigations are now recorded appropriately. The home provides a written complaints procedure. The manager confirmed that people living in the home are protected from abuse and that satisfactory checks had been carried out on all staff via the criminal records bureau, although these continue not all to be available in the home. A regular residents’ meeting is held which includes health and safety issues. Residents can watch appropriate videos about adult protection. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 17 The home has a system in place, which aims to protect the financial interests of residents and holds small amounts of cash on their behalf. This is kept securely. All money is stored individually and transaction records are maintained. Cash checked tallied with accounts seen. Receipts are kept for purchases made on residents’ behalf. The manager said that no one within the organisation was an appointee for any resident. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, comfortable and homely environment. Those with a physical disability would be better protected by access to staff call alarm points at all times. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents benefit from living in clean and comfortable accommodation. They have access to an attractive garden with a patio. The house is maintained and decorated by Moat Housing Association. Since the last inspection, the drainage in one of the bathrooms has been improved. There are plans to replace the carpets in some residents’ rooms. Adequate recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides a lounge, dining room and conservatory. The manager stated that residents accommodated on both the first and the ground floors use the communal areas on the ground floor. The inspector was assured that sufficient space is available. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 19 All residents have their own rooms, which are big enough to store their possessions. Bedrooms are comfortable, furnished and decorated according to individual taste and reflect the interests of the occupant. Residents clearly like their rooms, which are highly personalised. They are able to choose colour schemes and how their furniture is arranged. There are no passenger or stair lifts within the home and residents provided with accommodation on the first floor have no mobility problems. The ground floor accommodation is equipped to provide care for residents with physical disabilities. Currently one resident uses specialist equipment such as a hoist and reclining chair. They have been assessed by an occupational therapist. There is a staff call system throughout the home. One physically disabled resident is not able to reach the staff call alarm point when they are in bed. The premises were clean and hygienic. There is a laundry room used by residents with support from staff. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 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, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a sufficient number of appropriately supervised staff who have a good understanding of their needs. They would be better protected by improvements to the systems for staff recruitment and training. EVIDENCE: People living in the home benefit from the support of enthusiastic and caring staff, who demonstrate a good understanding of residents’ needs. Residents benefit from good support and interaction. The home aims to meet the needs of residents by providing appropriate staff training. The senior support worker said that all staff have undertaken courses in manual handling, the use of the hoist and mental health. The manager described essential staff training as also including food hygiene, fire, medication, infection control and first aid. Although the home provides care for people with autism and epilepsy, staff training has not yet been provided. It was mentioned that all courses were useful and up to date. The home’s induction training leads into an NVQ qualification. Currently four of the ten support workers have obtained an NVQ qualification at level 3, with a further two currently undertaking the course. Training certificates are kept in staff Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 21 files. Since the last inspection, the manager has developed a training matrix. Because of the nature of the records kept it was not possible to fully evidence all training undertaken had been updated. At the time of the site visit, there were sufficient numbers of staff on duty to support people within the home. A recruitment procedure is in place that aims to protect residents and appoint staff suitable to meet their needs. One individual, who has not yet started work, is in the process of recruitment. The required checks have been undertaken and some results are pending. Previous inspection identified that whilst newer staff files evidenced appropriate recruitment checks, it was difficult to establish if this had been the case for staff who had been working in the home for some time as these records were stored centrally by the organisation. In spite of requests from both the previous and the current manager to send copies to the home, this has not yet happened. The senior support worker said that staff receive support and regular monthly supervision on a one-to-one basis to ensure that their work is monitored and training and development needs are identified. It was stated that regular staff meetings held twice a month were supportive and helpful. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 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, 40, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run effectively and in the best interests of residents, although they would benefit from the qualification of the manager. Residents could be better protected by improvements to record keeping and a review of the system for quality assurance. EVIDENCE: Since the last inspection, a new manager was appointed in December 2005 who has recently been registered with the CSCI. The manager has relevant experience of service provision for older people and for people with learning disabilities. They have previous management experience. The manager commenced an NVQ level 4/Registered Managers’ Award in June of this year. There is an open and inclusive atmosphere in the home. Residents are comfortable chatting and spending time with staff. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 23 The quality assurance system for the home was discussed. The manager explained that the organisation undertakes regular monitoring visits to the home. Reports are supplied to the CSCI. The organisation has a quality assurance system, which includes the use of questionnaires for residents; it was unknown at the time of the site visit whether these are used for residents’ relatives and relevant health and social care professionals. A regular residents’ meeting is held to discuss individuals’ views. Residents receive continuity of care by having individual key workers, who meet with them on a monthly oneto-one basis to talk about any issues. The home has comprehensive recorded policies and procedures that are available for staff. Since the last inspection the majority of these have been updated. In order to evidence consistency of care for residents, a number of records have been looked at as part of the inspection process. These have been mentioned within this report where appropriate. Accidents and incidents are recorded appropriately with any action to be taken signed off by both the manager and area manager. Information provided within the home’s pre-inspection questionnaire and records seen indicated the regular testing and maintenance of systems and equipment within the home, with the exception of emergency lights checks, which are undertaken but not recorded. Health and safety issues are included within residents’ meetings and individuals can watch appropriate videos about fire and adult protection. External doors are alarmed and the garden enclosed for the security of residents. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 3 2 2 X Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5(1)( c ) Requirement The registered person shall produce a written guide to the care home, which shall include the terms and conditions including the amount and method of payment of fees. In that, the service agreement for residents must include the required information about fees. This requirement has been repeated from previous inspection dated 3rd October 2005. 2 YA6 12 & 15 & Schedule 3 The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met and shall keep the service users plan under review. In that, although up to date information is available and residents are involved in their own personal plan, the home Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 26 Timescale for action 10/11/06 10/11/06 must produce a cohesive plan of care themselves, rather than rely on the Local Authority document. This must provide objectives and clear staff guidance about how to achieve all the goals identified. This requirement has been repeated from previous inspection dated 3rd October 2005. 3 YA20 13(2) The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medecines received into the care home. In that, hand written medication administration records must be countersigned by a second member of staff as accurate and confirmed in writing by the prescribing GP. The home must be able to evidence that a GP has confirmed the use of homely remedies as not contraindicating residents’ prescibed medication. 4 YA29 23(2)(n) The registered person shall having regard to the number and needs of the service users ensure that suitable adaptations are made, and such support, equipment and facilities…as may be required are provided, for service users who are…physically disabled. 10/11/06 10/11/06 Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 27 In that, the staff call alarm points must be accessible to residents with a physical disability at all times. 5 YA23 YA34 YA41 17(2)(3)(b) The registered person shall maintain in the care home the records specified in Schedule 4. The registered person shall ensure that the records…are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. Schedule 4:6 Other records to be kept in a care home: A record of all persons employed at the care home, including in respect of each person…records in relation to his employment… In that, records regarding the recruitment of all staff working within the home must be kept at the home in order to evidence a sound recruitment procedure. 6 YA35 18(1)(c)(i) The registered person shall, having regard to…the numbers and needs of service users ensure that the persons employed…to work at the care home receive training appropriate to the work they are to perform… In that, relevant and appropriate staff training must be provided, including autism and epilepsy, in order to meet all residents’ needs. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 28 10/11/06 10/11/06 Issues regarding staff training have been repeated from previous inspection dated 3rd October 2005. 7 YA42 23 (4)(c)(v) The registered person shall 10/11/06 after consultation with the fire and rescue authority make adequate arrangements for…testing fire equipment, at suitable intervals. In that, emergency lights within the home must be recorded as checked on a regular basis. 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 YA5 Good Practice Recommendations It is recommended that service agreements include residents’ room numbers and specific information about individual care plans. It is strongly recommended that agreement to the use of bed rails by the resident concerned and/or their representative should be recorded. With regard to residents’ holidays, it is recommended that: 1. A review should be undertaken to ensure clarity regarding the funding of staff who go on holiday with residents. 2. The option of a minimum seven day holiday for residents should be included within the basic contract price. Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 29 2 YA6 3 YA14 4 YA20 It is recommended that the home should obtain an up to date copy of the Administration of Medication in Care Homes produced by the Royal Pharmaceutical Society. It is recommended that the manager complete their stated intention to develop a complaints procedure that is easier for residents to read. It is strongly recommended that a review should be undertaken to ensure that 50 of the staff team achieve an NVQ qualification as soon as they are able. It is recommended that the home’s training matrix is amended to show details of all courses undertaken and can evidence that courses have been updated. It is strongly recommended that the registered manager complete their stated intention to complete their NVQ level 4/Registered Managers’ Award course as soon as they are able. This was an expectation of the CSCI at the point of the manager’s registration. It is recommended that a review should be undertaken to confirm that feedback from residents’ relatives and relevant health and social care professionals is included within the home’s quality assurance system. 5 YA22 6 YA32 7 YA35 8 YA37 9 YA39 Pelican Court DS0000024003.V307527.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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