Inspection on 03/10/05 for Pelican Court

This inspection was carried out on 3rd October 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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pelican Court 27/09/06

Pelican Court 02/02/05

Pelican Court 08/06/04

Pelican Court 11/12/03

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Ruth Burnham Unannounced Inspection 3rd October 2005 13:00 Pelican Court DS0000024003.V251580.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 Pelican Court DS0000024003.V251580.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. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 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) MacIntyre Care Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 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. 2 people with a learning disability will also have a physical disability Date of last inspection 27th June 2005 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 accommodation is arranged on two floors in the main premises. There is a separate one bedroom flat on the site which is also registered. The care providers are Macintyre Care, a national care provider of care for people with learning disabilities. The owners of the premises are Moat Housing (responsible for repairs and upkeep of the premises). The accommodation is purpose built. 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. There is other accommodation on site where supported housing (only one flat is registered with the CSCI) is provided for more independent service users. The project officer for these service users has an office at Pelican Court. 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 possibly less dependency needs. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out by a regulatory inspector who was in the home from 13.00 to 16.30. 3 service users, 3 members of staff and the manager were spoken with. Part of the premises was inspected and a number of records were examined. What the service does well: What has improved since the last inspection? What they could do better: The statement of terms and conditions must include the amount of fees. Care planning by the provider, must ensure that the service provided, maintains the safety of, and is in line with, the wishes of residents. These plans, risk management and other documentation must be maintained up to date and based on the most recent care management assessment. Complaints must be recorded in line with the complaints procedure. Adequate communal space must be established for people living on the first floor and necessary repairs must be carried out. A manager must be appointed who is suitably qualified and competent and management practice must ensure that all regulations are complied with, in a way that protects and enhances the health and welfare and quality of life of service users. Staff must have qualifications suitable to the work that they perform and documents required in respect of persons working in the home must be available on the premises for inspection. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 6 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.V251580.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, & 5 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: People living in this home and their supporters are provided with information within a statement of purpose and service users guide, to assist them to decide whether the home is suitable for them. The new statement of purpose now contains all the information required by regulation and a new service user guide has also been prepared in an accessible format to enable prospective residents to make an informed choice about the home’s suitability to meet their needs. No new people have been admitted to the home since the last inspection, it was not therefore possible to test the admission procedures at this inspection. Residents have all signed tenancy agreements with the housing association who own the premises however, they have still not all signed a statement of terms and conditions about what they can expect in terms of their rights and responsibilities as these relate to the care provided. A new statement of terms and conditions has been drafted but not yet introduced, this draft omitted the required information about fees. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Improvements are in progress for care planning and risk management to ensure that people living in the home are protected and their independence and privacy is promoted EVIDENCE: Work is progressing to improve care planning and recording systems in the home to ensure that residents’ needs would be met. Two care plans were examined in depth in which some elements were still out of date. Discussion with staff revealed that there is still a great deal of reliance being placed on the Local Authority assessment/care plan, rather than in producing a cohesive and holistic plan of care in consultation with the people who live in the home. This would provide clear guidance to staff about how to achieve all the goals identified within the assessment. It is recognised that a great deal of time and resources have gone into the planning of support and care for a minority of residents who have more challenging needs. They have benefited from specialist interventions and professional involvement in care planning and risk management with staff being provided with specific training in mental health issues. Decisive steps Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 10 have now been taken by the management to ensure that other residents are no longer disadvantaged by the drain on staff time. Significant work has been done to maintain the safety of people who live in the home through a risk assessment process, however those seen had not been updated to reflect change as it occurred. Staff explained that the management of risk for one person, in relation to health, had been thwarted by the difficulty in accessing advocacy services. It was explained that, in these circumstances duty of care must override protocols and clear guidance must be provided on how to manage the delicate balance between risks to health and the personal lifestyle choices of people who live in the home. Discussion around this issue indicated that people living in the home are given the freedom to make decisions and they are provided with the information and assistance to support their individual lifestyle choices. People living in the home can be confident that their 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.V251580.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14 & 17 Residents’ lives are enriched by the variety of opportunities, which are offered for personal development and individual choices are catered for wherever possible. EVIDENCE: People who live in the home benefit from opportunities for personal development through attendance at colleges and day services. They also benefit from a variety of leisure activities including attendance at clubs, outings and meals out. Residents are able to fulfil many of their hopes and dreams through consultation about lifestyle choices and leisure activities as recorded in the care plan. Staff spoken with confirmed that, where it had not been possible so far, to fulfil all of these wishes, progress was being made wherever possible towards achieving these aims and these staff were clearly committed to providing all necessary support to do so. People living in the home are able to plan their own meals with support from staff and records indicate that meals are wholesome and nutritious. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 12 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): 21 People living in the home can be assured that their wishes will be respected EVIDENCE: People living in the home can be assured that every effort will me made to ensure that they can remain in the home until death wherever possible. Efforts are being made to ascertain the wishes of service users and their families in relation to illness and death. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 13 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 Poor record keeping made it impossible to make a judgement that people in the home can be confident that their complaints will be dealt with. EVIDENCE: The complaints file was examined and it was clear that people living in the home, cannot be confident that procedures will be followed where complaints and concerns are raised. Records do not comply with the regulations to show that a full investigation has taken place, what action has been taken or that feedback has been given to the complainant within 28 days and not all concerns and complaints raised are being dealt with via the 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 were not all available in the home. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 14 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 & 30 Service users’ quality of life has been enhanced by improvements in the cleanliness of the home. EVIDENCE: People living in this home benefit from having their own bedroom, which is of sufficient size to store their belongings, they are able to lock their rooms, which are furnished and decorated according to their individual taste. Both floors have adequate bathroom and toilet facilities for all residents although the home is still awaiting improvements to the drainage in one of the bathrooms, which has been requested, of the landlord. Risk of infection through communal use of bath mats and rubber slip mats has now been eliminated and the health and safety of service users has been further promoted by improvements in cleaning routines and a deep clean of the premises. Food storage and stock control has been improved through the delegation of this responsibility to a named member of staff and with the provision of new freezers. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 15 The manager is checking room sizes to ensure that communal space on the first floor is sufficient for people who live on this floor. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 The quality of life of People living in the home is enhanced by the support of a caring and committed staff team however, there may be some risk to residents where tasks are being carried out by inadequately trained staff. EVIDENCE: People living in the home benefit from the support of enthusiastic and caring staff who are committed to achieving their goals and who develop relationships, particularly with the individual residents they support, via a keyworker system. Residents’ quality of life is enhanced through the support of staff who work well as a team and have excellent attitudes and a strong commitment to improving their knowledge and skills by achieving National Vocational Qualifications at either level 2 or 3. Residents are protected through the sound recruitment procedures, which are in place, records examined for new staff demonstrated that two written references are taken up and checks are made with the criminal records bureau prior to appointment. 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 are stored centrally and, in spite of requests from the manager to send copies to the home, this has not yet happened. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 17 There are sufficient numbers of staff on duty to support people who live in the home, the care staff receive support and supervision on a one to one basis at regular intervals to ensure that their work is monitored and training and development needs are identified. However, there was some concern that service users could be placed at risk by the delay in providing competence based training for a number of staff in basic food hygiene, moving and handling, fire safety, health and safety, infection control and first aid. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 The provider has taken steps to address the recent poor management of the home, which has undermined the quality of life and safety of people living there. EVIDENCE: The care provider is taking steps to address the serious concerns of the Commission expressed in the previous reports, in relation to the management of the home, where the welfare of service users is being compromised by poor management systems. The manager has now resigned and every effort is being made to recruit a suitably qualified manager. In the meantime measures are in place for the temporary management of the home to safeguard the welfare of people who live there. Work is progressing to meet the requirements in relation to record keeping, which is required to ensure consistency of care for residents. An effective internal quality assurance system is being put in place, which will ensure that requirements from previous inspections are complied with and service users are not being placed at risk and their quality of life is improved. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 19 Service users may be at risk due to the lack of competency based training for a number of staff in safe working practices particularly where staff are preparing food without having undertaken basic food hygiene training. Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 x 3 LIFESTYLES Standard No Score 11 3 12 x 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pelican Court Score x x x 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 2 2 x DS0000024003.V251580.R01.S.doc Version 5.0 Page 21 YES 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 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. 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 The registered person shall ensure that unnecessary risks to health or safety of service users are identified and so far as possible eliminated.Risk assessments should be up to date and include all aspecs of service users lives including health. The registered person shall ensure that the complaints procedure is followed in line with the regulation and that a summary of the complaints with action taken is supplied to the commission annually Timescale for action 30/11/05 2 YA6 12 & 15 & Schedule 3 30/11/05 3 YA9 13(4)( c ) 30/11/05 4 YA22 22 30/11/05 Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 22 5 YA24 6 YA27 7 YA37 8 YA39 9 YA41 10 YA42 The registered person shall ensure that adequate communal accommodation is provided for service users on the first floor. 23(2)(b) The registered person shall ensure that the premises to be used as the care home are kept in a good state of repair externally and internally, specifically, the problems with drainage in one shower area should be addressed. 9(b)(2) The organisation shall appoint a registered manager who has the qualifications, skills and experience necessary to manage the care home. The manager must demonstrate the necessary qualifications skills and experience to manage the care home. 24 An effective quality assurance system shall be developed and regular reports supplied to the commission in line with the regulation. 17(1)(a)&(3) The registered person shall 19. Schedule maintain service user records 2 and shall ensure that these records are kept up to date i.e. signed and dated. All records required in the Schedules must be available for inspection 19(5)(b) All staff must have the qualifications suitable to the work which they perform 23(2)(i) 30/11/05 30/11/05 31/12/05 30/11/05 30/11/05 30/11/05 Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Pelican Court DS0000024003.V251580.R01.S.doc Version 5.0 Page 25 - 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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