Inspection on 26/02/07 for Pemdale

This inspection was carried out on 26th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pemdale 06/01/06

Pemdale 07/04/05

Pemdale 12/10/04

Pemdale 14/04/04

Pemdale 16/09/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Beau Sejour

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

CARE HOME ADULTS 18-65 Pemdale 26a Nursery Close off Sandy Road Potton Bedfordshire SG19 2QQ Lead Inspector Mr Paul Worthy Unannounced Inspection 26th February 2007 1:00 Pemdale DS0000014947.V331080.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 Pemdale DS0000014947.V331080.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. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pemdale Address 26a Nursery Close off Sandy Road Potton Bedfordshire SG19 2QQ 01767 262515 F/P 01767 262515 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.aldwyck.co.uk Aldwyck Housing Association Mr John Farrar-Hockley Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability over 65 of places years of age (6) Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Pemdale is a purpose built bungalow on the edge of Potton. The home is within walking distance of local shops, pubs public transport and place of worship. The home was registered in 1996 to provide residential care for 6 people with learning disabilities including those who are also over 65 years of age. The building was built to a full wheelchair specification and provides six single bedrooms, a bathroom and shower room, large lounge and kitchen combined with dining room. There is also a quiet room/study and an office combined with sleep-in room. The home has parking facilities and a beautiful garden at the back of the home Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 1.00 p.m. It took place over 7 hours. The inspector met all the people living at the home and talked to one. He also talked to two staff and the manager, saw the service users having dinner, saw a service users room with the service user, looked over the public parts of the building, and saw some records. Account was taken of the preinspection information that the manager had returned prior to the inspection. The inspector is very grateful to everyone at the home for their help during this inspection. What the service does well: What has improved since the last inspection? What they could do better: As part of the programme of continuous improvement the following are projects that are either under way or being planned. None of these reflect inadequacies in service provision. The decorating of the bathroom is ongoing. This is being done using the designs of the service users and with their help so that the project has become a valuable way of involving the service users. The garden, with its prize winning sensory garden, is an ongoing project involving those living at the home. The two major tasks for the future are to raise the funds and build a conservatory onto the building so as to provide more activity space and to have the camouflaged cesspool removed from the garden. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pemdale DS0000014947.V331080.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 Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements for assessing the needs of service users to ensure that they could be met. EVIDENCE: There had been no moves to the home since the last inspection, when it had been noted that there were good arrangements in place for assessing the needs of a person wishing to move to the home to determine if these could be met. Good arrangements were, however, seen to be in place for ensuring that there was up to date information about the changing needs of those living at the home, where this was being helped by the involvement of the appropriate professionals. Excellent recording and monitoring arrangements were in place for ensuring that changing needs were monitored. The information was being translated into visual form so that patterns reflecting change could be easily identified. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There were good service user plans which ensured that the needs of those living at the home would be met in ways that took account of their wishes and encouraged as much independence as possible. EVIDENCE: Comprehensive and up to date planning information was seen on the personal files of those living at the home. There were very well structured service users plans, which included for each section a cross referencing to source material and material such as risk assessments and guidance notes relating to the best way to meet a service users needs. The records and talking to the manager and staff provided evidence that there was ongoing work to establish the most effective person centred planning approach for each of the service users. There was no doubt talking to the manager and staff that on a daily basis the emphasis on involving service users in decisions relating to themselves was basic to the homes approach. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 10 The staff talked to were all very aware of the service users plans, and key workers were involved in constantly monitoring them. There were reviews of the service users plans every six months. The key workers were seen to produce excellent notes for the reviews. Staff confirmed that staff meetings were used to provide updating information regarding the service users and that the handover meetings ensured the consistency and continuity of care and support. Risk assessments were seen to be in place to allow service users to undertake a range of activities that required special precautions to ensure their safety. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. Those living at the home were provided with the support they needed to be able to lead fulfilling and enjoyable lives in and outside the home. EVIDENCE: Arrangements were seen to be in place, including assessment and planning information, to ensure that those living at the home were able to enjoy a full range of normal activities in and out of the home. There was a manager responsible for ensuring that this happened by arranging the activities and arranging for enough staff to be on duty to allow the activity to occur. As well as leisure activities there was also an attempt to encourage the service users to have some participation in normal domestic activities and to extend their self-help skills. Watching the staff relating to the service users during the day showed that they were very sensitive in determining what the service user Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 12 wanted. Annual holidays were also organised for small groups or individuals. The practice observed at the home was for staff at any time they felt a service user was expressing a wish to do something to record this on a notice board in the kitchen so arrangements could be made for it to happen. There were excellent arrangements for monitoring the amount of activity the service users were having and to identify when there were failures to support an agreed activity and why. Talking to staff provided evidence that the contact between those living at the home and their relatives or friends was encouraged. The quarterly Stakeholders Meetings provided further support to relatives. The home had its own advocate who came to some service users meetings and was available should any service user need an advocate. Good arrangements were seen to be in place for ensuring that the service users had nutritional and healthy meals that reflected their known preferences. This included dietary information held on service users plans and appropriate working with the dietician. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There were excellent arrangements for providing personal care and obtaining medical care to ensure that those living at the home were cared for in ways that respected their dignity and ensured that they enjoyed as much good health as possible. EVIDENCE: All the service users needed staff to help them with personal care. The details of the related needs and how they were to be met was given in the service users plans or guidelines and risk assessments that were referred to in the plans. The assessment and planning information about the medical needs of those living at the home was seen to be up to date and to cover routine, emergency and ongoing medical care. There were effective arrangements to ensure that regular checks were maintained. There were excellent arrangements in place to monitor health conditions and produce graphs of the findings, so that evidence was available to the medical specialists. The health needs were Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 14 complex but staff spoken to were very aware of the conditions and the importance of working with other professionals. Excellent arrangements for managing medication were seen to be in place. The service users plans were complemented by a file containing source material relating to medical needs. The file also included a medication profile for the service user. The health plan included information relating to the medication being taken by the service user. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective arrangements for identifying and addressing the concerns that those living at the home might have and for ensuring they were protected so that they would feel in control and safe. EVIDENCE: There were formal complaints procedures in place that could be used by the representatives of the service users. Representatives also had the opportunity to be involved on behalf of the service users through the quarterly stakeholders meetings and through their encouraged informal contact with the home. There had been no complaints since the last inspection. It had been noted in the Annual Quality Assurance Report for the home that relatives, while mostly aware of how to make a complaint did not have a copy of the procedure. The plan to remedy this was to send out a copy of the procedure with the annual quality assurance questionnaire that would be sent out to relatives each year. The report picked up on a number of concerns that had been fed back and noted how they were to be addressed, which demonstrated a serious commitment to ongoing improvement. The communication needs of those living at the home were in some cases particularly complex because of changes depending on their health. The ability of staff to work with and pick up on their concerns of the service users was Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 16 seen to depend on the knowledge they had of them and the very positive relationships that they had with them. There had been a recent POVA investigation, which provided evidence that there were robust procedures, which linked into the local protocols, in place and which ensured that what service users said was taken very seriously and acted on. Staff confirmed that there was training relating to the protection of vulnerable adults and they were aware of the action they would need to follow if they had concerns of this nature on behalf of a service user. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation was well maintained and furnished so that it provided those living there with a homely and comfortable environment. EVIDENCE: The public areas of the accommodation were seen to have a homely and comfortable feel and to be well maintained. The home was observed to be being kept clean and fresh. On bedroom was adjacent to the shower, which had resulted in damp seeping through the wall was seen. Work was underway at the time of the inspection to remedy the problem. The intention was then to redecorate the room. The person whose room it was appeared to remain comfortable in the bedroom but to be looking forward to it being redecorated in the way they wanted. The service users were involved in an ongoing art project to redecorate the bathroom. They had helped design the pictures and Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 18 are helping to copy them onto the wall. Each service user was seen to be making their own contribution. There was a well designed and attractive garden, which included a sensory garden. There was also a bed belonging to one of the service users just in front of their bedroom window, while a greenhouse had been put up for another of the service users. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff were appropriately trained and organised to ensure that all the needs of those living at the home would be met. EVIDENCE: There was a staff rota that reflected the staffing on for the day and showed good staffing levels were being maintained when service users were at home. The manager confirmed that there were three vacancies for support workers but that interviews were arranged for the day following the inspection. The vacancies had meant that some agency staff were used but these were people who knew the home and the service users well. Staff felt that there were enough staff normally on duty to ensure that those living at the home could be supported to undertake their normal range of activities. The staff confirmed that there were good arrangements for induction. The LDAF induction and foundation training was in the process of being upgraded Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 20 and there was an ongoing programme of NVQ training. Staff confirmed that there was a robust training programme and ongoing updating. Speaking to staff and observing them interacting with those living at the home showed that they had a good knowledge of the service users and their need to be supported if they were to live as independently and fully as possible. The staff confirmed that there were regular supervision and team meetings. A member of staff recruited fairly recently provided evidence that the correct procedures had been followed to ensure that people who could endanger those living at the home were not recruited. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Those living at the home benefited from the excellent management, which allowed them to live as independently and fully as possible. EVIDENCE: There was an experienced registered manager in post. Staff confirmed that he was supportive and provided positive leadership. The manager was seen to be supported by an excellent staff and management team. Observing the running of the home provided evidence of excellent systems, including administrative ones, being in place to ensure that the needs of the service users were met. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 22 Excellent arrangements were seen to be in place for monitoring and reviewing the services provided. These included the required monthly visits on behalf of the provider and quarterly reports produced by the manager for the stakeholders meetings. The latter meetings provided an opportunity for service users and their representatives to have an input. The manager had produced an annual development plan for 2006/2007 and there was an annual quality assurance report that summarised the findings from questionnaires completed by service users and their representatives. It was seen that there were excellent monitoring arrangements in the home relating to health and safety issues. There was seen to be an appropriate emphasis on a risk assessment approach in respect both of the environment generally and the specific service users. Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 23 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 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 x x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 4 4 4 x x 4 x Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pemdale DS0000014947.V331080.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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