Inspection on 07/04/05 for Pemdale

This inspection was carried out on 7th April 2005.

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 26/02/07

Pemdale 06/01/06

Pemdale 12/10/04

Pemdale 14/04/04

Pemdale 16/09/03

Similar services:

Coopers Mill Ltd

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Paradise Lodge

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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 Ansuya Chudasama Announced 7th April 2005 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Pemdale Address 26a Nursery Close, Sandy Road, Potton, Bedfordshire Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01767 262515 01767 262515 Aldwyck Housing Association Mr John Farrar-Hockley Care Home 6 Category(ies) of Learning disability under 65 years of age (6), registration, with number Physical Disability under 65 years of age (6) of places Pemdale Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Pemdale is a purpose built bungalow on the edge of Potton, 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 dining/room. There is also a quiet room/study and an office/sleep-in room. Pemdale Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 11 hours. The inspection comprised of a tour of the communal areas, talking to staff, the manager, the service manager, and five service users. Two service users’ files and other records were also inspected. What the service does well: What has improved since the last inspection? What they could do better: Pemdale Version 1.10 Page 6 The complaints policy needed reviewing however the inspector was informed that this was being produced in a format suitable to service users needs. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pemdale Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Pemdale Version 1.10 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 standard(s) 1,2, 3, 4, 5 The homes statement of purpose and introductory visits provided potential service users, and their representatives with details of the services and facilities the home provided. This enabled them to make an informed decision about admission to the home. EVIDENCE: The home had a statement of purpose and service users’ guide, which set out the services and facilities to be provided by the home. The service users’ guide was being produced in a format suitable to meet the needs of the service users. The home had an admissions policy and staff spoken to explained the procedures. Two service users files inspected showed that detailed assessments of service users were undertaken prior to admission. Records also showed that service users and their families had visited the home on an introductory basis. These visits were extended to overnight stays. A review meeting was held with the funding authority when a service user, and their representative decided to accept the placement. A Review meeting was held after a six to eight week period to ascertain if the service user was happy to carry on with the placement. Further reviews were held on a three monthly, six monthly and annually basis. Service users’ licence agreement seen was in two parts. One part was in picture form and this was very good. Information on the funding agency was available in other information but needed to be in the contract. Pemdale Version 1.10 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 standard(s) 6, 7, 8,9 10 The home had clear care planning systems in place to provide staff with the information needed to meet the needs of the service users. EVIDENCE: The service users’ files inspected showed that the information on care planning had been reviewed and this was very good. Each service user had a file on personal information, assessment and care planning, guidelines on service users and key worker responsibilities, health care information, risk assessments, and service users’ finances. The information on service users personal information gave detailed information about the service user. The daily record sheet for each day gave information of what the service user ate, medication taken, personal care given, appointments attended, and activities undertaken. The forms were designed for individual service users and signed by day and night staff. The information seen on assessments and care planning was very detailed and explained how the personal, social and healthcare needs of service users were being met by staff. Care plan reviews were undertaken regularly. An annual review had also been held in January 2005 for one of the files inspected. The staff spoken to had been involved in the care planning process. They stated that they were very pleased with the new care-planning format as they understood it, and it worked. All service Pemdale Version 1.10 Page 10 users had key workers and those staff spoken to understood their roles in undertaking this task. They also held meetings to discuss ways of further improving the quality of care for service users. A file on risk assessments for each individual service user was available. The information was well recorded and staff understood the information. Staff spoken to understood information on confidentiality. This was also discussed in their induction programme. All service users had a file on service users’ finances. The two service users files inspected showed that they had bank accounts but due to their disability, they were unable to sign the book. The housing officer was the appointee for the service users. The money checked was correct and well audited by the organisation. Pemdale Version 1.10 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 standard(s) 12, 13,14, 15,16, 17 EVIDENCE: The service users in the home were unable to get involved in employment training due to their disabilities. Service users’ meeting were held on a weekly basis to discuss their choice of activities. The service users file inspected had activities recorded for mornings and afternoons. One service user was unable to communicate verbally. Symbols were used to help the service user to choose the activity that she wanted to undertake. A communication board was displayed near the kitchen, where the service user was encouraged to pick a picture of an activity, and then she had to take it to the activity room. Guidelines were written for staff on this. The service user enjoyed drawing, listening to music, setting tables, making cups of tea, and matching objects. It was good to see pictures made by service users displayed in the home. The service user also enjoyed going to the shops, horse riding, outings, holidays, tea dances, and going to the park to feed the ducks. The service user had a cat and she was supported by staff to care for it. This was observed on the day of the inspection when a member of staff encouraged the service user to Pemdale Version 1.10 Page 12 feed her cat by taking her in the kitchen. The homes day care coordinator monitored each service users’ day care activities and a report was written on a three monthly basis. This information was discussed at the stakeholders meetings. The out door activities were accessed by using the homes mini bus. Service users likes and dislikes for food were recorded in their files. The menu seen was varied and nutritious. The staff spoken to were aware of what the service users likes and dislikes for food. The inspector had lunch with the service users and this was eaten in a relaxed atmosphere. The staff were observed helping service users in a sensitive manner. Staff addressed service users by using their names. They were observed accessing all parts of the communal areas safely. Service users opened their mail with support from staff. The home also had volunteers from the church and they undertook activities in singing and music to movement twice a week. Some also attended church service. Records showed that the home had good working relationships with families. The home also had a beautiful garden with a green house. This was created from the support from the local communities. Pemdale Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21 Service users’ personal and health care needs were being met by the home. EVIDENCE: The care plans gave detailed information on how service users’ personal care needs were being met by the home. The inspector was informed that male staff did not give personal care to female service users unless it was an emergency situation. Staff supported Service users to choose their clothes. A hairdresser visited the home to cut the female service users hair. This was because the service users knew the person well and felt relaxed. The male service users used the community barbers to have their haircut. Each service user had a file on health care needs. This contained up to date information on current medication and reviews undertaken. Records were kept of appointments with different medical professionals and the outcome of the visits was well documented. Monitoring charts for behaviour and other issues, and weight charts were seen. The information was recorded very well in the file. The staff also took the file on health with them when they accompanied service users to their appointments. It was stated by staff that they found this very helpful because they were able to provide all information on service users health needs at the visit. All staff had received the medication training and the mars sheets were completed properly. The home had written procedures on ageing illness and death. The files seen had information recorded on service users wishes concerning burial arrangements. Pemdale Version 1.10 Page 14 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 standard(s) 22,23 The staff had good understanding of Adult Protection issues, which protects service users from abuse. EVIDENCE: The home had a complaints policy but needed reviewing to meet the standard. The inspector was informed that this policy was being produced in a format for service users to understand. Service users who were able to communicate verbally were asked if they knew who to speak to if they were unhappy. It was stated that they would speak to the manager or the staff. The manager and staff were asked how they would be able to know if a service user who was unable to communicate verbally was unhappy or being abused. They stated that they would know if some thing was wrong by the change in the service users behaviour pattern. Many examples given about the service users behaviour pattern showed that the staff understood the needs of the service users well. The home had policies and procedures on adult protection. This was also covered in staff induction programme. Some staff had been on training courses on POVA. Pemdale Version 1.10 Page 15 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 standard(s) 24,25,26,27,28,29.30 Service users live in a homely, comfortable, and safe environment. EVIDENCE: The home was purpose built and provided accommodation to meet the needs of service users with a physical disability. The premises were pleasantly decorated and very clean. Service users’ rooms seen were individualised and decorated to a very high standard. One of the service users spoken to stated that she liked her room and had chosen the colours and ornaments. Service users were observed accessing all parts of the communal areas safely. The home had a fully adapted bathroom with multi-level bath and spa facility as well as a wheel-in shower. The home also had four toilets. The equipment provided included a range of hoists and slings, and adjustable height washbasins. Pemdale Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 EVIDENCE: The staff spoken to stated that the organisation provided excellent training for all staff. She also discussed and identified training for staff to attend. The staff stated that she had attended many courses and this included all the mandatory courses. At present she was doing the Registered Managers Award and was due to complete this month. The staff member was also a qualified NVQ assessor. Two staff were undertaking NVQ level 3, three staff were undertaking NVQ level 2 and 1 staff had NVQ level 3. New staff undertook the LADAFF induction training. The staff received regular supervision on a monthly basis, and yearly appraisals. The staff stated that weekly team meetings were held. The staff files randomly inspected showed that all staff had CRB checks, job descriptions, two references, and contracts. A copy of the current passport or birth certificate was not available. The home had vacancies for three full time and one part-time staff. The home used permanent staff, bank staff and agency staff to cover the vacancy hours. The agency staff used by the organisation had worked for them for a number of years, and they knew the service users needs well. Pemdale Version 1.10 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41,42,43. There were appropriate systems in place to ensure the health and safety of staff and service users. EVIDENCE: The manager was very experienced and had completed his Registered Managers Award. The home was maintained at a high standard. The staff and service users stated that the manager was very supportive. The management style of the home was described as being open and positive. The manager and the staff appeared very enthusiastic and motivated. The home used regulation 26 visits, letters from friends, families, and student placements feedback, investors in people, service users and staff surveys, and stake holders meetings held on a three monthly basis to monitor their aims and objectives of the home. It was stated that the results from the service users recent survey was very positive. The information needed to be displayed in the service users’ guide. Records sampled on the day of the inspection were well recorded and well maintained. The staff spoken to stated that she did fire training with staff. The staff also explained fire testing procedures to service users. Fire Pemdale Version 1.10 Page 18 testing, fire drills and emergency lighting were carried out regularly. Risk assessments on the environment and service users had been carried out. All staff had received training on safe working practices. The home had a business plan and the manager had systems in place to monitor the homes budgets. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Pemdale Score 4 3 3 4 3 Standard No 24 25 26 27 28 29 30 STAFFING Version 1.10 Score 4 3 4 3 3 3 3 Page 19 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score 3 3 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 3 x 3 3 3 Pemdale Version 1.10 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 1 22 34 Good Practice Recommendations Provide the service users, guide in a format that is userfriendly. Ensure that the complaints policy is reviewed to include all the information stated in the standard. Ensure that a copy of the staffs birth certificate and passport are obtained when recruiting new staff Pemdale Version 1.10 Page 21 Commission for Social Care Inspection Clifton House Goldington Road Bedford MK40 3NF 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 Pemdale Version 1.10 Page 22 - 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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