CARE HOMES FOR OLDER PEOPLE
Pendarves 25 Pendarves Road Camborne Cornwall TR14 7QF Lead Inspector
Paul Freeman Announced Inspection 1st December 2005 10:00 X10015.doc Version 1.40 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 Pendarves DS0000008928.V258800.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 Older People. 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. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Pendarves Address 25 Pendarves Road Camborne Cornwall TR14 7QF 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) 01209 714576 01209 714576 Mr Davood Mohajeran Mrs Kima Mohajeran Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. To temporarily accommodate one named person outside the registered categories of the home from 14/3/05 to 18/3/05 Total number of service users not to exceed a maximum of 10 Date of last inspection 27th June 2005 Brief Description of the Service: Pendarves is a three storey Victorian house situated on the outskirts of Camborne. There is therefore a large range of social amenities in close proximity to the home. The home provides twenty four hour care for up to 9 older people and presents as warm and friendly. The care home is owned and run by Mr and Mrs Mohajeran who are committed to providing care that encourages independence and meets individual residents needs in a manner that promotes independence, dignity and choice. Mr and Mrs Mohajeran are also committed to take all reasonable steps to provide a healthy and safe environment. The home is well maintained and a chair lift is provided for access to the upper floors. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned announced inspection took place on 1 December 2005 and lasted for six hours. The Inspector looked over the building and at a number of records and documents. Six of the residents, two of the staff and Mr and Mrs Mohajeran the Providers were spoken to. The environment and facilities provided were also considered. Written comments about the services and facilities provided were also received from two residents and two visitors to the care home. The Inspector found the requirements and recommendations set at the last inspection had been worked upon. What the service does well:
Each resident is provided with a suitable contract that details the terms and conditions of residency at the home. Where funding is provided by a third party the funding agency issues the contract and the Providers issue terms and conditions of residency that detail any areas that are not covered in the contract. All prospective residents needs are assessed by the Providers to make sure the home is able to meet the individual’s needs, preferences and choices. The prospective resident and their relatives or representatives are also fully consulted about the assessment. In addition the Providers with obtain the views of any appropriate professional that are actively involved with the person concerned. Residents that had recently moved to the care home said they had been fully consulted about their needs, preferences and choices and felt in control of the events leading up to their admission. A dedicated intermediate care or rehabilitation service is not provided at the home. The Providers and staff make every reasonable effort to encourage and support residents to maintain their independence and dignity. Each resident has a care plan that details their needs and the most appropriate ways of providing the care and support they require. The information in the plans provides staff with clear directions about the care and support required. The plans are regularly reviewed with residents and their relatives or representatives to make sure they are up to date and that a satisfactory service is provided to each person residing at the home. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 6 Residents were very complimentary about the care and support they receive and said that staff always treated them in a positive, respectful and dignified manner. Residents stated they felt in control of their lives and found the staff and Providers to be trustworthy, reliable and approachable. Residents said they were very satisfied with the lifestyle they experienced at the home. They feel in control of their lives and have appropriate opportunities to participate in activities and recreational pursuits at the home and in the local community. The visiting arrangements are flexible and residents commented that the staff always positively welcome visitors. Written information about visiting is provided to relatives that has recently been reviewed and improved by the Providers. Satisfactory arrangements are in place to deal with any concerns or complaints the residents may have. Residents commented they comfortable about discussing any issues or concerns with the Providers and staff. A homely and well maintained environment is provided. Residents said they were very satisfied with the facilities provided. A programme of redecoration and replacement is in place and residents commented that any repairs are completed efficiently. Appropriate communal areas are located on the ground floor and comprise of two sitting rooms and a dining room. Residents’ bedrooms have single occupancy and are suitably furnished and decorated. The rooms have all been personalised by the occupants and are furnished to the required standard. Residents are provided with suitable disability equipment to maximise their independence when this is required and a stair lift is in place to promote access to the upper floors. Bathrooms and toilets are distributed throughout the care home and are within a reasonable distance from the communal areas and residents bedrooms. The home is pleasant, clean and a good standard of hygiene is maintained. Sufficient number of staff is on duty to meet the needs of residents. Residents commented they were very pleased with the manner in which the staff provided care and support. The residents said staff were flexible and treated them in a respectful and dignified manner. The staff is appropriately trained and an ongoing programme of training is in operation. This makes sure that staff has the skills and abilities to provide a positive and reliable service to residents. The home is well run and managed by the Providers and in a manner that promotes the best interests of the residents. Both Providers play an active role
Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 7 in the day to day delivery of care. Appropriate on call arrangements are also in place for staff to contact the Providers when they are not on duty at the home if any support or guidance is required. The staff are appropriately supervised and stated that advice, guidance and support is always available whenever it is required. What has improved since the last inspection? 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. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Reliable arrangements are in place to assess the needs of prospective residents to make sure the Providers are able to meet the individual’s needs, preferences and choices. Each resident is issued with a suitable contact that details the terms and conditions of residency at the care home. EVIDENCE: Each resident is provided with a contract that details the terms and conditions of residency at the home. The contract is issued by the Providers where an individual funds their own care or by a third party where assistance is given towards meeting the fees. In theses circumstances the Providers also issue terms and conditions of residency that detail any issues that are not covered in the third parties contract. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 10 Each prospective resident needs are assessed by the Providers to make sure the services and facilities provided are suitable to meet the individual’s needs, preferences and choices. The prospective resident and their relatives or representatives are involved in the assessment process and the Providers stated that every reasonable effort is also made to also consult with any speaclist workers that are involved with the person concerned. It is recommended the providers make a record of their attempts to obtain information from speaclist workers given limited information was available for consideration in the assessment records sampled by the Inspector. A dedicated intermediate care or rehabilitation service is not provided at the care home. The providers and staff do make every reasonable effort to promote residents independence. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. The care planning arrangements continue to improve but need to include the night time arrangements to make sure staff are provided with a comprehensive picture of each residents needs. EVIDENCE: Each resident has a care plan that is draw up in consultation with the individual concerned. The care plans provide information, guidance and direction to staff about the most suitable and safe means of meeting the persons needs, preferences and choices. The plans are well written and provide staff with the easily accessible information they require. The plans do not however cover the residents’ nighttime arrangements or needs. Residents said they were very satisfied with the care and support at the home and said they had trust in the staff and found them to be reliable. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 12 The evidence indicates that care plans are regularly reviewed with residents to make sure the care and support provided suitably meets the persons needs and wishes. Residents commented they were very satisfied with the dignified and respectful manner in which staff treated them. Residents said they felt in control of the care and support provided and found the staff to be reliable, responsive and available when they are required. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Residents experience a positive lifestyle and feel in control of their lives and the care and support provided. EVIDENCE: Residents said they were satisfied with the lifestyle they experience at the care home. All residents stated there were sufficient activities occurring in the home and the local community to satisfy their needs and interests. Activities regularly occur at the home but at this time they occur spontaneously and are not programmed. This reflects the residents’ preference and choice and provides suitable stimulation and occupation. The visiting arrangements are flexible and residents commented that visitors are always welcomed at the home. Visitors are requested to avoid mealtimes to avoid any potential disruption to the other residents at the home. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 14 Residents stated they felt in control of their lives and are able to direct the care and support they require from the staff and Providers. Therefore residents were confidant they were able to make decisions for themselves and their personal choices and preferences are consequently accommodated. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Arrangements for responding to residents concerns and complaints are satisfactory. Further improvement is necessary about the adult protection measures in order to make sure that every reasonable step is taken to protect residents. EVIDENCE: A suitable policy and procedure is in place for dealing with complaints. The home or the Commission has received no complaints since the last inspection. Residents commented they feel very comfortable about discussing any issues or concerns with the Providers or staff of the home. The home has improved the arrangements in place to protect residents from abuse. The policy and procedure requires further improvement in order that it meets the Department of Health guidelines. The additional guidance notes provided for staff also requires amendment to make sure that any concerns or allegations are reported to the appropriate statutory bodies. A satisfactory whistle blowing policy and procedure is in place. This provides staff with an opportunity to raise any concerns or issues with a third party and offers residents further protection. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 and 26. The environment and facilities is well maintained and provides a homely setting for residents. The laundry facilities would benefit from relocation and this will enhance the bathroom arrangements on the upper floor. EVIDENCE: The environment comprises of a three storey building that has bedrooms on three levels. The facilities provided are of a good standard and are well maintained. Therefore a homely atmosphere exists and residents said they were very satisfied about all aspects of the environment. Communal areas are located on the ground floor and comprise of a sitting room, an adjoining dining room and a conservatory at the rear. The rooms are appropriately decorated and suit the needs of the residents. Bathrooms and toilets are located throughout the care home and in reasonable proximity to communal areas and residents bedrooms.
Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 17 Residents’ room are also well presented and the occupants have clearly personalised their rooms. All the rooms have single occupancy and include a sink. Some of the room are also provide with a toilet. The furniture and fittings in the rooms are domestic in nature wherever possible and appropriate heating and lighting is provided throughout the home. A good standard of hygiene and cleanliness is maintained and where required residents are provided with disability equipment to maximise their independence. A chair lift is also provided to access the upper floors. The laundry is located on the upper floor in a room that also includes a bath. It is the Providers intention to relocate the laundry to the ground floor and provide a suitable bathroom in the present location. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 Sufficient numbers of staff are employed during waking hours to meet the needs of residents. No waking staff is on duty at night but staff sleep in to deal with emergencies. This is a satisfactory arrangement given the presents needs of residents. Staff are appropriately trained in order to develop their skills and the care and support provided to residents. EVIDENCE: The staff roster indicates that sufficient numbers of staff are on duty during waking hours to meet the needs of the residents. Additional staff is also provided at peak times e.g. first thing in the morning to make sure residents needs and choices are accommodated. Residents commented the staff were “very good” and they were very satisfied with the manner in which the staff provided care and support and met their needs. Residents said they felt in control of the care they received and found the staff to be flexible in their approach and available when required. No waking night staff is currently employed but staff sleep at the home to assist with emergencies. The residents are also very satisfied with this arrangement. Staff is regularly provided with training and the evidence indicates the Providers have established an ongoing training programme for all staff members. The training reflects the individual needs of each staff member as
Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 19 well as making sure that staff are trained in the core areas of the work they undertake. In addition a number of staff are trained to NVQ 2 standard. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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 and 36. The home is well run and managed by the Providers in a manner that promotes the best interests of the residents. Staff are also well supported and regularly supervised by the Providers to make sure that residents’ needs are met. EVIDENCE: The home is well run and well managed by the Providers who both play an active part in the day to day delivery of care. Residents commented they found the home was run in a way that promoted their best interests. The staff said they found the Providers to be supportive and available whenever they required assistance or guidance. The Providers have recently moved from the care home to a house in the immediate vicinity. Therefore they have appointed a staff member to be
Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 21 responsible for providing any care and support required over night. The staff member concerned resides at the care home in the flat previously occupied by the Providers. The Providers have also established reliable on call arrangements when they are not on duty at the care home. Staff at the home are regularly supervised by the Providers and staff said that informal advice, guidance and assistance is available when required. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 3 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X X Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No 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. 2. Standard OP7 OP18 Regulation 15(1) 12 and 13 Requirement Night time arrangements must be included in each residents care plan. A comprehensive policy and procedure and guidance notes for protection must be established and must reflect the Department of Health guidance No Secrets. (Previous timescale of 30 April 2005 not met). Timescale for action 28/02/06 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Copies of any assessments completed by professionals or any discussions that take place with the professionals involved with prospective residents should be obtained or made by the Providers. The laundry facilities should be relocated to the ground floor and a suitable bathroom should be established in the
DS0000008928.V258800.R01.S.doc Version 5.0 Page 24 2 OP21 Pendarves current location of the laundry. Pendarves DS0000008928.V258800.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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