CARE HOMES FOR OLDER PEOPLE
Pendarves 25 Pendarves Road Camborne Cornwall TR14 7QF Lead Inspector
Paul Freeman Unannounced 27 June 2005 09.30 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 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 D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Pendarves Address 25 Pendarves Road Camborne Cornwall TR14 7QF 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) 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 D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: 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 31 January 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 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 D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over five and quarter hours. The Inspector looked over the building and at a number of records and documents. Eight of the residents, three of the staff and Mrs Mohajeran the provider were spoken to. The Inspector found the requirements and recommendations set at the last inspection had been worked upon. What the service does well: What has improved since the last inspection?
The home has improved their arrangements to protect residents from abuse. Further improvement is required about the reporting arrangements to make sure every reasonable step is taken to protect residents.
Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 6 The arrangements to select and recruit staff have improved and now meet the required standard. The arrangements to provide a safe environment for staff and residents have also improved and are now satisfactory. The staff is provided with sufficient guidance to make sure that people are not placed in a position of unreasonable risk. Where there are concerns about an individual resident a risk assessment and suitable action plan are completed. What they could do better: 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. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 8 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 standard(s) 3 and 5 The admissions process is well managed and prospective residents are assessed by the providers to make sure the home can meet their needs. The records of the assessments need to be improved to make sure that all needs are considered. Prospective residents are able to visit the home to help them make a decision about their plans for the future. EVIDENCE: Before a prospective resident moves to the care home the providers meets with them and complete an assessment of their needs. This makes sure the home will be able to meet the needs of the person concerned. The assessment takes account of the views of the person’s relatives and any professionals involved. Residents that had recently moved to the home commented they had been fully consulted about their needs and preferences. The records of the assessments were not fully completed on some occasions. Prospective residents have to opportunity to visit the home to help them decide if this is a suitable setting for them to live. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 9 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 standard(s) 7, 8 and 9 Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Each resident has a care plan that outlines the care and support they require. The plans provide staff with the information and guidance they need to meet the needs, preferences and choices of the person concerned. The plans are regularly reviewed with the residents and amendments are made when required. Residents commented they were very satisfied with the care and support provided at the home. The home is keen to make sure that residents’ health needs are met appropriately. Residents commented they were very confident about the way the home meets their health needs and health services were promptly accessed when required. The records at the home indicate that health professionals have regular contact at the home. Positive arrangements are in place to administer medication in a safe manner. The staff responsible for medicines are appropriately trained and residents are able to look after their own medicines when it is safe to do so.
Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 10 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 standard(s) 13 and 15 The visiting arrangements are flexible but the written information about visiting should be improved. The meals are satisfactory and a varied menu that reflects residents choice is provided. EVIDENCE: The visiting arrangements are flexible and residents commented that visitors are always welcomed at the home. Visitors are requested to avoid mealtimes and a recent letter about the visiting arrangements has been issued to relatives. The contents of the letter would benefit form further consideration to make sure relatives are fully aware of the flexible arrangements. Residents commented they were satisfied with the food provided and a varied menu that provides a nutritional balance is available. Residents said their preferences and choices were taken account of at each mealtime. Refreshments are also readily available when required. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 11 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 standard(s) 16 and 18 Arrangements for responding to residents concerns are satisfactory. Further improvement is necessary about the adult protection measures in order to meet the required standard. EVIDENCE: A suitable policy and procedure is in place for dealing with complaints. No complaints have been received by the home but one was received by the CSCI. The concerns raised were not upheld. Residents and staff commented they feel very comfortable about discussing any concerns with the providers and 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. A satisfactory whistle blowing procure 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 D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 12 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 standard(s) Not assessed. EVIDENCE: The Inspector noted no significant concerns. Residents commented they were very satisfied with the accommodation provided and the good standard of hygiene and cleanliness maintained. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 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. The procedure for the recruitment and selection of staff are satisfactory. 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 are 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 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. 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. No new staff has been appointed but two staff are currently in the process of being recruited. The staff recruitment arrangements have improved and a satisfactory process has been established to select, recruit and vet staff. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 37 and 38 The home is well managed and in a safe in a way that promotes the best interests of the residents. Satisfactory records keeping arrangements are in place. EVIDENCE: 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 written to residents or their representatives about the laundry arrangements. The information provided is not satisfactory, as it does not accurately detail the arrangements that are in place. The records at the home are well maintained and meet the requirements laid down in the regulations. Records are kept on a daily basis of the events that occur to residents and record any action the staff has taken. These records are available to the person concerned if required.
Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 15 A number of measures have been put in place to provide a safe environment for residents and staff. The arrangements to manage risks have been improved and where appropriate specific guidance is provided to staff to minimise unreasonable risks to residents. This makes sure that every reasonable step is taken to remove or minimise risks around the home. A number of satisfactory policies and procedures are in place for the staff to give direction about working in a safe manner. Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 16 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. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 2 14 x 15 3
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x x 3 3 Pendarves D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 17 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. 2. Standard 3 18 Regulation 14 12 and 13 Requirement The record of the assesssment for prospective service users must be comprehensive. A comprehensive policy and procedure for protection must be established and must reflect the Department of Health guidance No Secrets. (Previous timescale of 30 April 2005 not met). The written guidance about laundry must be reviewed and reissued to residents and their realatives or representaives to indicate the laundry that is regaulry undertaken as part of the contractual arrangement. Timescale for action 30.9.05 30.10.05 3. 33 16 30.9.05 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 13 Good Practice Recommendations The written information provided to realtives about visiting should be written in a manner that demonstrates the flexibe nature of the arrangements.
D52-D04 S8928 Pendarves V222176 270605 Stage 4.doc Version 1.20 Page 18 Pendarves Commission for Social Care Inspection 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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