CARE HOMES FOR OLDER PEOPLE
Pendean House West Lavington Midhurst West Sussex GU29 0ES Lead Inspector
Mrs S Rodgers Unannounced Monday, 12 September 2005, 10:00 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. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Pendean House Address West Lavington, Midhurst, West Sussex, GU29 0ES 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) 01730 812896 01730 817294 www.bupacarehomes.cp.uk BUPA Care Homes (BNH) Ltd Mrs Jaqueline Travers CRH(N)-Care home with nursing 44 Category(ies) of OP-Old age, 44 places registration, with number of places Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13 October 2004 Brief Description of the Service: Pendean House is registered as a care home with nursing to provide accommodation for up to 44 residents in the category, Old age not falling into any other category. Pendean House is a large detached property situated in the rural setting with extensive well maintined garden and grounds. Accommodation is provided in 23 single rooms and 10 double rooms. Communal space comprises of a garden room, lounge and dining room. Pendean House is owned by BUPA Care Homes Liminted, the responsible individual on behalf of the organistion on behalf of the organisation is Mr Stuart Pendlebury. the registered manager in charge of the day to day running of the home is Mrs Jacqueline Travers. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was carried out as part of the routine programme of inspections. Preparation for this inspection focused on a review of previous inspection reports and general correspondence. During the course of the inspection the inspector toured the home, spoke with residents either privately in their own bedrooms or within the communal areas of the home in order to gain a sense of how the home is being run and how they experienced living at the home. Three staff were spoken with in order to gain a sense of the support and training they receive in order to carry out their jobs and to gain insight into how their knowledge of the aims and objectives of the homes philosophy of care. Following the last inspection carried out on the 13th October 2004 both the requirements identified at that inspection have been addressed in full. One remains outstanding. Both recommendations from the last report have been addressed. The registered provider is required to write to the Commission for Social Care Inspection by the 16th September 2005 to advise them of action taken with regards the requirement identified in this report. What the service does well:
Residents spoken with told the inspector that the care and services they receive are of a high standard. Comments such as “nothing is too much trouble for staff” and “ I can’t speak highly enough they do anything for you” were just some of the compliments made about the service. Residents who were asked said that they feel able to develop individual lifestyles within the home they confirmed, “Staff will come back if you don’t want to get up”. The inspector also noted that residents were frequently going out to local shops, local coffee mornings and out with relatives the only request is that they inform staff that they are leaving the home so that in the event of a fire their whereabouts is known. From touring the home the inspector was able to determine that the home was clean and free from offensive odours. The standard of cleanliness is very high. Residents told the inspector that domestic staff are very good and that should they not wish their room to be cleaned or they have visitors their room is cleaned at a more convenient time. The home employs a fulltime activities co-ordinator. Residents told the inspector that there is always something going on and that they can take part in planned activities or pursue their interest. Staff spoken with confirmed that they are actively encouraged to undertake training. New staff go through a 6 week induction programme followed by the foundation course.
Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 6 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. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 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 Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 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) 1, 3, 6 The information provided to prospective residents ensures that they can make and informed decision regarding the service meeting their needs prior to admission. The pre admission assessment enables the management to determine that the needs of person admitted to the home can be met. EVIDENCE: A copy of the Statement of Purpose and Service User Guide is made available to prospective residents or their relatives prior to admission or when they visit the home. Residents have a copy of the Service User Guide in their own bedrooms. The pre admission assessments seen on all new admission indicate that health, personal and social of a prospective residents reviewed, information gained at this time is used to devise a care plan for the prospective resident prior to them being admitted to the home. Intermediate care service is not offered at Pendean House. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 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 The health, personal and social care needs of residents are addressed. Residents’ health care needs are met. EVIDENCE: Care plans were reviewed. They clearly identified the individual needs of residents. Care plans contained all relevant information, including risk assessments for manual handling and nutritional information. Residents who were asked confirmed that they are aware of their care plan and said that they are consulted with regards their care needs. Residents commented that “care needs are totally met by staff”, “It’s going to be tough going home it has been perfect here”, “It is brilliant here” and “staff make sure your dignity and privacy is maintained”. During the course of the inspection the inspector was able to observe staff maintaining resident privacy and dignity by knocking on doors prior to entering their rooms. Residents who required a high level of nursing care appeared comfortable and relaxed. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 10 Care plans clearly record that each resident is registered with a GP. Records are kept of visits to or from the GP, District Nurses, and other Para medical professionals. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 11 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) 12,13 Residents are enabled to develop an individual lifestyle within their own capabilities. Contact with friends and access to the locally community can be maintained. EVIDENCE: Residents spoken with confirmed that the home runs a programme of social activities. The programme for forthcoming events is displayed within the home and residents each receive their won copy. An activities co-ordinator is employed and there is a garden room in which most of the activities take place. Residents spoken with said that the activities co-ordinator “does a fantastic job, there is something to do every morning”. Activities include crossword puzzles, quizzes, coffee mornings, general discussion and crafts. Holy communion is also offered. Residents confirmed that they are enabled to maintain contact with family and friends. They said that their visitors are made to feel welcome by staff and are always offered tea or coffee when they visit. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 12 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) 18 Systems are in place to protect residents from abuse. EVIDENCE: Policies and procedures are in place for staff to follow with regards action to take should they suspect abuse of a resident. Staff spoken with were able demonstrate their understanding of different types of abuse. All were clear of the action they would take should they suspect a colleague of abusing a resident. Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 13 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) 19, 26 The home is well maintained clean, pleasant and hygienic. EVIDENCE: Whilst touring the home the inspector was able to see that resident’s personal accommodation is of a good standard. Residents are encouraged to personalise them with furniture and personal items giving each room an individual homely atmosphere. Communal areas were welcoming and had a relaxed and peaceful atmosphere. All radiators have covers to reduce the risk of accidental burning and the inspector was advised that valves to regulate the temperature of hot water to basins and baths have been fitted. It was noted that some rooms did not have lockable facilities in which residents can store their valuables or medication if they self medicate. During a conversation with Mrs Travers following the inspection she confirmed that an audit of lockable facilities provided in residents private accommodation had been undertaken. The management are installing lockable facilities to all rooms. The standard of cleanliness throughout the home is of a high standard.
Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 14 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, 30 Residents are supported to develop an maintain an individual lifestyle in line with capability, need, and own personal wishes as the skill mix and numbers of staff on duty was sufficient for the needs of the current services. EVIDENCE: Duty rotas seen on the day of inspection evidenced that there were an appropriate number of staff on duty. The home also has a compliment of chef’s kitchen and ancillary staff which ensures that the care team can concentrate on care duties. Staff training records indicate that staff receive training regularly. Staff members spoken with confirmed that BUPA provides staff with a wide range of training opportunities that is augmented by the training co-0rdinator who arranges training session from external trainers. In house training from nursing staff is also organised. All new staff undertake a 6 week induction programme followed by the foundation course. NVQ is offered. At the time of this inspection 11 staff gained an NVQ qualification in care and 8 are currently on an NVQ course. NVQ training is also offered to ancillary staff, 2 staff have achieved the award. Staff spoken with said that “feel supported by senior staff, they listen to our views”.
Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 15 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) 38 EVIDENCE: Maintenance records were available which, clearly indicated that equipment is serviced regularly. Staff receive general health and safety training along side specific training such as manual handling, first aid and food hygiene. Fire training records seen on the day of inspection indicated that staff had last received fire safety instruction in February 2005, it is recommended by that fire safety instruction be carried out 6 monthly for day staff and 3 monthly for night staff. When giving feedback Mrs Travers confirmed that fire training had been given with in the recommended timescales but staff were unaware that the records were on her desk. Risk assessments of the physical environment of the premises was available.
Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 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. 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 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x
COMPLAINTS AND PROTECTION 3 x x x x 2 x x 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 Standard No 16 17 18 Score x x 3 x x x x x x x 2 Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 17 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. 2. Standard 24 38 Regulation 12 23 Requirement Residents must be provided with lockable facilities. Staff must have fire safety instruction at the recommeded intervals of 6 months day staff 3 months night staff. Timescale for action Done Done 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 Good Practice Recommendations Pendean House H60-H11 S24193 Pendean House V243955 120905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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