Inspection on 19/01/06 for Pendean House

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Pendean House 27/06/07

Pendean House 12/09/05

Pendean House 13/10/04

Pendean House 04/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pendean House West Lavington Midhurst Chichester West Sussex GU29 OES Lead Inspector Mrs S Rodgers Unannounced Inspection 19th January 2006 10:30 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 Pendean House DS0000024193.V273256.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. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pendean House Address West Lavington Midhurst Chichester West Sussex GU29 OES 01730 812896 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) BUPA Care Homes (BNH) Limited No. 2079932 Mrs Jaqueline Travers Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 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. The property is a large detached and extended house situated in the rural setting with extensive well-maintained 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 Limited, the responsible individual 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 DS0000024193.V273256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours and was the second visit carried out as part of the routine programme of inspections. Preparation for this inspection focused on a review of previous inspection report 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. Comments such as “the service is excellent”, “you have a choice of how to live your life, “staff are kindly and willing”, “staff sensitive to maintaining our dignity” and “it’s like an extended family, staff do so much to keep us involved and entertained”, were shared with the inspector. Two 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. Staff told the inspector that they “feel supported by the management”, “we are offered and encouraged to undertaking training” and “ we can discuss anything, we have regular staff meetings and formal supervision”. From reviewing records and from observation throughout the inspection the inspector gained the view that residents are satisfied with the services provided. Staff are fully aware of the needs of residents and carry out their duties in a sensitive manner. The general atmosphere within the home was relaxed and jovial. Further comments may be included in the main body of the report. All standards not assessed at this visit were assessed at the previous visit and were met in full. Following the last inspection carried out on the 12 September 2005 all requirements identified at that inspection have been addressed in full. One requirement was identified at this inspection. The registered provider is required to write to the Commission for Social Care Inspection by the 22 February 2006 to advise them of action taken with regards the requirement and timescale in which compliance with the regulations will be achieved. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 6 What the service does well: 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 DS0000024193.V273256.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed at this inspection as the reviewed at the last visit and were met in full. EVIDENCE: Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 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 the following standard(s): 9,10 Appropriate systems are in place for the receipt, recording, storage, handling, administration and disposal of medication. Residents are treated with respect and their dignity is maintained. EVIDENCE: The home has an agreement with a local pharmacy that supplies the home with prescription medication. The pharmacist visits the home twice a year to inspect the homes systems. The home uses the nomad system. All regular medication is received monthly. A system is in place to check medication coming into the home, a senior nurse signs in confirmation that they have been checked and records the number of tablets/quantity of medicine received. The home has a contract with a waste disposal company to dispose of unwanted/out of date medication. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 10 Records of medication administered to residents were in good order. The M.A.R sheets clearly indicate any known allergies. Trained nurses administer all medication; records of their signatures and initials are kept in the medication file. All medication is kept in lockable facilities. Residents who were asked confirmed that staff respect and maintain their privacy and dignity. When asked how residents responded with comments such as “staff always knock on doors prior to entering their rooms” and “staff minimise awkwardness when carrying out care tasks, they cover you up when they can and ensure curtains and doors are closed”. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 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 the following standard(s): 14,15 Residents are able to exercise choice over their lives. A well-balanced and varied diet is offered EVIDENCE: A number of care plans were seen that indicate that residents do have a choice in how care they would like care to be delivered. Residents spoken with confirmed that they are able to get up and go to bed when they wish, residents who needed assistance when getting confirmed that staff will go away and come back later if they do not wish to get up straight away. Residents also benefit from an extensive activities programme, which residents say they are able to access if they choose or they can purse their own interests. Residents spoken with told the inspector that food provided was of a high standard. A five weekly menu is followed, it was confirmed that the menus are going to be updated in the near future. Menus demonstrate and residents confirmed that a varied menu is offered. Special diets are also catered for. Liquidised meals are served appropriately with all vegetables, meat or fish being liquidised and served separately. Alternatives to the main meal are Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 12 available. The kitchen was clean and store cupboards appropriately stocked. Fresh fruit is readily available. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 13 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 A complaints process is in place enabling residents and relatives to raise their concerns with the management. EVIDENCE: The home has a written complaints procedure. It clearly states whom to contact should someone need to raise a concern and the timescales in which the complaint will be dealt with. The procedure is included in the Statement of Purpose and Service User Guide, each resident has a copy of these document within their own rooms. There has been one complaint since the last inspection that was dealt within stated timescale. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 14 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): These standards were not assessed at this visit as they were assessed at the previous inspection and were met in full. EVIDENCE: Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 15 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): 29,30 A recruitment procedure is in place to safeguard and protect residents. Staff are appropriately trained. EVIDENCE: A recruitment procedure is in place. All staff complete and application form, references and checks against the Criminal Records Bureau and the Protection of Vulnerable Adults list are sought. A formal interview is carried out prior to the post being offered. Records seen at this inspection indicate that the appropriate checks have been undertaken on all new staff. Records seen and staff spoken with at this inspection evidence that staff receive induction training, and are offered the opportunity to undertake an NVQ qualification. The home has a full time training officer who co-ordinates staff training. Mrs Travers confirmed that 66 of care staff hold an NVQ level 2 or 3 qualification. Staff were observed to be relaxed and confident whilst carrying out their duties. The inspector noted that they were also respectful when talking or assisting residents. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 16 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): 31,33,35 The home benefits from being run by an experienced manager who has a management qualification. The home seeks the views of residents. Systems are in place to protect the welfare of residents. EVIDENCE: Mrs Travers is the registered manager, she is a Registered Nurse on part 1 of the register, she advised the inspector that she has recently gained the Registered managers award. Staff said that they felt supported by Mrs Travers and that she listens to their opinions concerning care of residents. The home carries out various audits including seeking the views of residents however, the information gained from these survey is not collated into a report which informs providers and assists them to devise a development plan which is based on a systematic cycle of planning, action, review and reflecting the aims and outcomes for residents. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 17 All staff receive training in safe working practices. Maintenance records indicate that the physical environment and equipment is maintained in order to ensure the health and safety of residents. Risk assessments are undertaken on a wide range of topics such as the physical environment and any risk that may compromise the health and safety of residents and staff i.e. moving and handling. Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 18 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 19 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. Standard OP33 Regulation 24 Requirement The registered providers shall establish and maintain a system for reviewing at appropriate intervals; improving the quality of care provided at the care home, including the quality of nursing where nursing is provided. Timescale for action 22/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worthing LO 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 © 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 Pendean House DS0000024193.V273256.R01.S.doc Version 5.0 Page 21 - 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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