Inspection on 18/10/06 for Pendeen Residential Home

This inspection was carried out on 18th October 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

Pendeen Residential Home 20/12/05

Pendeen Residential Home 18/01/05

Pendeen Residential Home 13/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pendeen Residential Home 63 Pendeen Crescent Southway Plymouth Devon PL6 6RF Lead Inspector Kim Fowler Unannounced Inspection 18th October 2006 09:30 Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 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 Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 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 Adults 18-65. 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. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendeen Residential Home Address 63 Pendeen Crescent Southway Plymouth Devon PL6 6RF 01752 794447 01752 794447 headoffice@durnford.org 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) The Durnford Society Limited Mrs Kathryn Fiona Kerry Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9), Physical disability (9), of places Physical disability over 65 years of age (9) Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Pendeen is a care home for nine people of both sexes who have a learning disability. The home is managed by the Durnford Society and is situated in a purpose built, single level building that is owned and maintained by Plymouth City Council. The home is in a residential area of Plymouth and above the home in the same building are a number of flats, whose tenants have a separate entrance. The home has nine single bedrooms, and has a large lounge, dining area and conservatory that leads on to a pleasant garden area. The home is within walking distance of shops and is on a bus route. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 2 days. And the Registered Manager was available throughout the inspection to assist the inspector with changes made within the home. A full tour of the building was undertaken and the inspector spoke to all the service users. The staff that were on duty and a therapist visiting at the time were spoken with. Documentation relating to the care planning process and the management of the home were examined. On the first day of the inspection resident comment cards had been given to the care home to allow residents and families to comment upon their experiences. Three staff comment cards were received as well as one Professional and one relative feedback card. Any comments are discussed in the relevant section of the report. What the service does well: What has improved since the last inspection? What they could do better: Service users would be safer if staff who were responsible for the administration of medication had received more appropriate training and were better supervised. Also the home’s medication procedure for emergency administration medicines should be made available to staff which would ensure they were better informed. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1/2/4/5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective new service users can be assured that the home will complete a detailed pre-admission assessment which will assist staff in meeting their assessed individual needs. EVIDENCE: Service users files were examined during this inspection. Of these files 3 were new admissions to the home since the last inspection. One new service user had received copies of the homes statement of purpose and a service users guide. Both documents had been recently reviewed. Recorded on the files of two of the most recently admitted service users was preadmission assessment information. The assessment were comprehensive in detail showing full details of the needs of the service users. Records also Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 9 showed that these service users had been able to make visits to the care home before permanently moving in. Unfortunately another recently admitted service user, who had been transferred from another of the companies care homes, did not have a preadmission assessment. This service user had not been given the opportunity of a trial visit or a settling in period as the other care home had closed. This service user had previously resided at this care home and had requested to return. However many changes had taken place at the home. Which included new care staff and new service users. Of all the service users files examined 3 did not have a copy of the contract with the care service and the service user. Absence of a copy of a contract prevented these service users from having access to information about the terms and conditions that applied to their residence. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6/7/9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the care plans will provide information that enable staff to meet their care needs. EVIDENCE: Service users files contained a completed Care Plan. The care plans describe how the home will meet the assessed needs of individual service users. Of the 6 files examined all had good detailed records regarding medication, personal care needs and methods of communication. The level of detailed information enabled care staff to meet the assessed needs of each individual service user. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 11 The records show these care plans are reviewed regularly and record any changes in needs of the service users. Due to the complex needs of the service users in the home many are unable to make decisions independently. But care staff encourage service users to make many decisions and choices on everyday issues. Using public transport and going to leisure activities are among a list of experiences that need a decision to be made by service users. Some service users are able to assist with the day-to-day running of the home, however only a few of the service users are able to assist with managing their own finances. Records show one service user has their own bank book and assists with paying their own fees. Another service user has their own bankcard and is assisted to draw and manage their personal allowance. Individual risk assessments have been completed for each service user, which were available on file. These risk assessments are based on risk and choice. Many risk assessments relate to everyday issues including personal care. There was a record to show that the homes manager had made an application in order to obtain an advocate who would speak on behalf of one service user. As many service users have communication difficulties and find it difficult to make decisions independently it was felt most would benefit by having an advocate. Individual Bank Statements were seen and clearly state the income and expenditure for each service user. The money was checked for 2 service users during this inspection and was found to be correct. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/15/16/17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can be confident that the home will provide support for them to access the local community and many leisure activities. EVIDENCE: The home continues to encourage service users to participate in social activities and develop their social skills. This is assisted by providing transport and additional staff support to enable service users to access the community, day centres and to provide outings. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 13 Service user files contained information about their attendance at college courses, and there were certificates showing the achievements they had gained. This home and it’s service users relate well to the local community, local shops and banks are used and service users take regular walks around the local area. One service user had attended a music session at a local school. And another 2 service users were at a local club, called the “Orbit” club. This club has been set up for people based in the local area who have a learning disability. A further 2 service users were going to attend a sensory room later that day. One service user is residing at the home under a “shared care” scheme. This service user stays with their family part of the week. The remaining part of the week the service user stays at the home. A timetable showing planned dates and times of home visits has been recorded. Another service user stays with his family regularly. Some service users had information about the holidays they had attended this year, recorded on their files. This information was about trips to, Paris, Jersey, Austria and Yorkshire. The home has a daily activity file. Recorded in this file is information about the activities of each service user including what household tasks they may have carried out. All bedroom doors have suitable locks which service users are able to use when in their own bedrooms. The staff are able to override the locking device if needed. None of the current service users has been offered a key to their bedrooms. The information about why they are not able to hold a key has not been recorded in care plans. The Service users preferred form of address is recorded in their care plans, also those unable to open their own mail and therefore needing assistance, also appears. The homes menus were examined and staff confirmed a good budget to purchase provisions. The staff spoken with agreed that the home provides good quality and wholesome food. The menu is designed to meet the service users likes and dislikes and from discussion with the staff they are aware of each service users individual needs. Food prepared for the service users during the 2 visits was well presented. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can be assured that they will receive excellent healthcare support and that their privacy and dignity will always be respected. EVIDENCE: Staff were observed providing service users with personal support. This was carried out in private and the service users dignity was maintained. All Care Plans have details as to how personal support should be carried out. Also manual handling information is supplied to staff. Physiotherapist and Occupational therapist assessments are recorded on service users files as well. Some service users were found to have been provided with wheelchairs whose seats had been specially moulded to fit them. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 15 The home has a key worker system in operation, this assists service users in their daily lives, when faced with the need to make a decision or a choice, as their key worker has developed an in depth understanding of their personality, likes and dislikes. All service users health is monitored for any change in condition and, any extra provision or support needed is arranged. This was well documented on service users records. In particular, information relating to epilepsy was well organised. Two GP’s are regularly used for most of the service users in the home. One service user under the shared care system retains their own GP. Service users also receive a service from a Speech and Language Therapist and a Consultant Psychiatrist. The staff seek advice from outside professional agencies when required. This was confirmed as during the inspection a staff member was heard discussing a continence issue with a district nurse. The home uses the blister pack monitoring system and the pharmacist makes these up. For those service users that may need the emergency administration of medication a procedure was available. This described under what circumstances the medication may be given. However, it was not clear, and there was some confusion about the way this medication should be given. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service users can be confident that any complaints or concerns raised will be listened to. EVIDENCE: Although the homes complaints procedure was seen in the Service Users Guide and the homes Statement of Purpose, it was not displayed on the homes notice board for service users or visitors. The home does not have a designated file to record complaints and compliments passed onto the home. The Commission has not received any complaints, since the last inspection. All staff are booked onto an in-house course based on “No Secrets”. The Durnford Society is presenting this. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 17 None of the staff or management has completed the local Adult Protection course carried out by the local authority. This should be considered as this would ensure familiarity with local authority practices and procedures. Some longer serving staff members have not had a criminal record bureau check for a number of years. Regular checks should be considered as these could ensure the on going protection of service users. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24/30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The service users benefit from a homely, comfortable, clean and wellmaintained building that is appropriate to meet their needs. EVIDENCE: The premises are accessible to all the service users with level access throughout. It is comfortable, well furnished and clean. All bedrooms are single rooms and each bedroom is decorated to reflect the personality of the occupant, with many personal possessions. All furnishings are of good quality. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has extended the patio area in the rear garden to make it more accessible to all service users. The main kitchen has been refurbish allowing access to individuals. The premises were found to be clean, hygienic and free from odour during both visits to the home. Several staff spoken with confirmed they had completed Infection control training. The homes laundry facilities are sufficient to meet the needs of the service users in the home. The home benefits from having a sluice facility. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32/34/35 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are supported by well-motivated and caring staff in sufficient well trained numbers to meet the needs of those currently living at the home. EVIDENCE: The homes pre-inspection questionnaire stated that the home currently employs 14 care staff and presently 6 have gained and NVQ at level 2 or above. Staff files were examined during the inspection process. These files confirmed that not all relevant checks were undertaken prior to employment. One staff member’s files did not have any employment checks, and another only held one reference. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 21 However on the 2nd day of the inspection the manager had obtained a copy of all relevant checks for all staff from head office. No evidence of POVA checks having been carried out were seen on staff files. The manager stated that it is the company’s policy to obtain the POVA checks before commencement of employment. All staff files and discussion with the staff confirmed that regular and updated training is carried out. Some newly appointed staff members had receive Induction training. This is recorded on individual staff files which was examined during the inspection. Some newer members of staff said they had had a probationary period, whilst waiting for their CRB clearance. They then shadowed more experienced staff when first employed. Several staff interviewed felt that the home has sufficient number of staff on duty to meet the current needs of the service user group. However if one service user becomes challenging this can put a strain on the staff on duty. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37/39/42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can be assured that the management of this home is good. EVIDENCE: The Registered Manager has been in post for 11 months, and registered for about 9months. The manager is a qualified Social Worker and is currently undertaking the Registered Managers award. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 23 The manager listed the training she had received, and explained how this helped to maintain her social work qualification, as did being a trainer on the Person Centred Planning course and Fire Safety training. The home has quality assurance forms in place. And last years results were available during this inspection. Most comments were positive. The manager was aware that these surveys needed updating. Sampling of servicing records indicated that equipment is serviced regularly and maintained in good working order, including the fire alarm system. And certificates were available on all Health and Safety equipment to show they had been checked including a hoist. The fire protection system was well maintained. Maintenance checks are being carried out. Staff are receiving appropriate fire protection training to ensure they have the skills to deal with emergencies. The manager informed the inspector that gas and electrical appliances were being routinely serviced and checked, however the landlord holds the certificate. All staff have completed manadatory training in Fire safety, First Aid and food hygenie certificates. Accident records were accurate as these were crossreferenced with information recorded in service users files and in daily records. Good health and safety practices reduce any unreasonable risk, affecting residents or staff, to an acceptable level. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 24 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. 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 25 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. 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 4 5 6 7 8 Refer to Standard YA2 YA20 YA16 YA22 YA23 YA23 YA39 YA42 Good Practice Recommendations All new service users should have pre-admission assessments completed. A clear procedure for the administration of emergency medication should be put in place. All service users should be offered a key. Information on why a service user is unable to hold a key should be recorded into individual care plans. The complaints procedure should be displayed on the homes notice board. The management and staff should have the Adult Protection training provided by the local authority. The company should consider a policy on renewing CRB checks regularly. The Quality Assurance surveys should be updated. The home should hold a copy of the Gas and Electrical maintenance certificates. Pendeen Residential Home DS0000003526.V306838.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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