CARE HOMES FOR OLDER PEOPLE
Pendene House 15 Pendene Road Stoneygate Leicester LE2 3DQ Lead Inspector
Diane Butler Unannounced 24 August 2005 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. Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Pendene House Residential Home Address 15 Pendene Road Stoneygate Leicester LE2 3DQ 0116 2708911 na na Pendene House Residential Home Ltd 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) Mrs Janice Hill Care Home 12 Category(ies) of OP Older People - 12 registration, with number DE(E) - Dementia over 65 - 3 of places MD(E) - Mental Disability over 65 - 3 Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: No persons falling within categories MD(E) or DE(E) may be admitted to the home when 3 persons in total of these categories/combined categories are already accomodated within the home. Date of last inspection 19/04/05 Brief Description of the Service: Pendene House Residential Home is registered for twelve older people and is situated in a quiet cul-de-sac in the Stoneygate area of Leicester. The home is within walking distance to the local amenities and close to a local bus route. Accommodation is on two floors, which can be accessed by a shaft lift. There is a large dining room and lounge on the ground floor, which are furnished and decorated to a high standard. Further seating can be found in the home’s entrance hall. There is a large well-maintained garden at the rear of the home accessed by the shaft lift, which goes down to garden level. All rooms in the home are single, some of which are ensuite. Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two and a half hours and commenced at 10.15am on 24th August 2005. The main method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The Commission for Social Care Inspection is inspecting Pendene House for the eighth time and is in its third year of inspections being inspected against the Care Standards Act 2000. The registered manager was most helpful during the inspection process. What the service does well: What has improved since the last inspection?
Since the last inspection three care staff employed at the home have completed their National Vocational Qualification (NVQ) level two. Work has been carried at the rear of the home as required by the fire service following their inspection carried out in April this year. This includes a new side door and fire proofing of the stair well. Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 6 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. Pendene House C51 C01 S6353 Pendene House V245364 230805 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 Pendene House C51 C01 S6353 Pendene House V245364 230805 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) 1,2,3,5. Standard 6 was not applicable at the time of the inspection. Prospective residents are invited to look around the home and are given clear and detailed information about the services offered to enable them to make an informed decision about admission to the home. EVIDENCE: • A statement of purpose document is available. This includes information about the facilities in the home and the services that can be provided. It was noted that this document has been reviewed since the last inspection to show the Commission for Social Care Inspection’s correct title. This had been recommended at the last inspection. Two resident files were looked at during the inspection. Both included a copy of the initial assessment carried out by the resident’s social worker and a further assessment carried out by the manager. Both included a statement signed by the manager confirming that the staff could meet the assessed needs of the residents and both included a copy of their written terms and conditions. • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 9 • The manager stated that prospective residents and their relatives are invited to look around the home and stay for a meal. This was confirmed through discussion with the most recent resident into the home and inspection of their daily records. Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 10 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) 7,8,9,10 Residents are looked after well in respect of their health and personal care needs and personal support is offered in such a way as to protect the resident’s privacy, dignity and independence. EVIDENCE: • Two care plans were looked at during the inspection. Both were up to date and both had been reviewed with the resident and their next of kin. Both included the health, personal and social care needs of the residents and included details of Community Nurses and GP visits. The Procedures for the administration of medication were in order with all paperwork completed appropriately. Staff spoken with were aware of the individual care needs of the residents and residents spoken with stated that their care needs were being met. • • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 11 • Discussion with residents and staff and observations during the inspection showed that the staff had a good awareness of how to ensure a resident’s privacy and dignity are maintained. Comments made by residents during the inspection included: “I love it” “There good to me” “I’m happy”. • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 12 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) 12,13,14,15 Visiting is encouraged to enable residents to maintain contact with family and friends and the relaxed homely life style within the home enables residents to make choices on a daily basis. EVIDENCE: • Residents are offered choices on a daily basis. Choices include when to get up or go to bed, what to wear, where to eat meals and whether to join in activities. Residents were seen joining in a music and movement session during the inspection. The manager stated that family and friends are encouraged to visit the residents living at the home. This was evident during the inspection and on reading the residents daily notes. The menu record was seen. This offered a varied and nutritious diet. A copy of the day’s menu can be found on the notice board situated outside the dining room. A choice of meal is offered at every mealtime and meals can be taken in the resident’s own room if they wish. The meal seen on the day of the inspection was well presented and appealing in appearance. • • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 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 standard(s) 16,18 Arrangements for the receiving and responding to complaints are sound resulting in satisfactory protection of resident’s rights. Staff awareness of actions to take should any form of abuse be suspected ensures protection of the residents in their care. EVIDENCE: • There is a complaints procedure in place. A copy of this can be found on the homes notice board situated outside the dining room and a copy is included in the homes Statement of Purpose document. The manager explained that no complaints had been received since the last inspection in April this year. This statement was supported on checking the complaints book. Staff spoken with during the inspection were aware of what to do should they suspect any act of abuse and the manager was aware of the procedure to follow with regard to adult protection. • • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25,26 The standard of the accommodation within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: • The home is safe and well maintained. A shaft lift serves the garden as well as the two floors in the home enabling the resident’s access to the garden at the rear of the home. Decoration in the home is of good standard and furnishings in the communal areas are domestic in character and in good condition. The rooms belonging to the residents whose care plans were checked were seen. These were clean, appropriately furnished and included the residents personal belongings. All areas of the home seen on this occasion were clean and fresh.
C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 15 • • • Pendene House Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 16 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) 27,28,29, Sufficient numbers of staff are currently employed to meet the needs of the service users. Recruitment practices within the home ensure appropriate protection for residents. EVIDENCE: • There were sufficient numbers of staff on duty on the day of the inspection to meet the current needs of the residents. A staff member spoken with confirmed that staffing levels were sufficient to enable her to care properly for the residents. Through discussion it was evident that all the staff on duty were aware of the care needs of the residents case tracked. Three of the eight care staff currently employed have achieved their National Vocational Qualification (NVQ) level two. Two staff files were checked, both were found to include all the necessary information including references, proof of identity and a criminal record bureau check (CRB). • • • Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 17 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) 31,32,33,35,38 Resident’s benefit from an open, positive and inclusive atmosphere, which is evident throughout the home. Appropriate records are kept to ensure the residents health safety and welfare are protected. EVIDENCE: • The registered manager has many years experience in care and all staff and residents spoken with stated that she was approachable and supportive. One staff member stated, “Jan is brilliant”. It was evident during the inspection that the residents benefit from the ethos, leadership and management that the manager provides. Positive relationships between staff and residents were evident throughout the inspection.
C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 18 • • Pendene House • All records seen were up to date and accurate. Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 19 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 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 3 3 3 3 x 3 x x 3 Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 20 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. 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. Refer to Standard none Good Practice Recommendations Pendene House C51 C01 S6353 Pendene House V245364 230805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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