Inspection on 15/05/06 for Pendennis Residential Home

This inspection was carried out on 15th May 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

Pendennis Residential Home 18/02/08

Pendennis Residential Home 09/11/07

Pendennis Residential Home 13/01/06

Pendennis Residential Home 07/09/05

Pendennis Residential Home 16/03/05

Pendennis Residential Home 25/01/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Pendennis Residential Home 64 Dartmouth Road Paignton Devon TQ4 5AW Lead Inspector Graham Thomas Unannounced Inspection 09:300 15 and 17th May 2006 th 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 Pendennis Residential Home DS0000062705.V290545.R02.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 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. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendennis Residential Home Address 64 Dartmouth Road Paignton Devon TQ4 5AW 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) 01804 551351 01803 555100 Pendennis Ltd Mrs Rosemary Jane Bull Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: Pendennis is an extended three storey detached property, situated in a residential area of Paignton. The Home is near all local facilities and within a short walk from the sea front. Bedrooms are located on all three floors and a mezzanine level between the first and second floors. The home is situated in its own grounds to which service users have ramped access. Within the home, all the bedrooms are single, and all but two have en suite bathroom facilities. The home has a passenger lift, stair lifts to the mezzanine level and a variety of aids and adaptations for physically disabled service users. Care at the home is provided for up to twenty service users, who are over 65 and who may or may not have a physical disability or dementia. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a review of the Commission’s records about the home. Unannounced visits to the home took place over a total of nine hours on 15th and 17th May 2006. The Inspector spoke with eight service users, four staff and the Registered Manager. Records were examined including care plans, staff records, correspondence and other documents. The Registered Manager completed a pre-inspection questionnaire. Five staff completed surveys about the home. Written feedback was received from three General Practitioners and two relatives. What the service does well: What has improved since the last inspection? Information about all the medicines in the home is kept for reference. All the skin creams in use are now properly labelled with the service user’s name. The proportion of qualified staff has increased since the last inspection. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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 Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their needs have been properly assessed prior to their admission to the home. EVIDENCE: The files of recently admitted service users contained comprehensive preadmission assessments. The assessment material seen included the home’s own assessments as well as material gathered from referring agencies. Physical, social and psychological needs were covered by the assessments. One service user had been admitted to the home in an emergency just before the inspection. The Registered Manager stated that details for this person were being gathered. Each service user has a plan of care which is based upon the assessment. The home does not provide intermediate care. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that that their personal and healthcare needs will be well met in the home. EVIDENCE: The Inspector examined a sample of five care plans and daily records. One plan contained little information as the service user had been admitted just before the inspection as an emergency. The Registered Manager said that information was being gathered. All the plans examined contained details of the personal and health care needs of the individual and had been regularly reviewed. Where possible, service users had been involved in their plans and had signed them. Discussion with service users confirmed that they had been consulted about their plans. Relatives confirmed that they are consulted about important matters. Details of dietary needs and preferences were contained in the plan and records were seen of service users being weighed regularly. The content of some plans was disorganised and some areas required updating. This was discussed with the Registered Manager who provided evidence that this was being addressed under the home’s quality assurance process. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 10 Service users were asked about medical care. All those interviewed felt that they had access to the medical care they needed. This was confirmed in the individual plans where details of appointments were seen with Doctors, Chiropodist, Opticians etc. Two comment cards were received from doctors who confirmed that appropriate action was taken when the home could no longer meet the needs of service users. They also confirmed that the home communicated well and that staff understood the care needs of service users. Staff were asked about the individual service users for whom they were responsible as key workers. This further demonstrated their understanding. The Home’s systems for the administration of medicines were examined. Risk assessments for service users who self-medicate were contained in the care plans. Some of these were due for updating. There were clear records of all medicines coming into the home. Medicines are held in locked storage and further secure storage is available for controlled drugs (which were not in use at the time of this inspection). A mini fridge is available for those medicines which require cold storage. A monitored dosage system is used and records relating to this system were accurate and up to date. Safety of the system is enhanced by the use of photographs both on the records sheet and the medication cartridges. Reminder cards are inserted with the medicine cartridges for medications which are held separately. Medication training is provided by the local Pharmacy. The Inspector was shown a list of homely remedies approved for use in the home. Since the last inspection, patient information leaflets have been obtained for all medicines in use and skin creams were all labelled with the service user’s name. Records were kept of all medicines returned to the Pharmacy. Discussion with staff and service users as well as the observations of the inspector confirmed that service users are treated with respect. Individual preferences and choices (religion, food, preferred name etc) are recorded and respected by staff. Feedback from General Practitioners confirmed that appointments take place in private. The home has a private fixed telephone and most service users have access to telephones in their rooms. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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): 12 - 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well supported to follow the lifestyle of their choice and maintain contact with those who are significant to them. EVIDENCE: In discussion service users were largely content with the lifestyle in the home. This was confirmed in the written feedback received. Service users preferences and choices regarding religion, food activity etc. are recorded and respected. This was confirmed in discussion with service users and staff. Individuals were seen pursuing their own interests (e.g. doing crosswords, reading, watching television). A bright communal lounge area is available for those who wish to sit and chat. Those who wish to remain private are able to do so. Individual rooms contained personal possessions including items of furniture brought to the home by service users. During the inspection a visiting entertainer spent time with a group of service users who had chosen to participate. This is a regular event and appeared popular with those service users involved. Feedback from relatives confirmed that there are flexible and open visiting arrangements. Service users confirmed that their visitors were made welcome and that they are able to see them in private. In the home’s foyer there was Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 12 ample information for visitors and friends in the form of leaflets and brochures which include details of local advocacy services. Service users were generally satisfied with the meals provided by the home. A system of record cards is held in the kitchen detailing individual preferences and special dietary needs. Evidence was seen of a talk given by a dietician and speech therapist in January 2006. This resulted in the implementation of a Malnutrition Universal Screening Tool which was seen in individual files. Meals are thus tailored to individuals tastes and needs. Where service users do not wish to take the planned meal, an alternative is available. Kitchen staff confirmed that the components of liquidized meals were liquidized and arranged separately. The contents of fridges freezers and food stores was examined by the inspector. These contained a variety of foodstuffs including fresh ingredients. The Registered Manager provided sample menus which showed a varied and wholesome diet. Meals are taken in the home’s dining room. Service users confirmed that they can take meals in their room if they wish. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their families / friends can feel confident that individual concerns and complaints are taken seriously and that they are well protected from abuse. EVIDENCE: Satisfactory policies and procedures concerning complaints, adult protection and whistle blowing have been seen by the Inspector. At the time of inspection the home’s complaints record showed that no complaints had been received and none has been received by the Commission. Regular recorded meetings are held in which service users can voice their individual or collective concerns. In discussion service users felt confident that their concerns were listened to and acted upon. Similarly one relative commented “ When I take my mother out, I am always happy to take her back confident that she will be treated well. I have no hesitation in talking to Mrs. Bull, who is usually available at all times if I have concerns about my Mum”. All service users were able to identify the person to whom they would speak if they had a concern or complaint. Feedback from relatives indicated that they were aware of the home’s complaints procedure. A copy of the local adult protection guidelines as well as the local “No Secrets” training video are available for staff reference. Discussion with staff demonstrated that they were clear as to what they should do if an incidence of abuse arose. In the sample of staff records seen, each contained Criminal Records Bureau checks and checks against the national Protection of Vulnerable Adults register. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 14 Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 15 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users at Pendennis enjoy a clean, comfortable and well maintained environment. Their health is protected by good standards of hygiene and infection control. EVIDENCE: The inspector conducted a tour of the whole premises and examined various records concerning the maintenance and upkeep of the home. Pendennis is located close to local shops and services and ramped access is provided to the home’s well-maintained grounds. Accommodation is provided over three floors with a mezzanine level between the first and second floors. A shaft lift is in place which can accommodate wheelchairs. Two stair lifts provide access to the mezzanine level. All service users occupy individual rooms and all but two have en-suite facilities. Furnishings and décor both in communal areas and in the individual rooms were comfortable, homely and well-maintained. All areas were warm with plenty of access to natural light. Improvements to the electric lighting level in the dining room area were discussed with the Registered Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 16 Manager. This had been identified as an area for improvement and was in progress at the time of the inspection. Individual rooms contained personal possessions, photographs and pictures which some service users discussed with the Inspector. Service users felt that their rooms contained all the things they needed and were adequately comfortable. Maintenance and service records were inspected concerning gas and electrical supplies and fittings. These were up to date and in good order. A Fire Service inspection which took place shortly before this inspection resulted in a notice of non-compliance concerning evacuation policy. The necessary correction had already been made at the time of this inspection During the inspection staff were seen in the process of assisting service users with their routines, cleaning and making beds. All areas of the home visited were clean and free from offensive odours. Odour control in the home is of a commendably high standard. The laundry facilities, situated in an outbuilding, have cleanable walls and an impermeable floor. Hand washing facilities are available to staff in the laundry. Colour coded cleaning equipment was seen in use during the inspection. Facilities for the disposal of clinical waste were seen and a current contract for its removal. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 17 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): 27 - 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by adequate numbers of well-trained staff. EVIDENCE: Staffing as shown in the rotas inspected appeared adequate to meet the needs of the present service user group. Up to five staff are on duty at peak times of activity including the Registered Manager whose husband provides administrative and domestic support in the home. Dedicated cleaning and kitchen staff were seen by the Inspector. Night cover is provided by one waking staff member and the Registered Manager and her husband who live in a neighbouring bungalow.. Staff files revealed sound recruitment practices. These included the taking up of two references, and checks of criminal records and the national register for the Protection of Vulnerable Adults. One staff member recently recruited from abroad had undergone Police checks in her country of origin as well as the checks required by the National Minimum standards in England. Staff receive statements of terms and conditions and have access to the guidelines of the General Social Care Council. These recruitment practices were confirmed by staff in written and verbal feedback The staff on duty were comprised of a range of ages and experience. The Registered Manager stated that 70 staff hold a qualification at NVQ level 2 or above. Copies of certificates were held on files which were available for inspection. Other staff are currently undergoing this training. Induction training Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 18 to national standards is provided which includes the policies and procedures unique to the home. Individual training plans for staff were seen by the Inspector. These included training needs identified through supervision. Evidence of staff attendance at short courses relevant to their work was seen on files and confirmed by staff. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 19 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, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and welfare is promoted by sound management practice and a notably positive management ethos. EVIDENCE: Mrs. Bull, the Registered Manager holds an NVQ level 4 in Care and the Registered Manager’s award. Certificates were seen during the inspection which demonstrated her attendance at numerous courses relevant to her work in the home included the conditions and diseases relating to old age. In discussion, staff and service users were aware of the lines of accountability in the home. Service users and staff spoke warmly of Mrs. Bull’s management of the home. Staff expressed general satisfaction with the ethos of the home and felt that they were well supported. Regular meetings are held with staff and service users. Minutes were seen which indicated that new ideas were Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 20 welcomed and acted upon. A quality assurance system is in operation which reviews various aspects of the home’s operation on a rolling monthly basis. Documentation provided by the Registered Manager demonstrated continuous improvements in areas of practice, the environment and training. This was confirmed by feedback from staff and service users and the observations of the Inspector. The Registered Manager stated that where service users are unable to manage their own financial affairs, this responsibility is held by relatives or other advocates. Small amounts of money are held securely for service users. Records of all transactions, including receipts, are kept and were available for inspection. Personal possessions brought to the home are recorded in individual files. Staff records demonstrated that they receive training in health and safety topics such as infection control, food hygiene, fire safety and moving and handling. Risk assessments for safe working practices are in place. Radiators in the home are covered and hot water is regulated. Food was found to be correctly stored and labelled. Records were seen of fridge and freezer temperatures. All hazardous substances were found to be securely stored when not in use. Data sheets concerning their use are held on file. Staff were observed following appropriate infection control procedures such as the wearing of aprons and rubber gloves. Colour-coded cleaning equipment was in use during the inspection. Up to date records were seen regarding the maintenance of electrical wiring, personal electrical appliances, gas systems and fire equipment. Separate disposal systems for clinical waste were seen as well as a current contract for its removal. The home had recently had Fire Service and Environmental Health inspections. The issues identified in these inspections had been acted upon. Policies and procedures are in place concerning the risk of legionella infection. Mrs. Bull has maintained regular contact with the Commission to provide information required by regulation and to clarify areas of practice. Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 21 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 3 X X X 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 Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 22 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. 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 OP7 Good Practice Recommendations Individual service user plans should be reorganised to make the information in them easier to access Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Pendennis Residential Home DS0000062705.V290545.R02.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!