CARE HOMES FOR OLDER PEOPLE
Pendennis Residential Home 64 Dartmouth Road Paignton Devon TQ4 5AW Lead Inspector
Judy Cooper Key Unannounced Inspection 18th February 2008 10:00 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.V358382.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 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.V358382.R01.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) 01803 551351 01803 555100 pendennis64@fsmail.net Pendennis Ltd Position Vacant Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th November 2007 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 people who live at the home have ramped access. Within the home, all but two, of the bedrooms have en suite bathroom facilities. One of the large rooms within the home is currently being used as double room by a married couple. The home has a passenger lift, stair lifts to the mezzanine level and a variety of aids and adaptations for physically disabled people. Since the last inspection the bed places at the home have increased by two to now provide 22 places. Care at the home is for people, who are over 65 and who may or may not have a physical disability or suffer with dementia. The range of fees as at November 2007 was from £301 to £450. The owners make the report available within the home’s statement of purpose, which is sited within the home’s entrance hallway. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
This site visit took place on Monday 18th February between 10.00a.m. and 4.00 p.m. Opportunity was taken to look at the general overall care given to all the people. The care provided for four people was also followed in specific detail, from the time they were admitted to the home, which involved checking that all elements of their identified care needs were being met appropriately. A tour the premises, examination of records and policies, discussions with the owner, people and staff, as well as two visitors to the home, also formed part of this inspection, whilst staff on duty were observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of several completed questionnaires from people who live at the home and their relatives has provided further feedback as to how the home performs, and all of this collated information has been used in the writing of this report. All required core standards (as well as some additional ones) were inspected during the course of this inspection. What the service does well:
Pendennis provides a comfortable, secure and caring environment, where peoples’ individuality is encouraged and upheld. Basic rights, such as dignity, respect and privacy are also firmly upheld which was confirmed by the people themselves and/or their relatives. People receive good meals, visitors are always welcomed, various activities are made available and the there is a feeling of community within the home. The staff team are experienced and well trained and able to meet the needs of the people with the provision of appropriate, on-going relevant training. The homes real strength lies in the high value the owners and staff place on maintaining a good individual quality of life for each person. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 6 The people themselves, as well as their relatives, confirmed that they felt valued and their opinions are now sought in all sorts of aspects involved with the running of the home, whilst observation of care also confirmed this. The owners and staff continually monitor the quality of care given within the home and are currently in the process of completing the home’s annual quality audit. This home is maintaining good standards of care with all the several requirements and recommendations met from the last inspection while none were issued at this inspection. What has improved since the last inspection?
Since the last inspection, carried out in November 2007, this service has undergone a huge amount of change. This has involved a change of management, and a reorganisation of the staff group. It is to the owners’ credit that immediate action was taken to rectify the many identified shortcomings, from the last inspection carried out in November 2007 and in doing so have ensured that the service provided once again meets the minimum standards whilst fully meeting the peoples’ needs. Required actions that have been taken since the last inspection include the following: Upgrading of home’s statement of purpose and service user guide to reflect up to date information. Correct pre-assessment procedures now carried out to ensure that any new person coming to live at the home is correctly assessed and the management has agreed with the person and/or their family that the home can meet their needs. Correct and up to date care planning now operates within the home, including the carrying out and maintenance of up to date and relevant risk assessments. Staffing levels have been reviewed and are such that the staff on duty now have the time and resources to provide fully for the needs of the people who live at the home. Staff training has been extended to ensure that staff receive necessary training in relation to the work they do. The staff recruitment programme is now fully robust and ensures that suitable staff care for the people who live at the home.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 7 The management of the home has been changed. The previous manager is no longer in post, having left the employment of the home in January this year, and the owner has reverted back to being in day to day control supported by an experienced and well trained senior staff group. The owner has undertaken a quality audit exercise as part of her agenda for change which has helped her identify any areas that needed to be adjusted to ensure that home is always run in the best interests of the people who live at Pendennis. Regular staff supervision is being provided, which has aided staff communication within the home and helped ensure that the staff team bond well and work well together. Other areas identified within the last report as also needing to be reviewed (recommendations) have also been addressed and necessary action has been taken to amend these areas as well. This has included: Ensuring that the home’s menu and choices are displayed and made available to everyone. The home’s medication systems are fully robust and protect people who live at the home. The home’s activity programme is advertised and everyone is made aware of all activities within the home. People are aware of how to contact the Commission and know how to do so if they should need to. The home’s environment has been upgraded as required including providing new flooring to a bedroom and relaying flooring in a communal toilet. (Other additional upgrading, such as the provision of a new adapted bath, has also been provided as part of the home’s general plans to further upgrade the home). All records necessary for the running of the home are available to the staff that require them and the records are being maintained in accordance with the requirements of the Data Protection Act 1989. The owner communicates well with the Commission and has kept the Commission informed on progress and changes made in relation to these improvements. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 8 This proactive approach by the home’s owners to the major shortfalls noted in November 2007 has fully ensured, and will continue to ensure, that the care provided, to those people in receipt of a service within Pendennis, is of a good standard. 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. The summary of this inspection report can be made available in other formats on request. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 9 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.V358382.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable) Quality in this outcome area is good. The admission process is well managed with any new person’s needs well known prior to admission, to ensure that the person and/or their family/advocate can be certain that their needs will be met whilst living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has admitted some new people. A new person and their relatives were talked with during the inspection. They were able to confirm that the admission had been undertaken in such a manner as to allow them to be aware of what services the home could offer. The prospective person an/or their families had been given access to necessary information including the home’s newly amended statement of purpose. These documents have been completely updated to reflect the current facilities and care provision available at the home and have been forwarded to all existing peoples’ families as well as provided to any new person coming to live at the home.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 11 A pre admission assessment had been undertaken for the person, taking into account immediate need, which was after admission used as a foundation to create a larger more detailed care plan. Up to date and relevant contracts were also in place for all the people whose admission processes was looked at. A letter had been forwarded to the person/person’s family/advocate by the owners to confirm that the home could provide the care required. The home does not provide an intermediate care service but will provide a respite service if there is a vacancy and a need arises. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. All of the people who live at the home are looked after well in respect of their health and personal care needs. Peoples’ privacy and dignity is also upheld and their life style choices respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were seen in respect of the four people whose care was looked at in detail. These were thorough and covered all required care needs. Where possible people who wanted to and/or their family/advocate, had been fully involved in the drawing up of the care plan and continued to be involved in the regular monthly review process. A staff member stated: Since the last inspection we are getting all the relevant information about the needs of the clients.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 13 A family member stated: “ We are always kept informed to help make any decisions. X is very settled and at the home. All X’s needs are catered for by excellent staff. I cannot speak too highly about the care given. I feel confident that I will be contacted at any time if there were any concerns about X. The staff are very efficient and kind. The care given is excellent. X is well looked after. This can be seen by his appearance. X’s clothes are always smart and clean; X gets excellent meals and has a lovely room. X has a lovely relationship with all the staff and often tells me how well looked after X is. Another family member stated: I have not had great concerns about X’s care. I asked if X could have extra help with personal hygiene and rotating their clothes, which because of X’s lack of memory X was forgetting to do. This was discussed openly and agreed on and duly written in the care plan. This was dealt with in a sensitive manner”. Peoples’ health care needs were being fully met, including any specialist needs, for example on the day of inspection a care manager was coming to assess a person who wished to go back home but who the owner felt had some care needs that needed to be fully explained, prior to this happening. Feedback from family members, in respect of a married couple living at the home, stated: We are informed of hospital appointments and were informed when X had a slight fall which meant we were able to go and see them. X and X have been very happy with their room, the amount of help they receive and the food. X is visibly more relaxed since they went to Pendennis as X was finding it too much of a worry and strain trying to care for X. Its obvious to us that they are getting support and that they can concentrate on being together. We are so relieved that Pendennis can care for both their needs whilst keeping them together”. Medications were well managed with all necessary procedures being in place to protect the people. There is a fridge for the storage of any medication that requires a cold environment and a staff member was observed administering medication at lunch time. It was noted that she administered medication correctly and with due regard for a person’s need to feel in control, whilst still being vigilant to ensure the medication was taken, i.e. standing back and observing whilst a person took it in their own time. Medications given were correctly signed for.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 14 Any new presenting needs are fully reviewed i.e. increases in falls, continence needs, use of cot sides etc to ensure the most appropriate care is provided. Other professionals are also asked for advice as required and currently the home links in with local G.P practices and District Nurses as well as care managers and specialist services such as a local memory clinic etc. All the peoples’ individuality and dignity was noted as being upheld during the observation of care practise during the inspection. A new key worker system has recently been introduced within the home and is working well. This allows each person to have a named member of staff that they can identify to give them individual time for such things as buying personal items, maintaining their laundry needs etc. Other staff will also do this, but the key worker is the specific person a resident could turn to. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. The people enjoy a peaceful, pleasant yet varied life at the home, with visitors encouraged. Various regular different activities are made available to help vary peoples’ life at the home. Good nutritious meals are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of the people who live at the home at the home and discussion and feedback from relatives has indicated that that people are happy at Pendennis and enjoy living there. A comment received from family members stated: X and X are very content. It is of the utmost importance to them and their family that they could go into care together as a couple and that has been catered for with respect and consideration. Another family member stated: They always support X to be able to live the life X chooses and therefore X is always happy and contented when I visit, which is twice a week”.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 16 Another stated: “X says everyone is very kind to X and in my observation during visits service users seem to be treated with respect and regard for their age and ability level. Another stated: Because of the of the lack of memory X doesnt make many choices but is always asked what X would like to do and is always offered choices at mealtimes”. Visitors are welcomed and come and go as they wish with two spoken with during this inspection. They confirmed that they were always made welcome and that the care provided for their relative was good. It was noted that they were bringing in some pieces of the person’s own furniture to help the person feel at home. One person stated: “ I am made to feel welcome when I visit at any time of day. Meals provided are good with choice available. People spoke highly regarding the quality of the meals they received, whilst the meal on the day of the inspection was appetising and enjoyed by all. Special dietary needs were being met which was confirmed by the cook who discussed one person’s needs who has diabetes. This general discussion confirmed the cook, who has worked at the home for the past four years had a good understanding of elderly peoples dietary needs in general. Good use was being made of fresh vegetables, which formed part of the meal served during the visit. A comment contained within a returned questionnaire stated: “ I am very happy here at Pendennis”. Regular activities are made available within the home on a daily basis. On the day of inspection there was a large attendance for an outside entertainer who does interactive work with the people including singing requested songs, and it was noted that these were being sung enthusiastically by all taking part. A family member stated: The residents are offered entertainments by people coming in and from input by the staff”.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Arrangements for protecting people and responding to their concerns are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaint policy is displayed in an easily accessible area of the home and is also contained within the home’s statement of purpose. People who live at the home and/or their families/advocates were quite clear as to how to complain and felt they could easily approach the owner or any staff member should they have any cause to. A family member’s quote stated: We would always approach the owner first. She has provided details of any grievance procedures if anything was unresolved. If weve queried anything its always been explained satisfactorily. Another stated: We know how to complain but would be very surprised if we needed to”. Another stated: The complaints procedure is posted prominently in the house”.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 18 Other returned questionnaires from the people and/or their families/advocate indicated that they were aware of the home’s complaints policy. Staff have received training in the protection of vulnerable adults. All staff have an enhanced Criminal record Bureau check to ensure they are suitable to care for vulnerable people who live at the home. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The quality in this outcome area is excellent. Pendennis is very comfortable, clean, excellently maintained and provides a safe standard of accommodation for the people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the home confirmed that the owners now maintain excellent environmental standards within the home. Routine general upgrading continues to take place, including re-decorating, refurbishment and re-carpeting etc, which ensures that the accommodation is maintained to an excellent standard. The home’s fire precautions are maintained to the required standard with relevant documentation being seen. The management confirmed that hot surfaces are protected, and this was noted, and all hot water outlets either risk assessed or regulated to a safe temperature as required.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 20 A new adapted communal bath has been provided since the last inspection as well as a specialised cleaning unit to help clean the bath and prevent cross infection. New soft furnishings are being provided including curtains and some new beds have also been provided. There are several specialised profile beds in the home to help provide the necessary care for the more dependent person. Pressure relieving equipment has also been provided including air cushions etc. These have been provided in conjunction with the local District Nurse services. Communal areas were excellently presented and were being enjoyed by the people. There are photographs and useful information scattered throughout the home, which ensures that anyone entering Pendennis can be assured that it is very much classed as the peoples’ home. The home presented as very clean and feedback given from various parties, during the visit, indicated that this was normal. There were no unpleasant odours throughout the home as, where these had been identified as a problem at the last inspection, action has since been taken to minimise this, with the owners providing specialised, easy to clean flooring where incontinence has previously caused odour problems in two rooms. One relative spoken to commented on how fresh the home always smelt and looked on arrival. The laundering needs of the people are met appropriately, with all the peoples’ clothing, being worn, looking clean and well pressed. During the visit staff were noted as observing routine health and safety procedures, such as using gloves and washing hands which helps prevent any unnecessary cross infection within the home. Anti-bacterial hand gel is available within the home to help minimise the risk of cross infection within the home, which ultimately protects the people. The home’s external gardens provide a relaxing safe area for people to enjoy with the garden being easily accessible and level. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the residents’ needs at all times. The staff recruitment programme is robust and protects the people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people spoken to and/or their relative/advocate confirmed that the staff care for the people who live at the home well. On the day of inspection there were 21 people living in the home. Staff levels were discussed and are in order, with enough staff provided to ensure that the peoples’ needs can be met. On the day of inspection the owner was present, there were also 3 carers and 1 head of care as well as a cook and a cleaner. Between 2 p.m. and 4.p.m. numbers drop to two carers and the owner but increase again for the evening/teatime/bedtime routines to four carers. Training is provided regularly. Recent training provided has included statutory fire training and training, infection control (in liaison with the local hospital), an awareness course in caring for people with MRSA (in conjunction with the local college and an external training provider), protection of vulnerable adult training as well as manual handling training.
Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 22 Six staff are currently undertaking a national training course at an advanced level in care. This level of training ensures that staff are both appropriately trained and consequently able to provide suitable care for the people at the home. Staff on duty were spoken with and it was evident that they took pride in their role and felt that ensuring people had a good quality of life, irrespective of need or diversity, was the most important part of their role. A family member’s feedback stated: The staff at Pendennis are very committed to giving the residents a good standard of care and as much independence as possible. And another stated: I have noticed when I visit how well the staff look after the residents. All the staff are very good and professional in their work and also provide a friendly type atmosphere. I am confident that they always do meet different needs. X knows all the staff by name and likes and gets on so well with all of them. The home maintains a stable staff group. Minor changes that have occurred have been due to increasing staff numbers to meet additional need and ensuring that the staff team feel comfortable working together. This overall staff stability and staff confidence in each other allows people to feel secure and confident of the carers’ abilities to care for them. Since the last inspection the manager has appointed one new staff member from overseas. All of this staff member’s records were seen to be in order and the owner had obtained an enhanced CRB check for the person. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality in this outcome area is good. The home is managed efficiently and well, with the owners being easily available and approachable. The owner undertakes her role professionally and has an awareness of peoples’ needs and the staffs’ abilities to meet them. The home provides a safe, secure environment where peoples’ safety and wellbeing is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection there has been a major change regarding the management of the home. The previously registered manager left the homes employment in January of this year. The owner has now taken over the running of the home supported by experienced, trained senior staff. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 24 The owner is experienced and was judged as fit to be in charge when she and her husband took over the home over two years ago. In time it is her intention to re-register another manager but she is currently building on consolidating the hard work she and her staff have put in to bring the home back to the required standards. She is well respected by both staff, the people who live at the home and their families/advocates. All spoke highly of her ability to help them and her willingness to listen and act upon any concern etc they may have. They felt confident because they felt she ran the home efficiently and in their best interests. A comment received from family members stated: We can always contact the owner by phone and she notifies us of any problems or changes etc. Another comment stated: The owner discussed with me problems she had had with the previous manager which are now resolved. She was open and frank about this matter, which I appreciated. I continue to have faith in her and her staff. She is always available should I have any concerns. The owner was in the process of completing the home’s annual quality review when the site visit was undertaken and it was clear that she had taken all stakeholders feelings into account in the planning for the future needs of the service. The home will hold monies for people who live at the home and one random person’s was checked against records and found to be in order. All staff now receive regular supervision from the owner with records seen. Peoples’ health and safety continues to be maintained within the home and the owners continue to update risk assessments and comply with required health and safety legislation as necessary. The homes’ policies and procedures were up to date and had been reviewed. There was evidence to show that staff had read them and that the owner included new policies as she saw the need for them, for example she had recently written a “Visiting Doctors Policy” to inform staff of what actions are necessary to aid a doctor’s visit. The effect of this is that a G.P can be confident that the staff will inform the G.P. of the person’s condition and make sure that any new directions subsequently given are followed correctly by the use of good recording and communication to all relevant staff. Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 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 X 3 X X 3 X 3 Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 26 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. Refer to Standard Good Practice Recommendations Pendennis Residential Home DS0000062705.V358382.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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