Inspection on 07/09/05 for Pendennis Residential Home

This inspection was carried out on 7th September 2005.

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 15/05/06

Pendennis Residential Home 13/01/06

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 Announced 7th September 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. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pendennis Residential Home Address 64 Dartmouth Road, Paignton, Devon, TQ4 5AW 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) 01803 551454 Pendennis Ltd Mrs Rosemary Jane Bull Care Home 20 Category(ies) of Physical Disability - over 65 years of age (20), registration, with number Dementia - over 65 years of age (20), Old age of places not falling within any other category (20) Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th March 2005 Brief Description of the Service: Pendennis is an extended three storey detatched property, situated in a residential area of Paignton and is near to all local facilities and within a short walk to 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. At the time of this inspection, the home had been under the management of Mrs. Bull for ten months Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During this inspection, the Inspector spent time with fifteen service users in groups and / or individually. Discussion took place with five staff, the Registered Manager and her husband and a visiting advocate from “Vocal”. A pre-inspection questionnaire submitted by Mrs. Bull and comment cards submitted by service users and relatives were reviewed. A sample of care plans were inspected as well as a range of other documents such as staff files, health and safety and training records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 6 contacting your local CSCI office. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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 Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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) 3 and 6 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 pre-admission 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. Each service user has a plan of care which is based upon the assessment. The home does not provide intermediate care. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Service users personal and healthcare needs are generally well met. EVIDENCE: Each service user has an individual plan of care. These set out the service user’s personal, healthcare and social needs in detail. The plans sampled had been reviewed monthly and updated to reflect any change in the service user’s needs. Details were included in the plans of the involvement of health professionals. The plans contained personal risk assessments for a variety of issues including falls. In discussion, service users confirmed that they had been consulted over matters in their individual plans. One service user’s needs had changed significantly and discussions between the home, the family and the local Social Services Department had become complex. An advocate had been involved in this instance to ensure the service user’s wishes could be ascertained. This was reflected in the plan of care and understood and supported by the staff and Registered Manager. The care plans examined showed that service users have access to both routine and specialist healthcare according to their needs. A District Nurse and an Occupational Therapist visited the home during the inspection. Service users stated that they are able to choose their own GP and this was confirmed in the records examined. Records also showed that medical advice is sought promptly should the need arise. The home has contact with the local Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 10 Continence Nurse and evidence was seen of adequate supplies of necessary materials. During the inspection, service users were able to walk in the garden and some, who are more independent, take short walks locally. Specific exercise needs were identified in the care plans. Evidence of weight monitoring was seen as well as the provision for individual nutritional requirements. The systems for administering medicines were inspected. A Boots monitored dosage system is in use. Records relating to this system were sampled and found to be in good order. At the time of inspection, no controlled drugs were in use though facilities for storing them and recording their use are in place. Some homely remedies are used. An approved list was seen and their administration is separately recorded. Reference information concerning drugs and their side effects is available to staff. However, it is recommended that up to date patient information leaflets should be obtained for all drugs in use. A new mini refrigerator has been obtained since the last inspection for medicines which require cool storage. Evidence was seen of staff training in the administration of medicines. This includes the home’s own policies. Skin creams prescribed for individual service users’ use were found located in the wrong bedrooms. Immediate action was taken by the Registered Manager to remove them and notices were placed prominently to remind staff to check this. The Registered Manager stated that they had not been used for more than one service user. Service users stated that they felt that their privacy and dignity was respected by staff. Interactions between staff and service users observed during the inspection were supportive and respectful. The home has a payphone for private use. A cordless phone is also available if required. Service users confirmed that medical consultations take place in the privacy of their own rooms. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 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 standard(s) 12 - 15 Service users individual choices concerning their lifestyle are well supported by the home. EVIDENCE: Care plans included information on service users’ individual interests and preferences. Service users confirmed that the home’s routines were adequately flexible to cater for their individual needs and choices. Some service users attend local churches and a visiting clergyman visits regularly to take communion with those who wish to attend. The Registered Manager has recently completed a survey concerning activities and is implementing the findings. Information was posted in the dining area about forthcoming activities which included a regular visiting pianist. In house quizzes, games and singing are arranged on a shift by shift basis. Large print and audio books are supplied through the local library service. Some service users attend coffee mornings held at the local Methodist church. Details concerning family contact are held in the plans and service users confirmed that visitors whom they choose to see are made welcome by the staff. Service users are able to see visitors in the privacy of their own rooms if they wish. Personal finances are managed by service users themselves or their families. Small amounts of cash are held for personal spending either by service users or the Registered Providers. Records concerning the cash held were examined Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 12 and found to be accurate and in good order. Information about independent advocacy is on display in the home’s foyer and a visiting advocate was seen during the inspection. Service users confirmed that they can access their records if they wish. Where service users choose not to have facilities such as room keys, this is recorded in the care plans. Menus showed a varied and wholesome diet. The menu includes an alternative choice to the main meal and service users can request a different meal altogether if they do not like the available choices. The inspector joined service users for a meal. Staff were seen offering service users individual assistance with eating. Special diets are catered for and an index is held in the kitchen of individuals’ likes / dislikes. Trays of soft drinks are available throughout the day and service users confirmed that they could request a drink at any time. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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 and 18 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: Policies and procedures concerning complaints, adult protection and whistle blowing have been devised. 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 that their concerns were listened to and acted upon. A copy of the local adult protection guidelines as well as the local “No Secrets” training video are available for staff reference. The sample of staff records seen each contained Criminal Records Bureau checks and checks against the national Protection of Vulnerable Adults register. The Registered manager responded promptly to a recent theft by an intruder. The incident was reported to the Police and the Commission and Security arrangements have been reviewed and reinforced. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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 and 26 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: Pendennis is located close to local shops and services and ramped access is provided to the home’s 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. Since the last inspection, two new stair lifts have been installed to improve access to the mezzanine level. A tour of the home showed it to be comfortable, homely, attractively decorated and free from any obvious hazards. There were no offensive odours in the home. During the inspection, some service users were enjoying the good weather in the level and attractively laid out garden. A high standard of maintenance and refurbishment was evident throughout the premises. Cleanliness and hygiene are also maintained to a good 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. The Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 15 Registered Manager stated that the washing machine has the necessary capability to manage foul laundry. Table linen and other laundry is washed separately. Mops, buckets and cleaning cloths are colour coded for different kinds of use. Policies and procedures concerning infection control are in place and the Inspector saw evidence of staff training in this area. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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, 29 and 30 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. Night cover is provided by two sleeping and one waking staff. A part time cook is also employed. 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. Staff receive statements of terms and conditions and have access to the guidelines of the General Social Care Council. The staff on duty were comprised of a range of ages and experience. Half the current staff group are qualified to NVQ level two or higher and other staff are currently undergoing this training. Induction training to national standards is provided which includes the policies and procedures unique to the home. Each staff member has an individual training plan which includes training needs identified through supervision. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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) 32, 33, 35, 36 and 38 Service users’ health and welfare is promoted by sound management practice and a notably positive management ethos. EVIDENCE: The Registered Manager is commended for the particularly positive attitude and management approach she has adopted since taking over the home. Staff spoke highly of the quality of support received. An ethos of openness was apparent in her approach concerning visiting, staff supervision and management arrangements. Feedback is actively sought from service users, staff and others including the Commission. Very prompt action has been taken to remedy any shortfalls identified by inspection or the home’s own monitoring procedures. Practice is continually under review and the Registered Manager has sought to maximise staff development and encourage new ideas. A number of quality assurance and monitoring measures have been put in place since the current providers took over the home ten months ago. Each Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 18 service user has been interviewed individually by the Registered Manager and there are regular recorded meetings in which views and concerns may be aired. A survey has been conducted of service users’ preferences regarding activities. An audit of equipment checks has been conducted. The Registered Manager also described further quality assurance activity to be conducted which will be integrated into the home’s annual development plan at the end of the first year. All previous requirements and recommendations have been met very promptly. Evidence was seen that ideas and suggestion proposed by staff and service users had been considered and implemented where feasible. The Registered Manager stated that where service users are unable to manage their own financial affairs, this responsibility is held by relatives. Small amounts of money are held securely for service users. Records of all transactions, including receipts, are kept and those sampled were found to be accurate and up to date. Personal possessions brought to the home are recorded in individual files. Records of bi-monthly staff supervision were seen which covered general practice issues and work with individual service users. Individual training needs were identified through this process. Records were seen concerning the maintenance of health and safety of service users and staff. Staff receive training in health and safety topics such as fire safety, first aid, moving and handling, food hygiene and infection control. A fire risk assessment has been conducted and fire safety procedures are prominently posted. Food was found to be correctly stored and records are maintained of fridge and freezer temperatures. Infection control measures such as colour coded mops, buckets and cleaning cloths are in place. Contracts were seen concerning the disposal of infected waste. Hazardous substances were seen to be securely stored and data sheets were available for staff reference. A record of recent boiler maintenance was seen. Portable appliance testing has been conducted and all appliances are labelled. Policies and procedures concerning the risk of legionella infection are in place. All radiators in the home are covered and hot water temperature is regulated. Hot water temperature outlets in the home have been regulated except hand-basins at the request of service users. Individual risk assessments have, however, been completed. The Registered Manager stated that windows on the upper floors have restricted openings. The security of the premises has recently been upgraded following a theft by an intruder. This was reported to the Police and the Commission. A file of environmental risk assessments was seen which covered a range of potential hazards in the home. Accidents are recorded and falls are monitored separately. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x 3 3 x 3 Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 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 9 Regulation 13 Requirement The Registered Manager and staff must ensure that all skin creams are labelled with the users name and those prescribed are supplied exclusively to the named individual. Timescale for action Immediate and ongoing 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 9 Good Practice Recommendations Current patient information leaflets should be held for all medicines in use in the home. Pendennis Residential Home D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, 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 D54-D07 S62705 Pendennis Residential Home V237046 070905 Stage 4.doc Version 1.40 Page 22 - 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!