Inspection on 03/01/06 for Pendle View

This inspection was carried out on 3rd January 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pendle View 03/06/08

Pendle View 31/05/06

Pendle View 09/08/05

Pendle View 19/01/05

Pendle View 19/07/04

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

CARE HOME ADULTS 18-65 Pendle View 15/17 Chatham Street Nelson Lancashire BB9 7UQ Lead Inspector Mrs Keren Nicholls Unannounced Inspection 3rd January 2006 10:45 Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 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 Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pendle View Address 15/17 Chatham Street Nelson Lancashire BB9 7UQ 01282 690703 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) Pendle Residential Care Limited Mrs Ann Suleman Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service may accommodate up to a maximum of 6 service users in the category mental disorder, excluding learning disability or dementia (MD) 9th August 2005 Date of last inspection Brief Description of the Service: Pendle View provides 24-hour residential accommodation and staff support for 6 younger adults who have mental health problems. The home is part of a residential dispersed homes scheme in Nelson (which includes another 3 small terraced houses). Pendle View is a large mid-terrace house located on the outskirts of Nelson, near to local shops. Town centre services are a short distance away. There is off-street parking at the front. The house has a small front garden and a private paved garden in the back yard. There are good local transport links nearby. Transport is also provided for service users in staff cars. There is one double bedroom and four single bedrooms (one being on the ground floor). The home has two ground floor lounges and a dining area. Upstairs is a house bathroom and separate shower and there is a ground floor WC. Residents have access to the kitchen and laundry room. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced visit to Pendle View during the inspection year April 2005 to April 2006. The inspection took place between 10:45am and 5:30pm (6.45 hours). During the visit the inspector spoke with four of the six people who lived at the home and examined written information, including records. She also talked to the manager of the home and the staff on duty and, with the permission of service users, looked round the home. Since the last inspection, the specialist pharmacy inspector had visited Pendle View and looked at the medication practices. Her recommendations are made separately and will appear in the next inspection report. What the service does well: What has improved since the last inspection? The manager had reviewed and simplified the home’s contract/terms and conditions of residence, so it was easier for everyone to know what their rights and responsibilities were. The home had continued to improve the premises with redecoration and colour schemes chosen by service users. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 6 Regulating the hot water and ensuring kitchen cupboards were protected from fire risk had improved safety for service users. Risk to service users of harms had also been minimised by staff and residents undertaking Protection of Vulnerable Adults training. Regular management meetings had been held, to plan ways in which quality improvements can be made. 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. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Each service user had a contract / terms and conditions of residence (to ensure that both parties’ rights and responsibilities are protected). EVIDENCE: Service users had individual contracts/terms and conditions of residence, which specified the fees and how these were to be paid, what the fees did and did not cover, insurance arrangements, periods of notice and the rights and responsibilities of the service user and management. Copies were retained in service users files. The manager was reviewing the contracts, to ensure they were easy to understand. Fees were reviewed annually in April. Service users knew what the terms and conditions of living at the home were. They understood their rights and responsibilities, including those in respect of care planning, the mental health Care Programme Approach (CPA) and the house ‘rules’. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Service users were properly consulted on, and participated in all aspects of life at the home, which enabled them to influence how the home was run. EVIDENCE: Service users said that they had regular formal meetings (normally about every six weeks). Minutes were kept. Additionally, everyone met informally round the dining table and made suggestions for improvement. Service users made decisions about refurbishment, meals and activities and staff selection. They said they were encouraged to openly express their views and influence change, such as the recent purchase of a DVD player for the lounge. Service users were invited to join in with training at the home. In the past one person had gained certificates in basic food hygiene certificate and health and safety. Recently one person had joined in with and received a certificate for Protection of Vulnerable Adults training. Service users spoken with said they thought this was important, so everyone knew that things were done properly. Copies of the homes Statement of Purpose and service user guide were in the hallway and policies and procedures available in the dining room. The manager said policy review was discussed with service users. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 and 12 The home met service users’ aspirations for an independent and fulfilling life, with opportunities for personal development and enhanced skills. EVIDENCE: One person had a voluntary job in a shop and one service user explained she had recently successfully completed a college course, which had helped her with confidence and assertiveness. She was planning to progress to a more advanced course in the next term and thought she was “doing well”. Another service user said she felt much better since living at the home, because she had good support from staff and from her peers. She was the “happiest she had ever been” and this was giving her confidence. Staff also supported service users in techniques to lessen anxiety and promoted independence outside the home, for example through recreational activities and by helping service users to access advice from welfare rights. In addition to practising practical life skills, service users had opportunities to learn new skills, such as in the ceramics and craft classes held at the home every week. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 To ensure service users’ comfort and wellbeing, the home handled ageing and illness with sensitivity and respect. EVIDENCE: Staff were sensitive to need when service users are ill. For example, in the past one service user had said that staff were kind and looked after her well when she had ‘flu. Staff visited and supported service users and their families during periods of hospitalisation. A service user, visiting from another home was keen to know that residents could stay in their homes for as long as they wished, as they became older. Although Pendle View is primarily for younger adults, one person had grown older in the home. The home had met his needs for adaptations and increased personal care, which had enabled him to stay in comfort at the home as he wished. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Complaints were properly investigated and recorded according to the home’s procedure. Service users were protected from abuse by detailed protection procedures and staff training. EVIDENCE: The homes complaints procedure was in the service users guide. Service users said they knew to whom and how to complain if they had a problem. They knew they could talk to staff, the manager or provider and knew how to contact The Commission for Social Care Inspection, and their mental health or social worker. It was clear from discussion with service users that they felt they had peer support from other residents if they needed to raise a concern and most people had good support from families. Since the last inspection, there had been two complaints from service users, which had been dealt with according to the home’s procedure. Service users spoken with did not have any current concerns or problems. The adult protection procedures detailed an appropriate response to suspicion or evidence of abuse. All the staff had undertaken recent training in Protection of Vulnerable Adults (POVA) and certificates of this training were kept in staff files. Service users had been invited to attend the training. One person had done so and received a certificate. Staff and service users understood how to minimise risk of abuse and how to respond to allegations. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 26 The home was maintained in good order, providing a clean, safe, warm and comfortable environment, which met the needs of service users. EVIDENCE: The house was non-institutional and suitable for its stated purpose of supporting younger adults who have a mental health problem, being near to local transport, shops and other amenities and in keeping with other houses in the locality. The communal rooms are spacious, with good quality domestic style furniture, fittings and decoration, chosen by the residents. Service users’ personal belongings and pictures gave the house a ‘homely’ feel and the home had a ‘no smoking’ area. Service users said that they liked their home. The house and grounds were well maintained, with no obvious hazards to safety. Qualified persons carried out prompt maintenance. Since the last inspection, safety work had been carried out in the kitchen and the central heating and hot water system had been completely overhauled. With permission, private bedrooms were inspected. These had good standards and were personalised to each persons’ taste. Every room had a door lock and the double room had privacy screening between the beds. The registered manager should check the level of lighting, to allow sufficient light to read. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 Clearly defined job descriptions, appropriate codes of conduct and staff training underpinned staffs’ good understanding and implementation of the home’s aims and objectives. EVIDENCE: All the service users spoken with said they liked the staff. Residents and staff shared good relationships with good-humoured banter and underlying respect. Service users said support workers were always available and approachable and understood how to meet their needs. Staff had job descriptions. A support worker said she knew that these were under review and they were to have a meeting at the end of January to discuss the proposed changes. The home’s induction training covered discussion of the home’s aims and objectives. The care and support observed by the inspector confirmed that staff practice promoted service users’ independence, choice and rights. Codes of practice at the home reflected those of the General Social Care Council. Staff were enthusiastic and motivated. A support worker said she enjoyed her job and the training. A senior worker was undertaking NVQ level 4 to increase her level of expertise. Staff understood their own and each others’ roles, expertise and limitations, with staff referring some issues to the manager and understanding the roles of mental health professionals. Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 and 42 Sound and comprehensive policies and procedures underpinned care, health and safety, ensuring that good practice was followed and risks to service users were minimised. Systems that encouraged and enabled residents to express their views and opinions were in place. EVIDENCE: The home had a good quality assurance system. This included: • • • • • • Regular service user and staff meetings Using the Investors in People award as a basis for training and staff development Using and analysing satisfaction questionnaires Having good informal communication systems for gathering the views of all stakeholders Holding regular management meetings with external management Ensuring that requirements and recommendations from CSCI and other reports were dealt with promptly Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 16 • • • • • • • • Having regular formal and informal staff supervision, which included ensuring that staff were adhering to policies and procedures Ensuring that service users were consulted about and participated in their own care planning Regularly reviewing policies and procedures Promoting staff in-house and NVQ training Including service users in training Consulting service users about change and planning Complying with regulation for monthly registered provider visits Dealing with complaints effectively The manager should evidence how such strategies are used to forward plan and to improve service delivery: The registered persons need to prepare a report of the review of the quality of care, showing how improvements have been and are to be made. As discussed, the registered persons may wish to link this to their annually reviewed business and financial plan. A copy of the report should be made available to service users and to the Commission. Since the last inspection, the home had met recommendations to ensure safety in the kitchen (by providing fire protection in respect of the proximity of cupboards to the gas hobs) and was monitoring refrigerator and freezer temperatures. The home had also overhauled the central heating and hot water system, including fitting a thermostatically controlled device to regulate the hot water (to minimise risk of scald to service users). Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 X X 2 3 X 3 X Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 18 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 YA39 Regulation 24(1)(2) Requirement The registered person must supply a copy of the home’s quality of care review and improvement report to the Commission and make the report available to service users. Timescale for action 28/02/06 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 YA26 Good Practice Recommendations The manager should check the level of lighting in bedrooms, to ensure there is sufficient light, for example to read comfortably (26.2vii). Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Pendle View DS0000009589.V276102.R01.S.doc Version 5.1 Page 20 - 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. 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