Inspection on 31/05/06 for Pendle View

This inspection was carried out on 31st May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pendle View 03/06/08

Pendle View 03/01/06

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 Key Unannounced Inspection 31st May 2006 9:55 Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 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.V295894.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 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.V295894.R01.S.doc Version 5.2 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.V295894.R01.S.doc Version 5.2 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) 3rd January 2006 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. Pendle View is the ‘core’ house of a residential homes scheme comprising the core house and three smaller houses in Nelson. The registered manager has responsibility for all four houses. The fees charged at May 2006 ranged from £462.00 to £531.00 per week (depending on need). There are no extra charges, but residents are expected to pay for personal effects (such as toiletries, newspapers, clothing and hairdressing). Information about the service and CSCI reports are available in the hall and dining room. Copies of the service user’s guide and Statement of Purpose are given to residents. 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 sitting area in the back yard. There are good local transport links nearby. Transport is also provided for residents in staff cars. There is one double bedroom and four single bedrooms (one being on the ground floor). The home has two spacious 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.V295894.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over one day, when 6.20 hours were spent at the home. During this time the inspector talked to four of the six residents, a service user visiting from another home, staff on duty and the manager. She looked at records and care plans; had lunch with residents and staff; observed staff practice and toured the home. This report also includes evidence from written information provided by the manager and provider and details gained from previous inspections (including a visit from the specialist pharmacy inspector). Three residents returned surveys with their comments about the home. All key and additional National Minimum Standards were assessed. What the service does well: What has improved since the last inspection? Residents said there were more activities outside the home, giving them opportunities to be independent. Residents were also making more decisions about the running of the home, (such as decorating, housework rotas, smoking policy, trips out, charity activities and policy reviews) through their meetings The home had improved medication safety by implementing the requirements and recommendation of the pharmacy inspector. A service user’s suggestion Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 6 about having pocketsize medication details to take out with them has been implemented. The home had promoted advocacy awareness and one resident regularly used an independent advocate. Residents appreciated that the home had continued to improve the premises, with decoration and new lounge furniture. The home had produced a newsletter, so everyone knew what the home had achieved and the plans to improve the quality of the care service. 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.V295894.R01.S.doc Version 5.2 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.V295894.R01.S.doc Version 5.2 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): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: Prospective residents can be confident that their needs and wishes will be met at Pendle View, because the home carries out a comprehensive admission procedure with each person, including a properly conducted needs assessment. EVIDENCE: Discussion with residents about their admission and inspection of records showed that everyone had been consulted about needs and wishes prior to admission. Prospective residents had visited: “I came here twice and met everyone and then stayed overnight”; and been given written information about the home (service user’s guide and statement of purpose), which enabled them to make an informed decision about whether Pendle View was the right place for them to live. Trained people had helped to assess needs, to ensure that they could be met by the home. Individual contracts had been made with each resident, to ensure that both parties’ rights and responsibilities were protected. The manager said an Urdu translation of the service users’ guide and contract would be available soon. Residents said they were involved in their initial and on going assessments through the mental health Care Programme Approach (CPA) arrangements. Needs had been properly and fully assessed by trained persons under CPA and copies of these assessments and care plans were kept in personal files. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 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): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: There were good arrangements to ensure that residents were consulted about their care and the running of the home. Residents had choice and control over their lives because they were kept fully informed and staff respected their rights to make independent decisions and take responsible risks. EVIDENCE: Aims for care were detailed and explicit in care plans, as were limitations, risk assessment and the reasoning behind this. Residents said they had regular care plan reviews and had staff support in their CPA review meetings. Residents said they had regular formal meetings and were given copies of meeting notes. Additionally, everyone met informally round the dining table and made suggestions for improvement. Residents explained they made decisions about menu planning, activities and trips out and decorating. One person said she was taking a food safety course with the staff. Staff described how they supported residents to make individual choices and had helped one person to have an advocate and interpreter to assist with decision-making. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 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, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: Flexible routines and good personal support enabled residents to live meaningful, enjoyable and independent lives, with individually appropriate social activities and contact with family and the local community. Meal choices were varied. EVIDENCE: Residents described life at Pendle View as being “very good”. Throughout the visit residents made decisions about lifestyle (such as rising times, having a shower, tidying rooms, going out, doing laundry etc.). A rota had been agreed about everyone helping with washing up, which was thought to be “fairer”. Residents said they all got on well together, but had privacy and could be alone when they wanted to be. Several people said activities and opportunities to do things in the local community had improved. Everyone had something of interest they wished to do. These included going to the gym, cinema, resource centres (for crafts, Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 11 embroidery, cooking, joinery, cycling), mosque, college, pub meals, walks, shopping, bowling and ‘Greenspace’ gardening project. During the course of the visit one person was out at a voluntary job at a shop, two people went food shopping with staff, one person went with staff to visit a resident in hospital and one person visited his house in the community. At home, residents said they enjoyed having family and friends to visit, cooking and baking, playing guitar, listening to music and watching TV. One person explained staff helped with confidence building and managing anxiety. Staff supported one resident to keep in touch with a spouse who was abroad. ‘Self service’ breakfast and supper times were flexible, to accommodate each person’s preferred rising and retiring times. Everyone helped with cooking, menu planning and food shopping. One resident said he often made meals suited to his cultural preferences. Residents said they enjoyed eating out. Meals were a social occasion with staff and residents eating together and meals served records showed individual choice and variety. Staff promoted healthy eating options and one resident said that her health had improved with attention to her diet for diabetes and weight loss. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 12 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): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: Residents’ personal and healthcare support needs were identified and met in a manner that respected privacy, dignity and independence. EVIDENCE: Healthcare and personal needs were defined, identified and monitored by residents with observation from staff. Needs, including capacity for self-care, were recorded in each person’s care plan and monitored carefully through daily evaluation reports. One resident said staff had been “really helpful” in taking her to and supporting her through recent dental treatments. Staff visited and supported residents and their families during periods of hospitalisation. Residents said staff were “good” in supporting them during meetings with mental health professionals. A ‘bank’ staff member was available to help one resident with language and cultural support. The manager said she intended to develop staff skills in helping residents with psychological care. Improved medication policies and procedures were followed by staff who had accredited training. Self-administration was risk-assessed and a resident’s suggestion for a pocket-sized medication profile had been put into practice. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: The home followed a robust complaints procedure, so residents could be confident that any concerns were taken seriously and acted upon. An appropriate vulnerable adults procedure and staff training ensured that people living in the home were properly protected from risk of harm. EVIDENCE: Residents said they had no current complaints or concerns. There were no complaints recorded in the last twelve months. Residents knew how to complain. They explained they could talk to the manager or staff anytime and knew how to contact CSCI. Residents said staff checked they were happy – “staff talk to me”; “they ask how things are and write it down”. Problems were also discussed at residents’ meetings. There were adult protection and staff ‘whistle blowing’ procedures, measures to protect residents’ finances and a copy of ‘No Secrets in Lancashire’. These documents were available to staff and residents and set out the response should there be any allegations or evidence of abusive practice. Staff had received training in protecting residents and dealing with aggression. Staff on duty demonstrated a good understanding of what constituted abuse, how to protect residents from harm and risk of harm and what to do if abuse was evidence or suspected. Residents had joined in with protection training and one person had a certificate. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 14 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, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: The home was maintained in good order, providing a clean, safe, warm and comfortable environment, which met residents’ needs. EVIDENCE: The home was non-institutional, with good standards of décor and cleanliness. There were no obvious hazards to safety and the building and outside yard were maintained in good order. Refurbishment and safety checks were carried out in a timely fashion. Living rooms were spacious and comfortably furnished with a new suite. Residents’ belongings gave a ‘homely’ feel and residents said they liked living at Pendle View, describing the house as “nice” and “posh”. Residents had discussed smoking policies and one resident said she had been consulted about her choice of bedroom colour scheme. Everyone used the well-equipped laundry. There were sufficient toilets and a choice of bath or shower. One person had requested a shower downstairs. Residents liked their private and comfortable bedrooms. The double room provided minimum space and a good privacy screen, but space for personal belongings was limited. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 15 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): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: Thorough recruitment practices and a good programme of staff supervision protected residents from risk of harm. Competent staff met residents’ needs. EVIDENCE: Checks of two recently appointed staff files showed that robust procedures were followed. Checks were made before confirming new staff in post and staff had supervised induction training. This resulted in a properly vetted workforce and care workers suitable to work with vulnerable adults. 50 of the staff had NVQ qualification. This, and other training helped to ensure staff knew how to meet the aims of the home and changing needs of residents, although the home identified specific training in mental health issues as an area for development. Residents’ personal development was promoted and protected by a good programme of regular staff supervision and appraisal. Three residents commented they always received the care and support they needed. All those spoken to said they liked the staff. They had confidence in staff skills and could also “have a bit of fun”. Unusually, there had been three staff changes, but this had not affected care continuity. Staff said they enjoyed their work and had time to spend with residents inside and outside the home. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 16 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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: The experienced and competent manager provided good quality, consistent care for residents by ensuring the home was safe and there were systems that encouraged and enabled residents to express their views and opinions. EVIDENCE: The manager is experienced and qualified to NVQ level 4. She regularly updates her skills and is currently undertaking an NVQ trainer and assessor course, so she can provide ‘in house’ NVQ training for the staff team. The manager has plans to improve her knowledge and skills by taking teaching and psychology courses. The home had a good quality assurance system. This included: • Regular service user and staff meetings Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 17 • • • • • • • • • • • • • • • Using the Investors in People award as the basis for training and staff development Using and analysing satisfaction questionnaires Having good informal communication systems for gathering the views of all stakeholders Acting on resident’s suggestions and requests Distributing information and the home’s improvement plans in a ‘user friendly’ newsletter Holding regular meetings with external management Ensuring requirements and recommendations from CSCI and other reports were dealt with promptly 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 with residents Promoting staff in-house and NVQ training Including service users in training Consulting service users about change and planning Complying with Regulations for monthly registered provider visits Dealing effectively with complaints There were no obvious hazards to safety and the premises looked well maintained. Staff had completed health and safety, basic food hygiene, first aid and fire safety courses. Residents were included in safety training and were currently working through a distance learning food safety course with the staff. Residents said they thought it was important that they knew what to do to be safe and that they could “tell if staff were doing things wrong”. Fire drills were carried out regularly, accidents recorded and risks minimised. Good infection control practice was observed, water safety was monitored and checks for alarms, electrical and gas safety were up to date. Written risk assessments had been carried out for safe working practices and Control of Substances Hazardous to Health (COSHH) assessments were maintained. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 18 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 3 2 3 3 X 4 3 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 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations To enhance knowledge and skills, staff should undertake training in mental health conditions and develop specialist skills to meet the specific needs of service users, (32.3) as identified in the home’s staff team training needs assessment. Pendle View DS0000009589.V295894.R01.S.doc Version 5.2 Page 20 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.V295894.R01.S.doc Version 5.2 Page 21 - 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!