Inspection on 13/07/05 for Pendrea House

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pendrea House 22/08/07

Pendrea House 07/09/06

Pendrea House 03/11/05

Pendrea House 07/02/05

Pendrea House 22/06/04

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 Pendrea House 14 Westheath Avenue Bodmin Cornwall PL31 1QH Lead Inspector Elaine Bruce Announced 13 July 2005 08:15 a.m. 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. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pendrea House Address 14 Westheath Avenue Bodmin Cornwall PL31 1QH 01208 74338 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) Mrs Pauline Janet Difford Mrs Brenda Eileen Keen Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th February 2005 Brief Description of the Service: Pendrea House is registered to provide personal and social care for up to sixteen service users over the age of sixty five years. Nursing care is not provided. The detached house is situated on the outskirts of Bodmin within close proximity to the local hospital, shops, amenities and bus routes. Accommodation is provided on the ground and first floors. There is a stair lift to the first floor for and service users with reduced mobility. There are three bathrooms in the home with assisted bathing. The home offers level access throughout. All rooms (apart from one shared) offer single occupancy, many rooms have en-suite facilities. The communal areas comprise of a large lounge (in two parts) and a pleasant dining room that also has a seating area. There is a large conservatory with plenty of seating and a call bell system to the front elevation, overlooking the colourful, well-maintained garden. There is car parking to the front of the building. The registered provider runs a domiciliary care agency from the home and provides day care within the home (up to a maximum of four service users per day). Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 13th July 2005 over seven hours and was carried out as an announced inspection. A tour of the premises took place and care records and policies and procedures were inspected. Service users were spoken to during the course of the inspection. All the service users spoken to expressed very positive comments on the standard of the care that they are receiving at the home. Prior to the inspection three service users comment cards were received indicating positive comments around the running of the home. One relative comment card was also received prior to the inspection, again indicating positive comments. The registered manager and registered provider were present during the course of the inspection. What the service does well: What has improved since the last inspection? Each service user has now been provided with a contract of care which meets the statutory requirement of the inspection report dated the 7th February 2005. Correct recruitment procedures for employing new staff members are now fully in place which meets the statutory requirement of the inspection report dated the 7th February 2005. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 6 Correct procedures are now in place for the finances of the service users. This was a statutory requirement in the inspection report dated the 7th February 2005. The statutory requirement in the inspection report of the 7th February 2005 for staff to receive supervision is now being met. 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. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 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 Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 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) 1,2, 3 and 4 The home’s statement of purpose and service user guide provide service users and prospective service users with details of what the home provides helping an informed decision about admission to the home. The registered manager assesses all service users prior to admission to the home to ensure that the home will be able to meet their care needs. EVIDENCE: There is a comprehensive statement of purpose and service user guide which are made available to current and prospective service users. The service user guide is combined with the contract of care. It is recommended that information is included on the room sizes in the home as stated in the “schedule of information” for the statement of purpose documentation. The statutory requirement in the inspection report of the 7th February 2005 to issue each service user with a contract of care is now met. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 9 The registered manager assesses all new service users prior to admission to the home, and in her absence the registered provider would undertake this role. The assessment document that is used is a very detailed, long document which is then used as part of care planning documentation when the service user is in the home. It is recommended that information is included in the service user guide to advise new service users that an assessment of their care needs will be undertaken prior to admission to the home. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 10 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 and 9 Care plans are in place but more information is required to ensure that the care needs of the service users are being met. EVIDENCE: All the service users have a plan of care in place. The pre admission assessment document is part of the care planning documentation. Daily records also support the documentation. Night recording is kept separately to the daily records. Monthly reviews are evidenced as taking place. There is a large amount of information in place in regard to each service user but the records do not complement each other for example one daily entry stated that a service user now required to be washed daily but this information was not in care planning. Where a nurse is attending a service user this information was not in care planning. In some cases the reviews of the service users evidenced that they were at risk of falling but nothing had been transferred into the risk assessment heading in care planning. All the service users are registered with a general practitioner. Community nurses provide any nursing care as required. Pressure relieving equipment and continence aids are provided following assessment by the community nurses. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 11 An optician visits the home on an annual basis. Dental services are provided as required by the individual. The chiropodist visits every six weeks. There is no evidence that the service users are being weighed. The accident book is maintained appropriately but it is recommended that more information be given in regard to the reporting of any deaths in the home under the requirements of Regulation 37 of The Care Homes Regulations. It is also recommended that records of health care professional input to the service users is kept on a separate multidisciplinary record sheet (for easy reference purposes). The home has in place a medication policy and procedure that was immediately altered at the time of the inspection following an observation that a staff member had not signed the medication administration record after giving a service user their tablet. Evidence is required that staff have read this important documentation prior to having the responsibility of medication administration. Improvements to the storage of medication are noted since the last inspection and the blister pack system appears to be working satisfactorily. Unfortunately the medication is held in a corridor which during the course of the inspection was noted to be very busy. This was discussed with the registered provider and manager as to whether there were any other options available. All staff who administer medication have received accredited medication training. All service users who take responsibility for their own medication administration must sign a declaration to this effect. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 12 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) These standards were not assessed at this inspection. EVIDENCE: Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 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 The home has a satisfactory complaints procedure provided to the service users and their representatives in the service user guide. Staff are provided with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home has a complaints procedure (with timescales) which is available to service users in the service user guide. The home has an adult protection policy and procedure in place that includes information on whistle blowing. A copy of “No Secrets” and other general information on this topic is held on file for staff information. The registered manger has attended the local social services department for adult protection training. Nine more staff are due to attend the social services department training. Staff receive training in adult protection in their induction training. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 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) 19,20,21,22,23,24,25 and 26 The premises at Pendrea are very well maintained externally and internally offering a safe and pleasant environment for the service users. EVIDENCE: The home is well maintained, decorated and furnished. The gardens are attractive, well maintained and accessible to the service users. The home has in place the use of CCTV cameras which are restricted for security to entrance areas only. Car parking is available in the grounds of the home. The communal areas comprise a large lounge and a separate dining room. Furnishings are of a good quality and are domestic in nature. The rooms are light and airy with domestic lighting. There is also a very pleasant conservatory with a call bell system at the front of the home. The conservatory offers seating overlooking the garden. It is well used and appreciated by the service users. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 15 Ten of the bedrooms have en-suite facilities (toilet and hand basin) and the other bedrooms have toilets close to them. Toilets are located close to the communal facilities. There are two assisted bathrooms on the ground floor that are decorated and presented to a high standard. There is one assisted bathroom on the first floor which is again decorated to a high standard. It is recommended that an assessment of the premises takes place by a suitably qualified person to ensure that all disability equipment and environmental adaptations are in place. Fourteen of the bedrooms are over 10 square metres and one shared bedroom is over 16 square metres. The shared bedroom has an en suite facility. The bedrooms are furnished and carpeted to a high standard. Service users are able and encouraged to bring their own personal possessions with them when they move in. Radiators in the home should be guarded to reduce the risk of scalding to the service users. Some of the radiators are of a low temperature surface but others should be covered on a risk assessment basis. This was included in the inspection report of the 7th February 2005 with a timescale of 31/10/04. This is included again in this inspection report with a six month timescale for compliance as agreed with the registered provider. The water from the wash hand basins in the bathrooms appears to be very hot which could present a risk to the service users. This was commented on in the inspection report of the 7th February 2005 and is included in this inspection report as a statutory requirement. The home was found to be very clean on the day of the inspection. Specific staff members are employed for all cleaning duties. The laundry provision was not inspected on this occasion. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 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) 27,28,29 and 30 Staffing levels at Pendrea are satisfactory during the day but at night there is only one waking member of staff in the home which could pose a risk to the service users. Training is ongoing and should soon meet fully the requirements of The National Minimum Standards. EVIDENCE: There are a minimum of two carers at the home during the day with one waking night carer within the building and extended family (of the registered provider) on call to assist service users that require attention. It has been strongly recommended for some time that two carers are on duty at night, however the registered provider still states that the staffing levels meet the care needs of the service users. One of the care plans indicates that two carers are required by night and this appears to have been met by staff from the community care team coming into the home. The requirement to staff the home appropriately is included in this inspection report as a statutory requirement to ensure the health and safety of the service users (and the staff member) at all times. Six out of the sixteen staff employed at the home are trained to NVQ 2 in care. In addition four other staff have all started their NVQ 2 studies and one of these staff members is undertaking an NVQ 3. When these staff have obtained their qualifications the standard for 50 of care staff to have an NVQ 2 in care will have been met. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 17 Recruitment procedures were found to be satisfactory at the inspection. Written references and a criminal records bureau check are in place for all staff members employed. Application forms were found to be competed appropriately. As discussed at the time of the inspection it is recommended that a risk assessment is undertaken for the conviction on a staff members criminal record bureau check. Staff members are receiving induction training that is based on the TOPPS good practice documentation. Staff are receiving statutory training to include fire drill, moving and handling, first aid and basic food hygiene certificate. Good practice training that is planned or has recently taken place includes infection control, adult protection and medication accreditation training. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 18 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) 31,33,35 and 38 The manager has recently been registered at Pendrea. With the support of the registered provider they will now have to prioritise the standards that are not met in this inspection report. EVIDENCE: The registered provider is Mrs Difford who has managed the home with the support of her husband since 1990. A manager has recently been registered and between the registered provider and registered manager they are in the home most days. The registered manger is undertaking studies for the registered managers award and she hopes to have achieved this soon. A discussion took place on the requirements for meeting the standard on effective quality assurance and quality monitoring. The service users have completed a questionnaire with a staff member about the care at the home. It is noted that the comments received about Pendrea were positive. This Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 19 documentation is to be further expanded to include stakeholders in the community. The service users at Pendrea control their own money except where they state they do not wish to or lack the capacity to. All records are in place where money is being given to the service users and items are being purchased for them. All records are in place for all finances being kept on the premises on behalf of the service users. The statutory requirement of the inspection report dated the 7th February 2005 is now met in regard to the service users finances. The requirement in the inspection report dated the 7th February 2005 for staff supervision is now being met. Records are in place to evidence that staff supervision and a yearly staff appraisal are taking place. All maintenance records in regard to the running of the home are now in place. This was a statutory requirement in the inspection report dated the 7th February 2005. This standard is still not met and again included in this inspection report. The health and safety and welfare of the service users is at risk around the environment and staffing. As stated in the environmental section of the report the radiators are not consistently guarded in the home and water was found to be of a very high temperature and posing a risk to the service users. The staffing levels at night also pose a risk to the service users in the event of an accident or fire. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 20 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 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 2 3 3 1 3 STAFFING Standard No Score 27 1 28 2 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 3 x 2 x 3 3 x 1 Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 21 YES 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 25 Regulation 13(4)(a) Requirement The registered provider must ensure that all parts of the home to which service users have acccess are so far as reasonably practicable free from hazards to their safety. The registered provider must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The regsitered provider must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Timescale for action 31/01/06 2. 27 18(1)(a) 31/08/05 3. 38 13(4c) Immediate 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 1 Good Practice Recommendations To include information in the statement of purpose on the room sizes in the home. D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 22 Pendrea House 2. 3. 3 8 4. 5. 6. 8 7 9 7. 8. 9. 22 29 33 To include in the service user guide information that service users will be assessed prior to admission to ensure that the home will be able to meet their care needs. To record all health care multidisciplinary visits to service users on separate sheets for easy tracking purposes. To ensure full informaiton is given when recording any deaths in the home to the CSCI under Regulation 37. To regularly weigh the service users. To ensure that the care planning documentation evidences that all care needs of the service users are being met. To evidence that all staff who have medication administration responsibility have read the medication policy and procedure. To evidence documentation that service users have signed a self declaration for medication administration. To review the storage of the medication in a busy corridor. To request an assessment of the premises by a suitably qualified person to ensure that all disability equipment and environmental adaptations are in place. To carry out a risk assessment for the criminal records bureau conviction in regard to the staff member employed. To evolve the quality monitoring document to the stakeholders in the community. Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell, Cornwall PL25 4AD 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 Pendrea House D52-D04 S9202 Pendrea House V228050 130705 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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