Inspection on 22/08/07 for Pendrea House

This inspection was carried out on 22nd August 2007.

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 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 07/09/06

Pendrea House 03/11/05

Pendrea House 13/07/05

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 Key Unannounced Inspection 22nd August 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendrea House Address 14 Westheath Avenue Bodmin Cornwall PL31 1QH 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) 01208 74338 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 DS0000009202.V344101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2006 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 DS0000009202.V344101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection at Pendrea took place on the 22nd August 2007 from the hours of 0900 to 1500. The inspection took place with the assistance of the registered manager and registered provider. A completed annual quality assurance assessment was received at the CSCI before the inspection. During the course of the inspection six people were spoken to. In addition one person was spoken to whilst he was attending the home for day care. The home is able to provide a small number of places for day care and the interaction between day care and long stay people appears to work well. Each person spoken to expressed very positive comments on the standard of the care they are receiving at Pendrea and excellent comments were received in regard to the meals being provided at the home. One person said “I am very happy here, the food is very good and the staff are kind”. In addition to the meals provided in the home meals are delivered into the community and on the day of the inspection this consisted of 37 meals. During the course of the day records for case tracking were inspected as were staff files, policies and procedures, medication arrangements and the standard of the meals at the home as well as an inspection of the premises. The range of fees for the home are from £293.25 to £400. What the service does well: Pendrea is a very well maintained, very pleasant homely home. The home has been owned and run by the registered provider for a considerable period of time and she is very involved in the running of the home. All the people spoken to during the course of the inspection expressed very positive comments on their surroundings and the cleanliness of the home. The garden is also spoken about with enthusiasm, it is well maintained and full of colour. The standard of the meals in the home is good. Every person spoken to during the course of the day expressed very positive comments on the meals being provided. One lady said: “It is lovely here, the food is very good, I should know as I used to cook meals for schools”. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It has been consistently recommended by the CSCI that the registered provider gives serious consideration to employing two members of staff in the home at night at all times. It is understood that when care needs of the people in the home increases at night that there are two staff members on duty but this does not take place every night. The staffing rota must be correct at all times as discussed at the time of the inspection. The adult protection policy and procedures should be updated and read by all the staff to ensure they are aware of the home’s policy should there be an adult protection alert. In addition it is important that staff receive internal adult protection training until this can be received externally. A statutory requirement for staff to receive statutory fire drill training is included again in this inspection report. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive procedures prior to admission ensure that the people being admitted to Pendrea (and their relatives) can be confident that their care needs will be met. EVIDENCE: The registered provider is presently updating the statement of purpose/service user guide and the planned changes to the documents were discussed at the inspection. When the changes are done and new information is included the documents will be very informative and meet fully the requirements of legislation. Each person in the home will be issued with the new documentation. The registered provider also plans to issue the documents to some health care professionals for information. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 10 The registered manager assesses all potential residents prior to admission to the home. The pre admission assessment document is very detailed and is completed well by the manager to include the views of the person involved in the assessment. The home recognises the importance of the assessment to ensure that the home will be able to meet the assessed needs. All prospective people who are considering admission to the home are invited to the home to spend time there and become familiar with the surroundings and staff prior to admission. The home has in place a good practice admission policy and procedure for guidance to staff. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Pendrea can be confident that they will be treated with respect, privacy and dignity and that their personal and health care needs will be met. EVIDENCE: Each person at the home has in place a care plan that is problem based and identifies the care required to meet the needs of each aspect of the problem identified. This information is taken from the detailed pre admission assessment document. The registered manager has responsibility for the care plans which are evidenced as being reviewed and updated monthly. All the care staff are involved in the daily recording and it is noted that the content of these records has improved since the inspection of the 7th September 2006. All the people at the home are involved in the care planning process. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 12 It is recommended that all the information that is included in the detailed pre admission assessment is included into care planning. An optician visits the home on an annual basis. Dental services are provided as required by the individual. The chiropodist visits every six weeks. The people in the home are weighed monthly and there are plans for monthly blood pressure screening and urine checks to take place. Nutritional screening documentation is now included in care planning. The storage of the medication was found to be satisfactory on the day of the inspection although ideally the medication would be stored more appropriately in a room rather than a wide corridor. Medication administration records were found to be completed correctly except for one entry which was discussed at the time of the inspection. Controlled medication is stored and recorded appropriately. All the staff who have medication administration responsibilities have received training for this task. There is a medication policy and procedure in place to guide staff on best practice. It is recommended that the staff signature list is updated with initials for audit purposes if required and that evidence is in place that the staff have recently read this important policy and procedure. Each person spoken to during the course of the inspection expressed very positive comments on the care that they are receiving in the home. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines in the home are relaxed, relatives and friends can be confident that they are welcomed and social activities are available. The dietary needs of the people at Pendrea are very well catered for with a balanced and varied selection of food that meets peoples’ tastes and choices. EVIDENCE: Each person spoken to during the course of the day expressed very positive comments about the daily life at the home. People chose to spend the day how they wish and should they so wish there are weekly activities that take place at the home. These include for example scrabble, bingo or cards and a regular trip out. The home has it’s own transport and last week a day out took place to a garden centre where a cream tea was enjoyed. A fete recently took place with the proceeds raised donated to the local hospice. The registered provider stated that she was going to provide more information for the notice board on the activities that the home provides. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 14 The daily records include information on how people are spending their time to also include information when they have received visitors. Visiting to the home is open and encouraged. All visitors to the home are asked to sign the visitors’ book on arrival at the home. The home provides opportunities for hairdressing, library visits and church services. Information is included in the service user guide to indicate how the home can help meet the religious and spiritual needs of the people living there. The conservatory is a very popular area where a number of people sit talking and looking out over the attractive gardens. The home has a small number of people who attend the home for the day. One person attending for the day was spoken to he said that he really enjoyed coming for the day and “the meals are excellent”. All the people spoken to during the course of the day suggested that the food in the home is “excellent”. The cook is long standing and is qualified with a basic food hygiene certificate. In addition to the meals provided for the home she cooks a large number of meals for the community. On the day of the inspection the main meal was roast pork, roast potatoes, apple sauce, stuffing with cauliflower, carrots and cabbage followed by blackcurrant crumble and custard. On Wednesday and a Sunday sherry is served before the meal and wine during the meal if wanted. There is always an alternative choice to any meal offered and records are fully in place of all meals provided. The home is following the District Council Environmental Healthy Eating, Better Business guidelines and paper work. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some staff require more training in adult protection to ensure the safety and well being of the people in the home. People spoken to are aware of who they should complain to and written documentation is to be provided to ensure that all complaints are taken seriously. EVIDENCE: The registered provider is presently updating the complaints policy and procedure so each person at the home (and their relative/representative) has the correct information should they so wish to complain. When completed each person will be issued with this documentation. It is anticipated that this task will be competed very soon. The home has in place an adult protection policy and procedure but there is no evidence in place at this time to state when this important policy has last been read by the staff. It is also recommended that the policy and procedure be expanded with information on the role of the local Adult Social Care Department. Six staff are due in September to attend external training in adult protection with three staff still due to receive training. As discussed at the time of the inspection it is recommended that supervision and internal training in this important area takes place until the external training can be obtained. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 16 The registered manager is due to attend the managers’ training for adult protection which is being provided by Cornwall County Council. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pendrea provides a well maintained home that is warm, comfortable, safe and secure. EVIDENCE: Pendrea is well maintained, decorated and nicely furnished. The gardens are attractive, well maintained and accessible to the people in the home. Seating is provided in the gardens. The home has in place CCTV cameras that are restricted for security to the entrance areas only. Car parking is available in the grounds of the home. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 18 The communal areas comprise a large lounge and a separate dining room. Furnishings are of good quality and are domestic in nature. The rooms are light and airy with domestic lighting. There is also a pleasant conservatory with a call bell system at the front of the home. The conservatory is well used by the people in the home. Ten of the bedrooms have en-suite facilities (toilet and hand basin) and the other bedrooms have toilets close to them. There is one shared bedroom at the home. The bedrooms are carpeted and furnished to a high standard. People are encouraged to bring their own personal possessions with them when they move in. The home was found to be very clean on the day of the inspection. Specific staff members (two) are employed for cleaning duties Monday to Sunday. The laundry is situated outside of the home and although small is provided with suitable equipment for the number of people in the home. All maintenance records were found to be in place and up to date. A fire officer inspection last took place in 2003 and it is recommended that fire risk assessments are improved/updated and discussed with the local fire officer. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people at Pendrea are cared for by knowledgeable, capable and caring staff. Consideration should be given to increasing the numbers of staff in the home at night to ensure the safety and well being of the people in the home at all times. EVIDENCE: On the day of the inspection two carers were on duty as per the rota and the cook and a cleaning staff member. The rota indicated that the manager should have been on duty at the commencement of the inspection but she was not there at that time. The staffing rota must have correct information included on it at all times. At night the home has one waking staff member on duty with on call assistance provided from a suitable person living in the property immediately behind the home. It has been consistently recommended by the Commission for Social Care Inspection that two carers should be on duty at night in the home to ensure the safety and well being of the people in the home at all times. The registered provider explained that when the care needs of the people in the home are higher at night there are two people in the home. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 20 Recruitment procedures were found to be satisfactory on the day of the inspection to include evidence in staff files of two written references and a criminal records bureau check. The inspection report of the 7th September 2006 recommended that criminal records bureau checks should be re submitted for staff who have not had a protection of vulnerable adults check undertaken. This has still to take place and on the the registered provider commenced this task on the day of the inspection. Staff records are organised and evidence that regular staff training is taking place at the home to include statutory and good practice training. It is though noted that the new night staff member has not received the correct amount of fire drill training which must be addressed as a priority considering she is in the home on her own at night. This is included in this report as a statutory requirement and was also included in the previous inspection report. Induction training has recently been improved in line with the Skills for Care common induction standards. Staff on duty were noted to be dressed very smart with their name badges and they presented well during the course of the day. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team have worked hard to meet outstanding requirements of legislation. Further progress is still required to ensure the well being of the people in the home at all times and it is anticipated that this can be achieved. EVIDENCE: The registered provider has run the home with the support of her husband for a considerable number of years. She is very involved in the running of the home to include a daily visit. The registered manager is a qualified registered nurse who has obtained the registered managers award qualification. In Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 22 addition she has recently attended training which has included the mental capacity act, adult protection training and infection control. Progress in meeting the requirements of legislation is noted since the inspection of the 7th September 2006. The registered manager works in the home over the week to include being on call when not at the home. A quality monitoring/auditing of the home has recently taken place in the form of questionnaires to the people, relatives and health care professionals. This has recently taken place and therefore the results have yet to be analysed by the registered provider. On a first read of the completed questionnaires it would appear that the comments are very positive about all aspects of care in the home. The home encourages the people living there to take responsibility for their own finances if they are capable and happy to do that. If not family members/representatives can undertake this task although the home can help if required. At present Pendrea is holding finances on behalf of three people. Records were found to be completed appropriately and the storage of money was also found to be safe. Staff supervision is taking place regularly as is an annual staff appraisal. Policies and procedures are in place to meet requirements of health and safety legislation. Policies and procedures are in place for infection control guidance and maintenance records for health and safety are also in place. Fire risk assessments require updating as already identified. Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 2 Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation 23(4)(d) Requirement The registered person shall after consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. (original date for compliance 31/03/07 Timescale for action 31/12/07 Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations To ensure that all medication is signed for after administration not before. To update the staff signature list of initials and ensure that evidence is in place that all the staff have read the medication policy and procedure. To update the adult protection policy and procedure and ensure that all the staff have read it. To provide interim supervision and internal training to three staff members until there is a vacancy on an external course. To consult with the local fire officer and update and improve the fire risk assessment for the home. To give serious consideration to employing two cares in the home at night. To ensure that at all times the staffing rota is correct. To update the criminal records bureau checks that are old and without an adult protection check included. 2. OP18 3. 4. 5. OP19 OP27 OP29 Pendrea House DS0000009202.V344101.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 DS0000009202.V344101.R01.S.doc Version 5.2 Page 27 - 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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