Inspection on 03/11/05 for Pendrea House

This inspection was carried out on 3rd November 2005.

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

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

Other inspections for this house

Pendrea House 22/08/07

Pendrea House 07/09/06

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 Mike Stokes Unannounced Inspection 3rd November 2005 1:30 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.V252322.R01.S.doc Version 5.0 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.V252322.R01.S.doc Version 5.0 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.V252322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: Pendrea House is registered to provide personal care and accommodation for up to sixteen service users over the age of sixty-five years. 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 to assist service users with reduced mobility. There are three bathrooms in the home with assisted bathing equipment. The home offers level access throughout. All rooms (apart from one shared) offer single occupancy, many rooms have ensuite facilities. The communal areas comprise of a large lounge 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 2 service users per day). Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection to review the standards of care provided at the home when the registered persons were unaware it was planned. I arrived at 1:30pm and left at 5.30 pm. During this time I met service users, care staff and the registered persons. The registered manager assisted me in looking at records kept to monitor the welfare of service users and discussed developments at the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 6 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.V252322.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1, 3 and 5. The registered person has provided a statement of purpose and service users guide that details the facilities and services available within the home. The registered provider will assess all prospective service users prior to admission to ensure that the home can 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. The registered manager visits prospective service users prior to admission to complete an assessment process. The process will include information received from other agencies to assist in appropriate admissions to the home. Prospective service users are invited to see the home and are involved in the completion of the dependency assessment documents. A discussion occurred regarding the regulation 4 (schedule 1.16). This states that details of the number and size of individual rooms at the care home must be included in the information in the statement of purpose and available to service users. A recommendation is made for the registered persons documents to include this information. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 7, 8, 9 and 10. It was agreed with the registered persons that the recording process requires some amendment to ensure that plans of care set out the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of service users are met. Since the last inspection some progress has been achieved with recommendations for the recording of health care visitors to the home, weighing service users and procedures for service users that are self-medicating. EVIDENCE: The registered persons are providing detailed assessments of service users needs and a monthly dependency assessment is recorded. A discussion occurred to clarify that the assessment detail currently identifies individual areas of need for service users. A service user plan for each service user is required that identifies the action required to meet this need and how it reviewed. The registered manager is responsible for providing this information for carers and the plan sets standards and provides the basis of care to be delivered at the home. Recommendations from the previous inspection regarding the recording of health care visitors to the home, weighing service users and procedures for service users that are self-medicating have been completed. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 12, 13 and 15. Service users are accessing community facilities with assistance as required and the home is providing some organised activities. Service users are receiving good meals at the home, in comfortable surroundings and consultation occurs regarding choice and preferences. EVIDENCE: The registered person stated that the home had a new minibus in October 2005 and service users were assisted with transport for local appointments and occasional trips to places of local interest. The vehicle has a tail lift to assist wheelchair users and a step has been added to assist service users in accessing the vehicle. 3 Carers are to attend the 2 day driving course provided by Cornwall County Council and the home ensures drivers have appropriate driving licences, insurance details and mobile phones are provided on outings to reduce the risk to service users. The home provides opportunities for musical entertainment, hairdressing, library visits, exercise groups, church services and service users can choose to use the communal lounge areas for the company of others or the privacy of their own rooms at various times of the day. All service users currently enjoy the support of visiting relatives. Service users were met in communal areas and at the dining room where the evening meal was served. Service users expressed approval of the catering provided and the services and facilities at the home. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 10 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 the following 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 that 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. A member of staff attended this training in July 2005 and the registered provider stated that other staff will have the opportunity to attend. Care staff also receive training in adult protection in their induction training. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 19, 20, 22 and 25. The premises 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 CCTV cameras that 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 domestic in nature. There is also a conservatory with a call bell system at the front of the home that offers seating, overlooking the garden. 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 and Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 12 one assisted bathroom on the first floor, which are decorated to a high standard. The registered provider has completed the requirement to provide mixing valves on the hot water outlets on wash hand basins in the 3 bathrooms. Radiators in the home should be guarded to reduce the risk of scalding to the service users. Some of the radiators provided are of a low temperature surface but others should be covered on a risk assessment basis. The registered provider stated that all radiators will be upgraded to meet the safer standards. A recommendation is made to provide a development plan, with timescales for the completion of this work. The registered manager has consulted the community physiotherapist and will include details of assessments as required in the developing care planning procedures. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. Staffing levels at Pendrea are satisfactory during the day but at night there is only one waking member of staff in the home with on call support provided. Training opportunities and supervision are provided to the staff group. EVIDENCE: The registered manager is in day-to-day control of the home, with a minimum of two carers during the day and appropriate ancillary support staff. At night this is reduced to one waking night carer within the building and a relative of the registered provider on call to assist service users that may require attention. The relative lives in an adjacent property and the registered provider stated that alarms are to be supplied in the relative’s house regarding a fire alarm or power failure within Pendrea House. A recommendation is made to include this in the development plan with timescales for completion. The home maintains a record of service user activity at night and they do not currently show a high dependency level of care required. The registered provider stated that staffing levels would be increased in the event of service users becoming ill or because of moving and handling risk assessments. The registered manager is recommended to record all risk assessments for staff and service users regarding staffing levels at night. Staff members are receiving induction training, fire precautions, moving and handling, first aid and basic food hygiene. Good practice training that is planned or has recently taken place includes infection control, adult protection and medication accreditation training. The homes recruitment procedures are appropriate and a recommendation regarding CRB checks has been complied with. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 37 and 38. The registered manager has recently completed the ‘Registered Managers Award’. The registered persons are providing clear leadership and supervision at the home. EVIDENCE: The registered provider is Mrs Difford who has managed the home with the support of her husband since 1990. The registered provider and registered manager are in the home most days and maintain contact with service users and staff to monitor standards at the home. The registered manger has recently completed the registered managers award and is advised to provide a copy of this certificate to the commission. The registered manager reviewed the list of records required in schedules 3 and 4, and the records inspected were appropriately maintained. The registered provider is recommended to supply to this commission, a copy of the recently completed quality assurance document. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 15 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 2 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X 2 X STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X 3 3 Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement The registered manager must ensure that plans of care set out the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of service users are met. Timescale for action 31/12/05 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. 2. Refer to Standard OP1 OP25 Good Practice Recommendations To include information in the statement of purpose on the room sizes in the home. The registered provider should supply a development plan that includes the timescale to provide low surface temperature radiator covers to the remaining areas at the home. The registered provider should supply a development plan that includes the timescale to provide alarms in the relative’s house regarding a fire alarm or power failure within Pendrea House. The registered manager is recommended to record all risk DS0000009202.V252322.R01.S.doc Version 5.0 Page 17 3. OP27 4. OP27 Pendrea House assessments for staff and service users regarding staffing levels at night. 5. OP33 To evolve the quality monitoring document to include the stakeholders in the community and provide a copy of this document to the commission. Pendrea House DS0000009202.V252322.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection St Austell Office 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 DS0000009202.V252322.R01.S.doc Version 5.0 Page 19 - 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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