Inspection on 07/09/06 for Pendrea House

This inspection was carried out on 7th September 2006.

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 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 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 7th September 2006 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.V298307.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.V298307.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.V298307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 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 DS0000009202.V298307.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 with the assistance of the registered manager. The registered manager has just returned to the home from a period of managing another home owned by the registered provider. The registered provider spent some time at the home at the commencement of the inspection. The inspection took place over six hours. During the course of the inspection service users and staff were spoken to as well as the inspection of a number of records to include care plans and staff files for example. Case tracking procedures were used for evidence gathering. The comments from all the service users spoken to during the course of the inspection was that they were very happy with the standard of the care that they are receiving at the home. The range of fees for the home are from £315 to £350 per week. What the service does well: What has improved since the last inspection? Improvements are noted to the care planning system since the last inspection and further improvements will be welcomed to meet the National Minimum Standards. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 6 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.V298307.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 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 the following standard(s): 1,2,3,4 and 5 The quality outcome judgement on these standards is adequate. The registered manager assesses all service users prior to admission to the home to ensure that the home can meet their care needs. Prospective service users are invited to see the home prior to admission. The statement of purpose document is being updated and currently unavailable to prospective service users. EVIDENCE: The registered manager assesses all prospective service users prior to admission to the home. Documentation that has recently been improved is completed so an assessment can be made that ensures that the home will be able to meet the care needs of the service user. Prospective service users are invited to see the home and are therefore involved in the completion of the dependency assessment documents. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 9 It is important that the statement of purpose document and the service user guide are updated as soon as is possible to ensure that important information on facilities and services is available to prospective service users. It is also important that all contracts of care are updated to ensure that correct information is presented to the service users of fees for example. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9 and 10 The quality outcome judgement of these standards is adequate. The improved care plans help the health and personal care of service users to be met but expansion on social care would adequately provide staff with the information they need. EVIDENCE: Each service user 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. The registered manager has responsibility for the care plans and has spent time improving them since the last inspection. The care plans are supported by daily recording which could be improved to include more information on the social care needs of the service users. It is important that the care plans are regularly reviewed monthly. 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 evidence in place that the service users are weighed regularly. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 11 The storage of the medication was found to be satisfactory on the day of the inspection and records are signed after administration. It is recommended that information is recorded on the quantity of medication received into the home. Staff who have medication administration responsibilities have received medication training. All the service users spoken to during the course of the inspection expressed very positive comments on the standard of the care that they are receiving at the home. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15 The quality outcome judgement on these standards is good. Service users are happy with the daily life at the home. Some organised activities are in place. Daily records could be improved to evidence how the service uses are spending their time. Service users are receiving good quality meals at the home in comfortable surroundings and consultation occurs regarding choice and preferences. EVIDENCE: All the service users spoken to expressed positive comments about daily life at the home. Once a week activities like scrabble, bingo or cards takes place and the home also has a minibus which is used for occasional trips to places of local interest. A number of visitors were seen during the course of the inspection. It has already been recommended that more information be recorded in daily records on the social care needs of the service users to evidence the positive comments from the service users. The home also provides opportunities for hairdressing, library visits and church services. A number of service users appear to enjoy their day at the home watching the world go by from the pleasant conservatory at the home. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 13 All the service users expressed very positive comments on the standard of the meals being provided in the home. The main meal of the day on the inspection was beef stew with swede, broccoli and cabbage. All records are in place as required by legislation of the meals being provided at the home. The home also provides a number of meals in the community. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 14 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 quality outcome judgement on these standards is poor. The complaints policy and procedure is not available to the service users at present. It is recommended that more staff attend training on adult protection to ensure the protection of service users from abuse as arrangements for protecting service users are not satisfactory, placing them at possible risk or harm or abuse. EVIDENCE: It is understood (from the registered manager) that each service user has received a copy of the complaints policy and procedure in their service user guide. This could not be confirmed at the time of the inspection. There is a complaints policy and procedure displayed in the staff room but this requires some amendment with the correct information included for example the name person to contact in regard to the procedures. The home has in place an adult protection policy and procedure but there is no evidence to suggest when the staff last read this documentation. There is also no information on local adult protection policies and procedures. It is generally recommended that more staff attend training in this important area to ensure the protection of the service users at all times. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 15 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): 19,20,21,22,23,24,25 and 26 The quality outcome judgement of these standards is good. 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 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 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 DS0000009202.V298307.R01.S.doc Version 5.2 Page 16 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. Fourteen of the bedrooms are over ten square metres and one shared bedroom is over sixteen 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 provided are of a low temperature surface but others are being covered on a risk assessment basis. The home was found to be very clean on the day of the inspection except for the laundry. Specific staff members are employed for all cleaning duties. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 17 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): 27,29 and 30 The quality outcome judgement on these standards is poor. Staffing levels at Pendrea are satisfactory during the day but at night there is only one waking member of staff in the home. It is recommended by the CSCI that consideration be given to employing two carers in the home during the night in the interest of service users. A statutory requirement is included in this report to ensure that all staff receive fire drill training which has not taken place this year. A statutory requirement is included to ensure that staff are not employed without a criminal records bureau check. EVIDENCE: There are a minimum of two carers at the home during the day with one waking night carer within the building with on call assistance if required. This on call assistance is provided from a property immediately behind the home. It is recommended by the CSCI that two carers are on duty at night. The registered provider states that the staffing levels meet the care needs of the service users. Staff records indicate that there has been no fire drill training in the home during 2006. This is included in this report as a statutory requirement. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 18 Recruitment procedures were found to be unsatisfactory on the day of the inspection. Staff are being employed without criminal records bureau checks being taken. In addition the recommendation to re-submit CRB’s for all the staff who have not have Protection of Vulnerable Adults Checks has not been addressed. It was noted that one of the staff members on duty at the time of the inspection was wearing a badge that indicated that she was the manager when she is not. It was also noted that she was wearing a navy blue uniform which suggests that she could be a nurse when she is not. As discussed at the inspection this could be misleading by implication to service users and visitors to the home. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 19 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): 31,32,33,34,35,36,37 and 38 The quality outcome judgement of these standards is poor. It is apparent that the absence of the registered manager from Pendrea has resulted requirements not being met. This does not appear to have impacted on the delivery of care at the home but the registered provider could have been more pro-active in their role to avoid this situation. EVIDENCE: The registered manager has run the home with the support of her husband for a considerable number of years. The registered manager has recently returned to the home and it is apparent that a number of requirements have not been met. This places the manager under immediate pressure to address these requirements. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 20 In addition there are good practice recommendations to address ie staff meetings, which should be taking place. There have been no staff meetings at the home for a considerable period of time. A quality monitoring assessment has not yet taken place at the home. The registered manager advised the inspector that the registered provider would undertake this. This is therefore included again in this inspection report as a good practice recommendation. The registered provider has been asked to provide a statement from an accountant to evidence the service users are safeguarded by the accounting and financial procedures of the home. It was noted during an audit of the finances that are being held at the home on behalf of the service users did not balance in two cases. This must be addressed to ensure correct record keeping at all times. Little staff supervision has taken place at Pendrea due to the absence of the registered manager. This is included in this report as a statutory requirement. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 21 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 x 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 2 1 2 1 Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19(1)(a) Requirement Timescale for action 30/09/06 2. OP30 18(1) 3. OP36 18(2) 4. OP38 23(4)(d) The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home. The registered person shall 30/09/06 ensure that the persons employed at the care home receive training appropriate to the work they are to perform. The registered person shall 30/09/06 ensure that persons working at the care home are appropriately supervised. The registered person shall after 30/09/06 consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000009202.V298307.R01.S.doc Version 5.2 Page 23 Pendrea House 1. Standard OP1 2. OP7 3. 4. 5. 6. 7. 8. 9. 10. 11. OP9 OP16 OP18 OP27 OP29 OP32 OP33 OP34 OP35 It is recommended that the statement of purpose and service user guide are updated as soon as is possible with a view to ensuring that this information is in the home at all times. To ensure that the care plans are regularly reviewed monthly and to encourage staff to include more information on the social needs of the service users in care planning. To ensure that the medication charts show the quantity of medication received. To ensure that the complaints policy and procedure has the correct information in it and is available to the service users at all times. To contact Cornwall County Council with a view to more staff attending adult protection training. To give consideration to employing two carers in the home at night. It is recommended that all staff employed prior to July 2004 have there CRB checks re-submitted to include the POVA check. To commence staff meetings as soon as is possible. To undertake a quality monitoring and quality assurance audit for the home that involves stakeholders in the community. To provide evidence to the CSCI that the service users are safeguarded by the accounting and financial procedures of the home. To ensure that all financial records that are held on behalf of the service users are correct. Pendrea House DS0000009202.V298307.R01.S.doc Version 5.2 Page 24 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.V298307.R01.S.doc Version 5.2 Page 25 - 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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