Inspection on 20/04/05 for Pendruccombe House

This inspection was carried out on 20th April 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

Pendruccombe House 19/09/06

Pendruccombe House 06/12/05

Pendruccombe House 05/10/04

Pendruccombe House 10/06/04

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 Pendruccombe Nursing Home 23 Tavistock Road Launceston Cornwall PL15 9HF Lead Inspector Alan Pitts Unannounced 20th April 2005 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. Pendruccombe Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Pendruccombe Nursing Home Address 23 Tavistock Road, Launceston, Cornwall, PL15 9HF 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) 01566 776100 01566 775700 A J & Co (Devon) Limited Mrs Janet Smith Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (27), Terminally ill (27) of places Pendruccombe Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 27 adults of old age (OP) Service users to incude up to 27 adults with a physical disability (PD) Service users to include up to 27 adults with a terminal illness (TI) some of whom may have nursing needs. That the home be allowed to use room 28 as a bedroom, but on the condition that the new `wet room` bathing provision is fully completed by 31/12/04 Total number of service users not to exceed a maximum of 27 Date of last inspection 05/10/04 Brief Description of the Service: Pendruccombe House (Nursing) provides accommodation and nursing care for 26 people in need of care due to old age, physical disability or terminally ill.Pendruccombe House is a large purpose built home on the edge of Launceston town. Also owned by the same company; and on the same site is Pendruccombe Residential Home.This report relates to the Nursing provision only. The accommodation offered is on two floors, with a lift access to the first floor.Service users have a choice of two sitting rooms, one of which also has a dining area and a separate dining room. Service users are encouraged to take their meals in the dining areas, but may eat within their private room if that is their choice. There is a large conservatory with comfortable seating which leads outside to a patio area, accessible to wheelchair users as well as those more mobile.Activities are arranged within the home as well as outings for Service users who wish to partake in these trips. For those who do not wish to visit or are unable to get into Launceston, there is hairdressing, opticians, chiropody and dental services arranged at Pendruccombe on a domiciliary basis.There is a hairdressing room with specialist equipment, which is operated once a week. Pendruccombe Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Pendruccombe nursing care home is a new building with service user accommodation on two floors. Rooms are clean, well decorated and personalised and the building as a whole is well maintained. The décor, staff and service users contribute to a relaxed, comfortable atmosphere that was evident throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Overall, the home does everything included in this inspection well, and there are only two recommendations for the Registered Manager to undertake. Pendruccombe Nursing Home Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pendruccombe Nursing Home Version 1.10 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 Pendruccombe Nursing Home Version 1.10 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, 3 The home’s Statement of Purpose and Service Users Guide are excellent providing service users and prospective service users with details of the home to help them make a decision about admission. EVIDENCE: Standard 6 was not assessed, as this home does not provide Intermediate Care. The home has a statement of purpose available on request and a service users guide that is distributed to all service users. The home has a comprehensive Statement of Purpose and Service User Guide (with photographs); which is available to existing and prospective service users and their families. A copy is held on file at the Commission for Social Care Inspection office. In part these documents are combined with the ‘residential’ side, but there is a clear indication of the division in service provision. New service users are able to visit/move in on a trial basis if they wish. Service users are assessed prior to admission to ensure that the home can meet their needs. Pendruccombe Nursing Home Version 1.10 Page 9 As discussed, it is suggested that the Registered Manager makes use of the fax facility for future ‘distance’ referrals and pre-admission assessments to the home. This would allow for the home’s own pre-admission assessment to be sent to the referrer for completion. Evidence: documentation, discussion Pendruccombe Nursing Home Version 1.10 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, 9, 11 Service users have full access to other healthcare professionals as appropriate. Service users spoken with had only positive comments to make about the quality of care provided. EVIDENCE: There is a comprehensive system of care planning. Care plans have been developed including all members of staff as well as service users or their representatives. Where possible service users have signed to agree the plan. Service users have been given the choice of keeping the care plan in their bedroom, which the vast majority have decided to do. For those service users who do not wish to keep their plan with them it is stored in the office. The plans include detailed, pertinent ‘care’ issues (physical, psychological and social) as well detailed risk assessments. Any personal information that service users choose not to have detailed in the plan is kept on file in the office. A daily record is maintained. Staff are to be commended for their hard work, and involvement of the service users / families. Evidence: documentation, discussion Pendruccombe Nursing Home Version 1.10 Page 11 The home promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. All service users are registered with a GP. Nursing care is provided within the home, with input from other professionals sought as and when required e.g. Tissue Viability (TVN) / Continence Nurses, and Speech and Language Nurses. Care plans clearly indicate visits from external professionals. Chiropody is available within the home six weekly, dental services as required and optical services six monthly. District Nurses visit to undertake the ‘free’ nursing care assessments. Evidence: documentation, discussion The home has policies and procedures with regard to medication. Only trained nurses administer medications; who are required to work to NMC guidelines and policies. The general medicines are stored appropriately. A ‘blister pack’ system is used for the medication. MAR sheets were seen to be in order and signed appropriately. A fridge is available specifically for the storage of medication. Each service user has their photograph contained within the medication file to aid identification. Controlled drugs (CD) are stored in a new secure cupboard. Evidence: documentation, observation Service user wishes in respect of death and dying are recorded in the care documentation. Service user wishes in respect of resuscitation are also recorded. Evidence: documentation Pendruccombe Nursing Home Version 1.10 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) 12, 13 The home offers a level of activity commensurate with the dependency and care needs of the service users. EVIDENCE: Service users said that they could make decisions with regards to their individual preferences/needs. The care documentation gives clear indication of service user input and recording of service user preferences. One carer is designated to coordinate activities five days per week. The service users spoken with at the time of the inspection said that they were happy with the amount of activities offered. Evidence: documentation, discussion The home has an open visiting policy; with visitors welcome at any reasonable time. Service users are able to maintain links with the community if they so wish, and confirmed that there are no restrictions on visiting. A Visitors Book is maintained. Evidence: documentation Pendruccombe Nursing Home Version 1.10 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, 17, 18 Service users are safe and able to voice their concerns. Appropriate policies are in place, and staff have a good knowledge and understanding of adult protection issues. EVIDENCE: The home has a comprehensive complaints policy, displayed within the entrance hall and distributed to all service users within the service users guide. This policy is also contained within the statement of purpose. Complaints are recorded. Timescales are included that are well within the ‘28 day’ deadline. Service users spoken with confirmed that they were able to vote if they so wished, and the Registered Manager said that all the service users are entered on the electoral roll. Service users confirmed that mail is delivered to them unopened. Written policies are in place to safeguard service users. This includes a whistle blowing procedure, Department of Health (DoH) guidance No Secrets and reference to the passing on of information to other appropriate professional bodies in line with the Public Interest Disclosure Act 1998. This included the Commission for Social Care Inspection and Social Services. Staff are advised re the protection of vulnerable adults during the induction programme. Service users said that they would feel able to voice any concerns. The Registered Manager should review the procedures to ensure that these provide clear instruction to staff as to the steps to take in the event of an Pendruccombe Nursing Home Version 1.10 Page 14 allegation of abuse, including the involvement of other agencies and appropriate contact details. Pendruccombe Nursing Home Version 1.10 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 standard(s) 21, 22, 25, 26 The environment is clean and well maintained, offering comfortable and homely surroundings for the service users, whilst providing ease of access and appropriate care aids where necessary. EVIDENCE: Service users have access to toilet facilities close to the communal areas. Many of the bedrooms have en-suite facilities, for those that don’t there is close provision of toilet facilities; and commodes are provided as required. There is provision of assisted bathing, including a ‘wet room’/‘wheel in’ shower room facility, which offers excellent ease of access. The home is well provided with care aids. There are individual moving and handling assessments. Access throughout the building is level and aided by wide corridors and hand rails. Rooms individually and naturally ventilated. The home is centrally heated, with each room heated by a covered radiator that allows the temperature control to be adjusted as required. Pre-set valves are fitted to all baths and hand basins Pendruccombe Nursing Home Version 1.10 Page 16 that are accessible to service users. Lighting in service users rooms is domestic in nature. A risk-assessment and action plan is in place in respect of legionella, and as discussed, it is suggested that this be forwarded to the Environmental Health Officer for comment. The home is clean, hygienic and free from offensive odour on the day of inspection. Domestic staff are on duty on each floor daily; and were evident during the inspection. There is an Infection control Policy. The laundry appeared industrial, well managed and clean with an appropriate floor covering. A sluicing facility is available on the washing machines. Washing is ironed and sorted into baskets (labelled for each service user) and then returned to the rooms. Protective clothing is available in the laundry for the staff. Sluicing facilities are provided on each floor. Pendruccombe Nursing Home Version 1.10 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 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, 30 Staffing levels are appropriate and service users expressed satisfaction with the level and quality of care provided. EVIDENCE: The Registered Manager informed the inspector that the current staffing levels are: 08.00-14:00 1 trained nurse plus 6 carers (or 2 trained nurses and 4 carers) 14:00-21:00 1 trained nurse plus 4 carers. 16.00-18.30 1 general assistant (suppers) 21:00-07:00 1 trained nurse plus 2 carers. 2 domestic staff and 1 general assistant are also on duty each day. An induction programme is in place for all new staff. The Registered Manager should contact Skills for care (formerly TOPSS) to ensure compliance and to obtain copies of the Foundation training units for staff in their first six months of employment. Service users were complimentary about the staff; the quality of care provided, their consideration and respect for the service users. Evidence: documentation, discussion Pendruccombe Nursing Home Version 1.10 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) 33, 34 This is an established home with an evident commitment to the happiness and welfare of the service users. Service users were positive in their comments about all aspects of life at the home and none could think of any aspect that they would like to change. EVIDENCE: A quality assurance questionnaire has been developed and circulated to staff, health professionals, service users and relatives. The questionnaires have been returned and are in the process of being analysed in order to establish outcomes so that any action required may be considered. The Registered Manager has undertaken to publish a summary of the feedback in the home’s Statement of Purpose and Service Users Guide Pendruccombe Nursing Home Version 1.10 Page 19 Appropriate insurance cover was seen to be in place. From observation of the premises, staffing levels, and the level of equipment available there is no reason to doubt the current financial viability of the home. Pendruccombe Nursing Home Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION x x 3 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x 3 3 x x x x Pendruccombe Nursing Home Version 1.10 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 18 Good Practice Recommendations The Registered Manager should review the procedures to ensure that these provide clear instruction to staff as to the steps to take in the event of an allegation of abuse, including the involvement of other agencies and appropriate contact details. The Registered Manager should contact Skills for care (formerly TOPSS) to ensure compliance and to obtain copies of the Foundation training units for staff in their first six months of employment. 2. 30 Pendruccombe Nursing Home Version 1.10 Page 22 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell 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 Pendruccombe Nursing Home Version 1.10 Page 23 - 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. 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