Inspection on 06/12/05 for Pendruccombe House

This inspection was carried out on 6th December 2005.

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

The inspector 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 20/04/05

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 House (Nursing) 23 Tavistock Road Launceston Cornwall PL15 9HF Lead Inspector Kerensa Livingstone Unannounced Inspection 6th December 2005 09:30 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 Pendruccombe House (Nursing) DS0000009244.V260540.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. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pendruccombe House (Nursing) Address 23 Tavistock Road Launceston Cornwall PL15 9HF 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) 01566 776100 01566 775700 pendruccombe@btconnect.com A J & Co (Devon) Limited Janet Kirsten Stewart 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 House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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 20th April 2005 Brief Description of the Service: Pendruccombe House (Nursing) provides accommodation and nursing care for 27 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 lounges, 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. Condition four above has been met. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Accommodation is spacious throughout, allowing easy access for service users and staff alike. The home is well provided with aids to care. There is an evident commitment to service user welfare and happiness, and this is reflected in the positive comments received from the service users spoken with at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: A review of the training and development of staff is planned; the Inspector would support the need for this. There appears to be some gaps in training, which undoubtedly will be addressed during this process. Environmental risk assessments must be completed and staff given the training that is required. The provision of a lockable facility and lockable door must be provided to promote the privacy and dignity of the Service Users. A risk assessment and discussion with the Service User will inform whether keys are provided. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 6 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. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 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 Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 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, 4 & 5 Prospective service users are provided with information to enable them to make an informed choice and a full assessment is completed prior to them moving in to the home. Terms and conditions are provided to all Service Users. EVIDENCE: The home has a Statement of Purpose that is a comprehensive document. The Manager and Inspector discussed the need for this document to be updated and several items elaborated upon to include for example the environmental information in National Minimum Standard (NMS), frequency of reviews. This document is combined with the ‘residential’ home, but there is a clear indication of the division in service provision. A copy of the updated document must be forwarded to the Commission for Social Care Inspection. General information is gathered about a new admission to the home, a Service Users Guide is sent to the prospective Service User. New service users are able to visit/move in on a trial basis if they wish. Service users are assessed by a qualified nurse, prior to admission to ensure that the home can meet their needs. There are currently no vacancies at the home. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 9 Contracts including terms and conditions include the required information and are provided to all Service Users. This document is signed by the Service User and/or their representative. Standard 6 was not assessed, as this home does not provide Intermediate Care. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 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 & 10 Service users are involved in the planning of their care, this must be extended to include regular reviews. The Service users spoke positively about the quality of care provided. Service Users were observed to be treated with respect, the Manager plans to formalise this within the documentation. EVIDENCE: There is a comprehensive system of care planning, this is currently under review. Currently Service Users plan of care is in their room and evaluation sheets are kept in the office. At inspection, there was evidence of Service User and/or representative involvement, however no evidence that monthly reviews are taking place. The plans include a detailed plan of care, which includes physical, psychological and social needs. A daily record is maintained. The Manager is reviewing the documentation and plans to develop the carer’s role within this. The Primary Healthcare team and Home have established links e.g. tissue viability, continence viability, community physiotherapist. Service Users confirmed that they are free to make choices about where they eat and menus. Staff were observed to knock on Service Users doors and use preferred names. The Manager plans to discuss with the Service Users their wishes, choices and routines for activities of daily living. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 11 All rooms are single occupancy, the home does have the facility to open a door to convert two singles into two adjoining rooms for a couple. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 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): 14 & 15 Service Users are assisted to maintain control over their lives and enjoy the food that is offered within the home. EVIDENCE: Service Users informed the Inspector that they are encouraged to make decisions about their day and how their room is furnished. The individual Service Users rooms are personalised and decorated with their own furniture or personal items. A varied, nutritious diet is offered to the Service Users, there is a choice at all meals. There is a choice of dining room to have lunch, whilst some Service Users prefer to take lunch in their room. Menus are changed on a four weekly cycle, this is posted in the reception area of the home. The kitchen is suitable for its purpose. On the day of the inspection the Cook had made pasties and apple pies. Fresh fruit and vegetables are included n the menu. The Inspector and Manager discussed how the food records need to be able to demonstrate that all Service Users have had a nutritious diet and include any special diets. Cleaning schedules are maintained and fridge temperatures checked. The Inspector was informed that all staff working in the kitchen has a Foundation Food Hygiene certificate and that the Head Cook has an Intermediate Food Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 13 Hygiene certificate. There is access to snacks at all times. Homemade cakes are often made and always provided for birthdays. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 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): Service users are safe and able to voice their concerns. Policies and Procedures are in place, and staff have a good knowledge and understanding of adult protection issues. EVIDENCE: The home has a complaints procedure, this is displayed within the entrance hall and distributed to all service users within the Service User’s guide. Complaints are recorded. The procedure includes timescales and that the complainant will receive a response within 28 days. It should include that the Complaint can contact the Commission for Social Care Inspection at anytime. Service Users were aware of who they would speak to if they had any concerns. 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. One member of staff has attended formal training, the Manager plans to extend this to include all staff. 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 allegation of abuse, including appropriate contact details. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 15 Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 16 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, 23 & 24 Service Users live in a safe, well-maintained and comfortable environment. The Service Users who spoke to the Inspector stated that their accommodation meets their needs. EVIDENCE: The home is well maintained, well decorated and accessible. There is wheelchair access. There is evidence that there is a programme of renewal and routine maintenance. The home is centrally heated, with each room heated by a covered radiator that allows the temperature control to be adjusted as required. There is plenty of natural lighting and opportunities for ventilation. There are lovely countryside views from the communal rooms and some of the Service Users rooms. The home looked tidy and clean on the day of the Unannounced Inspection. Storage is provided for equipment. The home is clean, hygienic and free from odours on the day of inspection. Housekeeping staff are on duty on each floor daily and were evident during the inspection. Protective clothing is available for staff. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 17 There are choices of seating areas, which are pleasantly furnished and spacious. There is a welcoming reception area with seating provided, a lounge, dining room and additional lounge/dining room on the lower floor. These areas are furnished comfortably and in a homely way. The need for the dining room furniture to be replaced has been identified. There is an accessible large patio area to the rear of the home and a passenger lift, which services the home. Service Users informed the Inspector that they liked the accommodation and felt that it met their needs. All rooms are single and one can be converted to a double by removing a door. Most rooms are ensuite with a toilet and a sink. Rooms individually and naturally ventilated. Adjustable beds are provided and furnishings as required. No lockable space or door lock is provided in any of the Service Users rooms. It is recommended that keys be provided unless a risk assessment suggests otherwise. All rooms should be fitted with these facilities. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 18 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): 28 & 29 Service Users are protected by a robust recruitment procedure. Staff training is provided, however this should be reviewed within a staff training and development programme to ensure staff receive the training that they need to perform their roles. EVIDENCE: An induction programme is in place for all new staff. Since the last inspection the Foundation training units have been obtained and the Inspector was advised that all staff are completing these. The Manager stated that seven of the carers had undertaken their National Vocational Qualification Level 2 or 3 training and three more were doing the training. Staff are given a copy of the General Social Care Code of Practice. The recruitment and selection procedures are very thorough and organised. Staff files were observed to include a Criminal Records Bureau check, two written references and a completed application form. All staff are provided with a Job description and contract. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 19 There must be evidence of a staff training and development programme. Training records are kept, the Inspector discussed concerns about apparent gaps in some areas of training for example Protection of Vulnerable Adults, Fire training. The Manager had identified this as an area that needs attention. Staff reported that they are supported to attend training. There is a designated training budget. Service users were complimentary about the staff; the quality of care provided, their consideration and respect for the service users. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 20 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, 35, 36, 37 & 38 There are established managerial systems within the home to protect the interests of Service Users. Staff and Service Users spoke positively about the leadership of the Manager of the home. There is evidence of management planning and leadership. The health, safety of welfare of the Service Users is promoted. Environmental risk assessments must be completed and staff given the training that is required. EVIDENCE: The Manager is a Registered Nurse, has completed the Registered Manager’s Award and has fifteen years of experience of working with the Older Person. The Manager who has only recently commenced working at Pendruccombe Nursing Home, has many ideas and aspirations about the work needed, with the staff to further improve standards. The Commission is processing an application for the Manager to become the Registered Manager. The Inspector and Manager discussed plans which demonstrated evidence of management Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 21 planning and strategies to enable staff, Service Users and stakeholders to affect the way the service is delivered. Service Users and their family/or representative are encouraged to maintain control of their money. Written transactions are maintained and receipts provided for all dealings with Service Users monies. There is a facility for the safe keeping of valuables on behalf of the Service User, a receipt is provided. Supervision has been taking place and staff meetings held. The Manager plans to increase their frequency to ensure that supervision takes place bimonthly and include an appraisal. Record keeping was observed to be of a good standard. A Visitors Book is situated in the reception area of the home. Accidents are recorded in an accident book that complies with data protection legislation. Records are stored securely. The Registered Provider has provided evidence of financial viability of the home, as a routine part of the annual inspection process. The home’s Administrator takes responsibility for the health and safety within the home, is the Fire trainer, First Aid trainer and assessor too. There are fourteen staff that are qualified First Aiders, to ensure that there is one on duty at all times. The Inspector was impressed with the organisation of the record keeping. Training records are kept; some staff were noted to have not attended any fire training this year. The Inspector was advised that further training is planned on food hygiene, moving and handling and health and safety. There is a comprehensive Fire risk assessment. The Fire Officer visited the home on the 21.11.05, no action was required. The Inspector was informed that all water is regulated, all windows restricted and all hot surfaces covered. There was evidence that equipment is serviced regularly e.g. hoists six monthly and Gas August 2005. No environmental risk assessments are completed. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 22 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 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X 3 X X 3 2 X X STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 2 Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP15 Regulation 17(2) Sch 4. Requirement The Registered Person must keep food records in such detail to enable any person inspecting to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual Service Users. The Registered Provider shall make arrangements by training staff or other measures, to prevent Service Users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered Provider must ensure that the persons employed receive training appropriate to the work they are to perform and suitable assistance, including time off for the purpose of obtaining further qualifications. The Registered Provider must ensure that all staff employed receive training appropriate to the work they are to perform e.g. Fire, Moving and Handling, Health and Safety, POVA. DS0000009244.V260540.R01.S.doc Timescale for action 01/03/06 2. OP18 13(6) 01/03/06 3. OP30 18(1) 01/03/06 4. OP30 18(1c) 01/03/06 Pendruccombe House (Nursing) Version 5.0 Page 24 5. OP38 13(4) 6. OP38 23(4) The Registered Provider must ensure that unnecessary risks to health or safety of Service Users are identified and so far as possible eliminated e.g. environmental risk assessments. The Registered Provider must ensure that staff receive suitable training in fire prevention. 01/02/06 06/12/05 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. 3. 4. Refer to Standard OP1 OP7 OP16 OP24 Good Practice Recommendations For the Statement of Purpose to be reviewed and the points discussed elaborated upon. A copy must be sent to the Commission for Social Care Inspection. For the Service Users plan of care to be reviewed at least monthly. For the complaints procedure to include that the complainant can contact the Commission for Social Care Inspection at anytime. For all Service Users to be provided with a lockable space and door lock. Individual risk assessments must be undertaken and recorded to ensure the appropriateness of providing keys to the Service User. Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 25 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 Pendruccombe House (Nursing) DS0000009244.V260540.R01.S.doc Version 5.0 Page 26 - 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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