Inspection on 10/10/06 for Pentlands Nursing Home

This inspection was carried out on 10th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pentlands Nursing Home 19/11/07

Pentlands Nursing Home 07/02/06

Pentlands Nursing Home 26/01/05

Pentlands Nursing Home 03/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pentlands Nursing Home 42 Mill Road Worthing West Sussex BN11 5DU Lead Inspector Mrs A Taggart Unannounced Inspection 09:30 10 October 2006 th 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 Pentlands Nursing Home DS0000024194.V302358.R02.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. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pentlands Nursing Home Address 42 Mill Road Worthing West Sussex BN11 5DU 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) 01903 247211 South Coast Nursing Homes Limited Post Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 people under the age of 65 years who may have a physical disability but are not independently mobile through the use of a wheel chair may be demitted. 7th February 2006 Date of last inspection Brief Description of the Service: Pentlands is a care home presently registered to provide nursing care for thirty- two residents in the category of Older People. An application is presently being processed by The Commission to enable the home to admit a number of younger people who require nursing care. South Coast Nursing Homes Ltd own the service. The home is situated in a residential area between Goring By Sea and Worthing West Sussex and is near to shops, a pub and cafes. Worthing town centre is a short drive away. The area is suitable for wheelchairs and the sea front is approximately half a mile away. Buses serve the area and pass the home and the railway station is about half a mile away. The home is a detached house that has been adapted for nursing care. All bedrooms except four on the mezzanine level are accessible by a lift and all have ensuite facilities. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was carried out at 9.30am and lasted for 5.5 hours, which covered the early and late staff shifts. During the visit the inspector made a tour of the premises, which included communal areas and private bedrooms and spent time talking to residents, the staff on duty and three visitors to the home. Five care plans were tracked and all contained comprehensive and current information. Five staff files were also seen but two did not contain Criminal Bureau Checks as required. The medication system was checked and a number of errors were brought to the attention of the manager Mrs. Herbert. The inspector observed lunch, which was the main meal of the day being prepared and served and also sat in for part of the staff handover at the shift change. Records for the running of the business were seen including the fire book, heath and safety reports and maintenance logs and most were in good order. A Requirement from the last visit regarding monitoring visits from the Registered Provider had not been met. Prior to the visit the inspector read the last two reports and any other documentation or correspondence regarding the home and an inspection plan was completed. Mrs. Herbert had completed a pre-inspection questionnaire and nine survey forms had been returned to the Commission. All made positive comments about the home. Information from these documents has also been used to inform the visit. The Inspector left an Immediate Requirement Form with Mrs. Herbert, in respect of medication procedures and staff recruitment processes and a Letter of Serious Concern has been sent to the Registered Providers. The Registered Provider Mr. P.G. Colville responded to the Letter of Serious Concern on 16/10/06 informing the Commission of the actions that would be undertaken to address the Immediate Requirements. The letter says that the two staff members, who did not have a current Criminal Bureau Check in place, did have a POVA first. These were not seen to be on file on the day of the visit. Current fees are £540 to £665 per week. The inspector would like to thank everyone who helped during the visit. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 6 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. Pentlands Nursing Home DS0000024194.V302358.R02.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 Pentlands Nursing Home DS0000024194.V302358.R02.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): 1236 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Prospective residents and their families can be assured that their needs and wishes will be assessed and recorded and that sufficient information will be provided about the facilities available in the home. EVIDENCE: The home has a current Statement of Purpose and Service User Guide in place, a copy of which is sent to prospective residents and their families. In order to ensure that specific care and nursing needs can be met, preadmission assessments are carried out at the potential resident’s current accommodation and relatives confirmed that they were involved in the process. Assessments for three recently admitted residents contained sufficient information to inform the staff team of the needs and preferences of each person they were supporting. Each new resident receives a ‘Patients Agreement’, which sets out the terms and conditions of residency and these documents had been signed by the resident or their representative. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 9 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 10 11 Quality in this outcome is Adequate. This judgement has been made using available evidence including a visit to the service. Although there are good care plans in place and residents are pleased with the service provided, the safety of resident’s is compromised by errors in the medication system EVIDENCE: For each person living in the home there is a comprehensive and detailed plan of care in place, which provides current information regarding physical, emotional and personal care needs. Plans contained sufficient information to ensure the staff team were aware of individual needs and recent reviews had been undertaken and recorded. In order that resident’s needs are met, care plans contain risk assessments and individual nursing plans and records show that the home works with a variety of other healthcare professionals. Good daily recording is in place and each resident’s current needs were seen being discussed at the handover meeting. Visitors said that they were very pleased with the care provided to their relatives and said that residents were treated with dignity and respect. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 10 A resident said, “ I have never been in a better place, I left another care home to come here and it is wonderful. I can’t tell you how pleased I am, its comfortable and everyone is so nice”. Another resident who is in the home for respite care said that they were being supported and encouraged to regain their independence. Medication in the home is securely stored and only trained nurses carry out administration. During the tracking of the Medication Administration Sheets, a large number of gaps were found in recording and in some cases it was recorded that resident’s had missed medication because there was “none in stock”. When this was discussed with Mrs Herbert she confirmed that some medication had been missed because the pharmacy were late in delivering orders. To ensure that residents are protected at all times an Immediate Requirement was made regarding the safety of the administration and recording of medication. This was also a Requirement at the last visit. The manager Mrs. Herbert has a background in caring for people who are terminally ill and has registered the home on The Gold Standard Framework for palliative care. Training is being provided for the staff team in order to ensure that residents receive the specialist care they require at the end of their lives. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 11 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 15 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. The people living in the home are treated with dignity and respect, visitors are made welcome and good food is provided. Activities should be offered to provide interest and stimulation. EVIDENCE: Care plans reflect the hobbies and interests of the people living in the home and religious beliefs are respected. Apart from massage sessions, there are no planned activities carried out within the home. Many service users are very frail and people spend most of their time in their rooms but Mrs Herbert said that some residents do come down to the lounge during the day. A number of residents said that it could be quite lonely at times and said they would enjoy some activities or stimulation and this was passed on to the registered manager. Visitors confirmed that they were made welcome at any time and said they were offered coffee or could stay for a meal. A resident said, “I get lots of visitors and they can come any time, sometimes they come every day”. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 12 The staff members on duty were kind and caring in their dealings with residents and were very attentive to their needs. The inspector observed lunch, which is the main meal of the day being prepared and served. The meal was toad in the hole with fresh vegetables and potatoes with strawberry trifle to follow. Some people chose an alternative and pureed meals and special diets are catered for. There are nutritional assessments included in the care planning process and snacks and drinks are available at any time. There were many very complimentary comments made about the food provided and residents confirmed that they were always given a choice. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 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 the following standard(s): 16 18 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. Although policies and procedures are in place, there are potential risks to service users by all staff not having had current Criminal Bureau Checks undertaken. EVIDENCE: There is a complaints procedure in place and complaints and concerns are recorded and acted upon in an appropriate manner by the manager. Residents and visitors said that they would feel confident in making a complaint and felt sure it would be taken seriously. A visitor said, “ I am sure complaints would be taken very seriously. If we have any concerns the staff records them and action is taken. The staff team have attended training in the protection of vulnerable adults from abuse and certificates are kept on file. Individual staff members were aware of their responsibilities should they suspect and abuse had taken place. Although policies and procedures are in place regarding the protection of residents from abuse, there are potential risks to service users associated with staff members not all having current Criminal Bureau Checks in place before commencing work. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 14 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 21 22 24 26 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. The home offers a clean, comfortable and well-maintained environment. The quality of life for people who wish to keep their bedroom doors open would be improved by the addition of automatic closing devices in their rooms. EVIDENCE: Pentlands offers a pleasant, well-maintained and comfortable environment for the people who live there. All communal areas are well decorated and attractively furnished and there is a programme of redecoration and improvement in place. There are adequate bathing facilities including specialist baths with hoists and there is a passenger lift, wheelchair lift, and specialist equipment in place in place in order to aid mobility and ensure accessibility. The manager, Mrs. Herbert said that requirements made by the Fire Department at their last visit had now been fully met. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 15 Resident’s private bedrooms are of a good standard, light, airy and comfortable and rooms had been personalised with belongings brought to the home by the people living there. There is pressure relieving and other specialist equipment available as needed and maintenance checks were up to date. Many residents asked that their bedroom doors be left open as they felt lonely and isolated with them closed. It is recommended that risk assessments be compiled for those people wishing to keep their doors open and consideration should be given to providing automatic closures to bedroom doors. The home was clean and hygienic throughout. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 16 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 30 Quality in this outcome is Adequate. This judgement has been made using available evidence including a visit to the service. Although the staff team in the home are committed, caring and well trained, there are potential risks to service users regarding the home’s recruitment practices. EVIDENCE: The staffing rota showed that there were sufficient numbers of staff on duty to meet the needs of current residents in the home. The staff on duty matched the rota. At least two registered nurses are available on each shift with one at night. Many of the staff team have worked in the home for a number of years and have built up good relationships with the people they support. All of the residents and visitors spoken to were very complimentary about the skills and commitment of the staff team and said that they were well treated. One resident said, “Everyone is nice here, staff are kind and caring and thank goodness they have a sense of humour. Another person said, “The staff are very kind, we are well cared for and I have lots of visitors”, There is a programme of development and staff training in place and training records were seen on file. Despite an Immediate Requirement having been made at the last visit regarding Criminal Bureau Checks for new staff, of the five staff files seen, one Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 17 had an out of date CRB brought from another home and one person did not have a CRB or POVA first check carried out before commencing employment. As this poses a potential threat to the safety of residents, a further Immediate Requirement has been made and a Letter of Serious Concern sent to the Registered Provider. The expiry date for one Registered Nurse’s PIN number was out of date on the staff records and Mrs. Herbert said that she would confirm the date it was renewed and forward it to the Commission. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 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 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 34 36 37 38 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. A qualified, competent and caring manager manages the home. To ensure that residents are protected at all times, systems should be reviewed and updated. EVIDENCE: The manager of the home Mrs. Herbert has been in post since April 2006, has qualifications both in nursing and management and specialist knowledge in palliative care. Mrs Herbert has made an application to be interviewed for the Registered Manager’s post. The home also has a deputy manager and management tasks are delegated as appropriate. Residents, staff and visitors were very complimentary about Mrs. Herbert and said they found her accessible, kind and caring. A staff member said, “ We get Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 19 lots of training. The matron does run the home in the best interests of residents and what they need they get”. The home does not act as an appointee for residents and families or legal representatives manage financial affairs. Staff confirmed that supervision and support sessions are carried out and records were seen on file but to ensure that all of the staff team receive consistent information staff meeting should be held on a regular basis. A Quality Assurance process has been started and questionnaires have been sent to residents, families and other professionals involved with the home. Replies have been received and Mrs Herbert said that she is now going to collate the comments and publish outcomes. A requirement made at the last visit regarding monitoring and quality visits from the providers South Coast Nursing Homes Limited has not been met and there were no Regulation 26 reports in the home. This Requirement is ongoing. Records for the running of the business were seen including fire records, maintenance books, accident and incident reports and annual checks. Most records were up to date but the annual electrical PAT tests were overdue. The manager said they were due to be done in the next few days and she would confirm when they were completed. As detailed in other parts of this report Immediate Requirements have been made and a Letter of Serious Concern sent to the Registered Providers, regarding medication systems and staff recruitment processes. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 1 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 1 2 Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP12 Regulation 16.2 (m) Requirement Activities should be on offer to provide interest and stimulation for residents The registered Providers should provide a monthly report on the conduct of the care home and records should be kept of the visit. OUTSTANDING REQUIREMENT The registered manager should ensure that all records for the running of the business are up to date and accurate. Timescale for action 15/11/06 OP32 26 (1) 15/11/06 3 OP37 17 15/11/06 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 OP14 Good Practice Recommendations In order to ensure that residents do not feel lonely or isolated consideration should be given to fitting automatic closures to the bedrooms of those people who like to keep their doors open. Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Southampton HO 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW 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 Pentlands Nursing Home DS0000024194.V302358.R02.S.doc Version 5.2 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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