Inspection on 07/02/06 for Pentlands Nursing Home

This inspection was carried out on 7th February 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 10/10/06

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 B Tye Unannounced Inspection 11:00 7 February 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.V278547.R02.S.doc Version 5.1 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.V278547.R02.S.doc Version 5.1 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 Mrs Alexandra Rose Baker Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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 admitted. 11th August 2005 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 catgeory 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 approximatley 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.V278547.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Beth Tye carried out the unannounced inspection on 7th February 2006. Prior to the inspection all records held on file since the last inspection were reviewed. During the inspection a tour of the home was carried out and the majority of rooms visited. Records relating to the care of the residents and the administration of the home, including a number of staff records were examined. Health and Safety records for the home were examined alongside medication storage and records. Staff were observed going about their work and during the inspection they indicated that the home does support staff and encourage high standards. The conclusion of the inspection was that a good standard of care is provided at Pentlands from caring and well-trained staff. However, an Immediate Requirement was made relating to the absence of CRB checks for some of the staff, and a feedback form was left at the home. Other requirements were identified and discussed with Mrs Baker at the conclusion of the inspection. Following the inspection, a Letter of Serious Concern was issued to the home in relation to the Immediate Requirement. What the service does well: The home is clean, well maintained and decorated, comfortable and homely. Equipment is provided related to the disabilities of residents. The manager of the home is very involved in each residents care to ensure their needs are fully met on a day-to-day basis. Staff work hard to meet the needs of residents in a caring and friendly manner and residents were positive about the home and the way the staff care for the residents. Care plans are well organised and detailed. This ensures staff are clear about meeting residents needs appropriately. Well-balanced and nutritious meals are served which residents were complimentary about. Staff training and development is provided and encouraged. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 6 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.V278547.R02.S.doc Version 5.1 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.V278547.R02.S.doc Version 5.1 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): 2&6 Contracts detailing terms and conditions were seen on residents files. Where respite care is provided, residents are encouraged to maximise their independence in order to return home. EVIDENCE: The inspector examined several case files and found all contained a signed ‘Patients Agreement’. This ensures each resident is aware of his or her rights and responsibilities within the home. Evidence from the case files indicated that residents who require respite care are fully assessed prior to admission. The focus of their care is based on stabilising and managing their condition in the early stages and then providing rehabilitation where possible. Which would enable residents to regain independence and return home. Case tracking indicated that care provided in these cases matched written records. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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, 9 & 10 There is comprehensive and current information in place to ensure staff members are aware of the care needs of each person living in the home. Residents are treated with respect and their right to privacy is upheld. Records showed that medication procedures are being adhered to as gaps were found on medication records. A requirement has been made in respect of this. EVIDENCE: The people living in the home said that they were always treated in a dignified and respectful manner. Staff were observed interacting positively with residents and the atmosphere within the home was friendly and relaxed. Creating a positive and homely environment for the residents. The inspector viewed care plans for residents, which contained information relating to the health, and social care needs of each person. Each plan was clear and easy to follow enabling staff to access information with ease. Assessed needs of residents are reviewed and updated on a needs led basis. This ensures staff members are aware of the daily care needs of each resident in respect of their health, social, emotional and personal issues. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 10 The home does not provide in house training to ensure a uniform approach to handling and dispensing medication. Only trained nurses dispense medication and there are policies and procedures in place to support staff practice in this area. The inspector examined all medication sheets and storage at the home. All medication is stored correctly and items seen were labelled and clear. However MAR sheets for recording the daily dispensing of medication were not all completed in full, and the inspector found several gaps on different sheets. A requirement has been made to ensure records are monitored by the manager on a regular basis, to avoid inconsistencies on the records. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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, 14 & 15 The inspector concluded that the home provides a lifestyle that respects the privacy and dignity of residents. Great importance is placed on nutrition at Pentlands. Meals served are varied, nutritious and well balanced. Specialist dietary requirements are catered for in line with residents assessed needs. EVIDENCE: Staff were observed being respectful of residents choices and were flexible in their daily routines to meet residents needs. Care plans seen reflected their individual preferences in relation to their social and leisure interests. Due to complex nursing needs and high dependency of residents there are no planned group activities, as most residents remain in their rooms. More independent residents are supported to pursue individual interests both at the home and in the wider community. Residents are able to receive visitors at any time and there are private spaces in addition to bedrooms where guests can be received. Policies and procedures relating to visitors to the home are in place and up to date. Ensuring staff and residents are clear about the homes expectations. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 12 The inspector observed the distribution of meals on the day of inspection. The food was home cooked and looked nutritious. Where appropriate food was liquidised in separate portions and presented well. Dietary requirements are considered as part of the care planning process and matched information held on resident’s files. All residents spoken to fed back that the food provided was of a good standard and there were always choices available. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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 There is a clear complaints procedure available and complaints are recorded appropriately. The inspector could not conclude residents are fully protected within the home as some staff have not undergone appropriate checks. This has been an ongoing requirement from the previous inspection. An immediate requirement was issued on the day of inspection followed by a letter of Serious Concern. EVIDENCE: Since the last inspection there has been one recorded complaint. The inspector examined related correspondence and found the manager had responded appropriately, in line with the homes complaints procedure. Adult Protection training is provided as part of the homes annual training programme. The inspector found most staff had received training in this area and certificates were seen on staff files. In addition, the home has relevant policies and procedures in place to promote positive practice in the area of dealing with suspected abuse within the home. Examination of staff files revealed that a previous requirement to complete staff checks had not been met. The inspector found some of the staff still did not have up to date CRB or POVA checks. Failure to undertake these checks could pose a potential risk to vulnerable residents. Consequently the inspector issued an immediate requirement and issued a letter of Serious Concern to ensure the home complies with legislation, and undertakes appropriate checks for all staff who work in the home, with immediate effect. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 14 Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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, 22, 24 & 26 Residents live in a well-maintained, clean and comfortable environment. Each room is personalised to suit the individual and equipment are available to meet identified needs. The inspector could not conclude all areas of the home were safe as some safety equipment checks were not up to date, posing a possible risk to residents. EVIDENCE: The home was clean and fresh with no unpleasant odours detected during the visit. All areas are decorated and furnished in a homely fashion with residents able to furnish their rooms with personal possessions. A call bell system is available for residents to summon staff if needed. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 16 There is a large pleasant lounge/dining room available for the use of residents, and a well-maintained garden to the rear of the home which can be accessed from the lounge. Car parking is available to the front and side of the home. A wheelchair lift has now been installed to serve four rooms on the mezzanine level in addition to a lift in the main building. Risk assessments are in place and where appropriate displayed throughout the building. Since the last inspection Mrs Baker has written to CSCI to confirm that the outstanding health and safety requirements made by the Environmental Health Dept have been complied with. Following a recent inspection by The Fire Department, some requirements have been made. A requirement was issued by the inspector to ensure these are complied within the stated timeframe. Following examination of Health and Safety checks within the home the inspector found that regular checks for the emergency lighting system, fire systems and water temperatures are not up to date. These should be regularly monitored and findings recorded for safety purposes. A requirement was issued by the inspector, to ensure these are kept up to date and relevant legislation complied with. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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): 28 & 29 Rotas reflected there are sufficient staffing levels over a 24-hour period to meet the needs of residents. The residents are not fully supported by the homes recruitment policy and practices, therefore the inspector could not conclude they are in safe hands at all times. EVIDENCE: Pentlands is committed to staff training and development and flyers advertising training sessions were displayed. The inspector noted the annual staff-training plan was displayed and covered the statutory training requirements for staff. The manager confirmed care staff are also encouraged to achieve a National Vocational Qualification while working at the home and staff records reflected this. Files seen by the inspector showed care staff had undertaken a TOPPS induction at the commencement of their employment. Duty rotas were available and these indicated that staff are employed with the appropriate skill mix to meet the needs of residents over the 24-hour period. A record of staff meetings was available and seen by the inspector. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 18 Following examination of personnel records the inspector found a number of staff had not undergone appropriate checks. Failure to comply with legislation in this area poses a potential risk to vulnerable residents. Mrs Baker informed the previous inspector that this would be addressed as a priority, however records seen were still not up to date. An immediate requirement was issued on the day of inspection to ensure appropriate checks are undertaken with immediate effect. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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): 32, 34 & 38 Overall the nursing care provided in the home is well managed by Mrs Baker and is run in the best interests of the residents. The inspector concluded that health and safety issues found at the inspection pose a potential risk to the overall welfare of the residents. Requirements have been made to ensure residents are fully protected within the home. EVIDENCE: Mrs Baker is the Registered Manager for the home and is assisted by a Deputy Manager. They both work well together to maintain high standards of nursing care at the home. Mrs Baker informed the inspector that the Directors hold an annual meeting to give her a financial overview of the service. Mrs Baker does not hold a budget Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 20 but confirmed that if she needed something for the home the directors provided it. Residents or their representatives look after their own finances. Regulation 26 Reports have not been provided to the commission since the last inspection despite a previous requirement. These reports should provide information on a monthly basis on the conduct of the care home and demonstrate the Company is monitoring the home on a regular basis. Another requirement was made in respect of this. The inspector was informed a Quality Assurance System was not yet in operation in the home. An on going requirement was made to ensure this is implemented. Policies and Procedures are in place to promote good working practices of staff within the home. Administrative systems, including health and safety checks within the home were examined. These included the accident book, maintenance log, water temperatures, fire records and risk assessments. Although the systems were all up and running and some were complete, the inspector found that checks for the emergency lighting system, fire systems and water temperatures were not up to date. These should be regularly monitored and findings recorded for safety purposes. A requirement was issued by the inspector, to ensure these are kept up to date and relevant legislation complied with. Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 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 X 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X 3 X 3 X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X 3 X X X 1 Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 22 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 Standard OP19 Regulation 16 Requirement Ensure the premises meet with the requirements of The Fire Department. CSCI to be informed of action. The registered providers shall visit the home and provide a monthly report on the conduct of the care home to CSCI according to legislation. OUTSTANDING REQUIREMENT The registered person to ensure appropriate recording of medicines The registered person shall ensure risks are identified and residents are free from hazards to their safety The Registered person shall establish and maintain a system to review the quality of care provided at the home. OUTSTANDING REQUIREMENT Staff records to be compiled to comply with the requirements of Care Home Regulations 2001. OUTSTANDING REQUIREMENT. Timescale for action 07/05/05 2 OP32 26 28/02/06 3 4 OP9 OP19 13 13 (4) 28/02/06 28/02/06 5 OP32 24 28/02/06 6 OP37 17 07/02/06 Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 23 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 Standard Good Practice Recommendations Pentlands Nursing Home DS0000024194.V278547.R02.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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