Inspection on 23/03/06 for Pentree Lodge

This inspection was carried out on 23rd March 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pentree Lodge 01/03/07

Pentree Lodge 12/10/05

Pentree Lodge 06/10/04

Pentree Lodge 19/05/04

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

CARE HOME ADULTS 18-65 Pentree Lodge 63/65 Pentire Avenue Pentire Newquay Cornwall TR7 1PD Lead Inspector Kerensa Livingstone Unannounced Inspection 23rd March 2006 09:30 Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 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 Pentree Lodge DS0000009210.V277406.R01.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 Adults 18-65. 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. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pentree Lodge Address 63/65 Pentire Avenue Pentire Newquay Cornwall TR7 1PD 01637 878437 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) Miss Leslie Christine Richardson Mr Neil Harrison Mrs Julie Wimberley Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include service users who are sixty-five years of age or under on admission to the home. To include one service user over the age of 65 years Date of last inspection 12th October 2005 Brief Description of the Service: Pentree Lodge is situated in Pentire approximately two miles from the centre of Newquay. The home provides accommodation and care for fifteen people with a Mental Disorder who are admitted to the home under the age of sixty-five. The Registered Provider owns another home catering for the same client group on the edge of Newquay and care staff work between the two homes. The Registered Manager works only at Pentree Lodge. The main part of the home accommodates twelve Service Users and the ‘flat’, which is attached, provides the opportunity for three less dependent service users where service users can be responsible for their own personal care and domestic tasks. All service users have their own bedrooms and there is a communal lounge in both parts of the home. There is a small parking area to the front of the home. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, by two inspectors, undertaken over a morning into the early afternoon. There were two staff on duty to undertake all the, caring, cleaning and laundry. The Inspectors spoke with several service users during the course of the inspection. Various records, care plans and policies and procedures were looked at. Discussions were held with the care staff and the registered manager on duty. What the service does well: What has improved since the last inspection? What they could do better: The registered provider should review the current staffing levels to ensure that a minimum of two members of staff are on duty at all times. A robust recruitment procedure should be followed at all times. It would be beneficial to service users and the staff team to have designated laundry and domestic staff. A duty roster of persons working at the care home, and a record of whether the roster was actually worked must be kept in the home. The systems of recording medication must be addressed to ensure that all staff follow the correct procedure and an investigation and appropriate action is taken when errors are noted. Service users should be offered a lockable storage facility within their rooms. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 6 It is recommended that the registered person have clear and accessible information identifying, which service users are present at the home and which are absent at any one time. 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. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The individual needs of service users are assessed. EVIDENCE: The care needs and wishes of service users are assessed prior to admission to the home. There is evidence of comprehensive social services assessments, with the care home undertaking their own assessment. The initial care plan is based upon the care needs assessment and written in concordance with the service user with a signature obtained, where possible, from the service user to demonstrate this. The registered person has developed the contracts for service users, following concerns identified at the last inspection. Each service user has been issued with and signed a copy of the new contract that enables service users to make decisions as to the care that they receive. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 8 Service users are supported to make decisions about their lives and are encouraged and enabled to voice their views regarding the running of the care home. EVIDENCE: Each individual service user has a care plan, risk assessment and daily record – all of which are recorded in detail. The daily records consistently demonstrate detailed information pertaining to the individual service user. The care plans are comprehensive, record any restrictions on the individual’s freedom and choice and include the identified need, aim and objective. Service users meetings are held regularly, with written minutes accessible to the service users and provided for the inspectors. Service users spoken with during the inspection commented that they felt able to contribute to the running of the home and that the routines generally meet their needs. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were fully inspected at the last inspection. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Service users physical and emotional health needs are met. EVIDENCE: The care planning documentation for service users details the individual choices and preferences (re routines) and demonstrates that these are respected and met wherever possible. One service user commented that on some occasions their personal care needs could be improved but acknowledged that their personal preferences did change regularly. This aspect of care was discussed with the registered manager who demonstrated that the care staff were aware and addressing the issue. Where possible the care home does aim to provide flexible routines, although for reasons of practicality meal times are at set times. Arrangements can be made to facilitate service users requests of alternative meal times when required. The minutes of the residents meetings demonstrate that this is a frequently discussed subject. The health care needs of service users are recorded fully and in detail with evidence available to support outpatients attendance, optician, dental and audiology visits. Annual health care checks have taken place in January February and March for all service users with the exception of two who refused to attend. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 12 The home has a detailed policy and procedure regarding medication that provides staff with advice on the recording, storage, handling, disposal, administration, receipt, homely remedies and covert medication. Each service users medication is recorded on an individual mar sheet. The home has systems in place for recording the PRN (as required) medication for individual service users. Inspection of records demonstrated that on many occasions the total of medication was incorrect. There is no evidence to support that any action has been taken in response to these discrepancies and this must be addressed as a matter of urgency. Medication is administered by the care staff, currently service users do not administer their own medication. The carer on duty informed the inspectors that service users come to the office and “line up” outside to receive their medication. This practice was discussed with the registered manager during feedback, as there is a concern that by not following a systematic process it is possible that on occasion medication may be omitted. It is also questionable whose best interests this practice is for and whether it is dictated by staffing levels. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse. EVIDENCE: The registered manager stated that there had been no complaints since the last inspection. The care home has a detailed policy and procedure regarding the protection of the vulnerable adult (POVA), and includes guidance on local contact details and a whistle blowing policy. The inspector was informed that all staff are booked onto POVA training. Evidence was available to demonstrate that two staff had completed the training. The registered manager stated that the home is awaiting certificates for other staff. There have been no allegations of abuse since the last inspection. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 Refurbishment is evident within areas of the home. Service users bedrooms do not promote their independence fully. EVIDENCE: Since the last inspection the dining room has been redecorated. This now has a light and airy feel, which service users commented upon. The registered manager was able to provide the inspectors verbally with a plan for updating other parts of the home. All bedrooms are lockable, although not all service users choose to hold the key and use the locking facility. It is recommended that all service users provide a lockable storage space. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 33, 34 and 35 Service users are at risk from the inconsistent recruitment procedure followed and the staffing levels at certain periods in the day. EVIDENCE: On the morning of the inspection there were two members of staff on duty supported by the registered manager who was undertaking administrative duties in the upstairs office. Staff duties are identified on a duty roster that follows a four weekly rota. The duty rota did not reflect the staff on duty on the day of the inspection. The registered manager stated that one member of staff was on holiday and another member of staff covered her duty – this was not recorded on the duty rota. Staff files were examined and concerns regarding the recruitment procedure identified in that two written references are not consistently obtained and held on file. The staff file of one member of staff on duty was not available for inspection as was located at the second home owned by the registered provider. Service users and staff commented that several members of staff have recently left the employment of the care home and the home has recruited new staff to replace them. The inspectors were concerned regarding the staffing levels during the afternoon and evening periods of the day, from 16.00 – 21.00 hours there is only one member of staff on duty at the home. The main meal of the day is prepared and served during this period. On the day of inspection two service Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 16 users were celebrating their birthday and had chosen pasties from a local bakery for the main meal of the day. Staff are provided with training in the form of induction and NVQ training. The registered manager is working hard to encourage staff to undertake and complete NVQ training level 3. One has completed this to date. Training is also provided to staff regarding mental health, diabetes, dementia and first aid. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 43 Service users views are sought regarding the running of the home and they benefit from the competent and accountable management of the home. EVIDENCE: The registered manager has conducted a quality assurance survey and has sent questionnaires out to service users, their families and representatives, professionals and hairdressers. Responses have been received but to date no audit of the feedback has been undertaken. The registered manager stated that feedback would be distributed to interested parties including the Commission for Social Care Inspection. Service users are encouraged to participate in residents meetings where their views are sought and ideas for change are considered. Service users were able to confirm to the inspectors their involvement at these meetings. Written records are maintained outlining the agenda and outcomes of discussions. The most recent meeting was 14.02.06 at which mealtimes, menus, activities and laundry were discussed. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 18 It is recommended that the registered person have clear and accessible information identifying, which service users are present at the home and which are absent at any one time. On the day of inspection the carer on duty was able to provide this information verbally to the inspector but had no written information relating to this. Evidence of financial viability has been provided to the inspector. Employers liability insurance is in place and displayed within the home, Since the last inspection the dining room has been refurbished. Service users were pleased to show this room to the inspectors and expressed their satisfaction with it. Two bedrooms have also been redecorated with input from the service users who reside in those rooms. The registered manager informed the inspectors that it is intended to refurbish the lounge area and refit the kitchen. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X X X 2 X X 2 3 Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 20 YES 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 YA20 Regulation 13(2) Requirement The Registered Provider shall make arrangements for the safe recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person shall, having regard for the size of the care home, ensure that at all times suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of the Service Users. Previous timescales not met 01/11/05 The registered person must ensure that a copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked must be kept in the home. The registered person must ensure that two written references relating to each member of staff are held. The staff file for each member DS0000009210.V277406.R01.S.doc Timescale for action 23/03/06 2. YA33 18(1a) 01/05/06 3. YA33 17(2) Schedule 4 01/05/06 4. YA34 7,9 and 19 Schedule 2 01/05/06 Pentree Lodge Version 5.1 Page 21 5. YA37 10(3) of staff must be available within the care home. The Registered Manager must undertake (and complete) training as is appropriate to ensure that they have the skills necessary for managing the home. E.g. National Vocational Qualification Level 4 in Management and Care. 01/05/06 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. 2. 3. Refer to Standard YA26 YA33 YA42 Good Practice Recommendations For Service Users to be provided with a lockable space to promote independence and respect the Service Users right to privacy. For there to be designated laundry and cleaning staff. It is recommended that the registered person have clear and accessible information identifying, which service users are present at the home and which are absent at any one time. Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 Page 22 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 Pentree Lodge DS0000009210.V277406.R01.S.doc Version 5.1 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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