Random inspection report
Care homes for adults (18-65 years)
Name: Address: Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ zero star poor service 28/09/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Beverly Hill Date: 1 1 1 2 2 0 0 9 Information about the care home
Name of care home: Address: Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ 01262674010 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Olu Femiola care home 13 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Conditions of registration: 13 The maximum number of service users who can be accommodated is: 13 The registered person may provide the following category of service only: Care Home only - Code PC, To service users of the following gender: Either, Whose primary care needs on admission to the home are within the following category: Mental Disorder, excluding Learning Disability or Dementia - Code MD, maximum number of places 13 Date of last inspection Brief description of the care home Pentrich is registered to provide accommodation and personal care for a maximum of thirteen adults who have a mental health problem. Nursing care is not provided. Should such care be required on a short-term basis then it will be provided by the community health services. Pentrich is a linked double fronted property situated in a residential area of Bridlington
Care Homes for Adults (18-65 years) Page 2 of 12 2 8 0 9 2 0 0 9 Brief description of the care home and is conveniently located for all of the main community facilities including the public transport network. A parking area is available at the front of the property. There is also restricted on-road parking. The property has three floors. The accommodation consists of three shared bedrooms and five single rooms, two of which have en-suite facilities. Bathing/toilet facilities are available on each floor of the property. A dining room and two lounges, one designated for the use of people who smoke, are located on the ground floor. The property does not have a passenger lift so is only suitable for people who are able to use the stairs. On 29 May 2009 the manager said that the weekly fees are £283.69. People pay extra for chiropody, hairdressing, transport and toiletries. Information about the home is available in the Statement of Purpose if people want to see it. The most recent inspection report is available on request. Care Homes for Adults (18-65 years) Page 3 of 12 What we found:
The reason for this inspection was to check the progress made against the requirements issued after the last key inspection on the 28th September 2009. The home was sent a warning letter regarding the requirements and had to produce an improvement plan stating how they were to meet them. We received the improvement plan on time. Choice of Home. There had been no new admissions to the home since the last inspection due to a suspension of placements by the local authority until they are satisfied the home has made improvements. This section will be assessed at the next key unannounced inspection. The recommendation regarding the home obtaining assessments completed by the local authority will remain in place until it can be fully assessed. Individual Needs and Choice. We looked at two care files during the visit and noted that they were much more organised. The care plans had been re-formatted and improvements noted in the content. They stated what the resident was able to do for themselves and the tasks that were required by staff to ensure needs were met. The care plans could contain more personalised details but this was an encouraging start. Evaluations of the care plans had just started so that staff could record changes and update them. The requirement regarding care plans will remain in place with an extended timescale and will be assessed at the next key unannounced inspection. The risk assessments had been reviewed by staff and some contained more information than others. This is an area that still requires more input and was discussed with the manager and deputy manager. The main area for improvement was in the actions staff needed to take to minimise the risks. For example, one risk assessment for a person that has the potential to misuse alcohol stated, monitor intake. It did not state how this was to occur, whether intake was to be documented, what amount was considered safe, what staff needed to do should the person exceed the amount considered safe, how it would affect their medication etc. Similarly, another risk assessment stated, occasional challenging behaviour but there was no explanation of what this was and how staff were to manage it effectively and consistently. Although some progress has been made the requirement regarding risk management will remain in place with an extended timescale and will be assessed at the next key unannounced inspection. Each resident had risk assessments that were all written on one page and this tended to dictate the space staff had to write them. It is recommended that a separate page be used for each identified risk, which will enable the staff to think more widely about risk analysis and the steps needed to minimise risk. Lifestyle. There were no requirements from this section at the last inspection. Some of the recommendations made at the last inspection have been met. For example, ensuring that people are consulted more about the way their home is run and ensuring that a resident
Care Homes for Adults (18-65 years) Page 4 of 12 that wished to be able to make their own hot drink had the facility to do this. Personal and Healthcare Support. Staff had made an appointment with a dietician to check out a specific residents dietary needs and care plans included health needs, and how they were to be met, more clearly. The requirements relating to these two points have been met. Staff completed a document called, what is important to me, regarding residents needs. It is recommended that this be completed in a more person-centred way to evidence that residents had participated in its completion. The documents seen need to be signed and dated. These will be looked at again at the next key unannounced inspection. A pharmacist inspector visited the home on 23rd November 2009 and concluded, the homes medication systems and record keeping have improved considerably since the last key inspection. The manager is making good progress with updating the medication policy and procedures which, when completed, will hopefully lead to further improvements in medication safety in the home. All three requirements regarding medication were met at that inspection. Concerns, Complaints and Protection. The manager and deputy manager have completed the local authority safeguarding training which details their role in the referral and investigation processes. They are now much more aware of what they have to do and who they have to contact should they become aware of safeguarding concerns or allegations of abuse. The requirement relating to safeguarding training for the manager has been met. Environment. The manager had forwarded to us a refurbishment and redecoration plan with timescales for completion. The manager has also set up a maintenance book so issues can be logged and addressed quickly. It details when jobs have been completed. The floor in the downstairs toilet still needs to be repaired but a quote has been obtained and work planned for January. We have accepted this and extended the timescale of the requirement until the 31st January 2010. The re-carpeting and redecoration of both lounges have been included in the plan for 2010. The home was cleaner and bedrooms were tidier. One residents stained pillows had been replaced and another resident had been supported to clear out their cluttered bedroom. One bedroom had been completely redecorated and a resident has decided to vacate their own very large room to occupy it. They told us they were very happy with the move and liked their new bedroom. The manager told us that the large room vacated is to be redecorated and used as a shared bedroom as it is larger than the shared room currently occupied by two residents. Both residents are happy with the arrangements and extra space they will be gaining. A deep cleaning rota for the kitchen has been devised but to improve it could detail what the jobs are that staff have to complete not just the time that has been allocated. Paper towels and dispensers have been purchased for two of the communal bathrooms/toilets. These need to be installed and the manager needs to ensure there are sufficient for each
Care Homes for Adults (18-65 years) Page 5 of 12 of the communal bathrooms and toilets. Although there is still work to be done on the environment, some improvements were noted and it is acknowledged progress will be slow in some areas. On the day of the visit it was noted that the washing machine/drier had broken down and was in need of replacement. The manager confirmed a machine had been purchased and they were awaiting delivery. Alternative arrangements had been put in place in the interim but one resident told us this was having an effect on their supply of clothes. Staffing. References, that were not in place for the latest staff member recruited at the point of the last inspection, have been obtained. The manager is fully aware that full checks must be in place prior to the start of employment. The requirement will remain in place until the next inspection so that the recruitment processes can be assessed in full. The recruitment of the deputy manager has meant that staffing numbers have increased. This means there are now two care staff as well as the manager on shift during the day. This enables the manager to complete management tasks that had previously slipped. The physical support required by the residents is minimal as all the residents are self caring other than prompts and supervision for two people. The main area of support is emotional and psychological. Care staff have more time to sit and talk to people. There is catering staff on duty five days a week but the two care staff on duty prepare meals at the weekend. The manager does not work at weekends. It is recommended that catering staff are in place seven days a week or an extra care staff member at weekends to enable support with any recreational or occupational activities. Three training sessions regarding mental health, facilitated by health professionals visiting the home, had been completed. These included mental health conditions, medication and their side effects, care planning, caring for people in crisis and improving communication, and dignity and equality including some role play. The deputy manager has been auditing staff training files so that a full range of training can be organised. Staff had completed first aid in November and moving and handling has been planned. All staff were up to date with fire safety training. This is an improvement on the last inspection, however, the requirement will remain in place until training can be assessed thoroughly once the internal audit has been completed. At the last inspection care staff were not receiving any formal, one to one supervision with their line manager. A system has now been organised, new supervision forms produced and five of the seven care staff have received a supervision session. Staff should receive a minimum of six supervision sessions per year. The recommendation will remain in place and checked at the next key unannounced inspection to ensure care staff are on track to receive this amount. Conduct and Management of the Home. We have been encouraged by the improvements made to the management systems in the home. On the day of this site visit the home was calmer and more organised. Residents spoken with all knew the staff team by name and told us that the manager and deputy manager were, very nice. All said they would speak to them if they had any
Care Homes for Adults (18-65 years) Page 6 of 12 concerns. The documentation required for the running of the home has improved, especially medication and care planning. Further improvements were required for risk assessments, and the training audit and staff supervision have just started. We are now receiving notifications from the home of any incidents affecting the wellbeing of residents. The manager has re-submitted an application form to be registered with the Care Quality Commission. This is being processed and will enable his fitness to be the registered manager of the home to be tested. What the care home does well: What they could do better:
Assessments completed by the local authority for people they fund need to be obtained prior to admission. We were unable to assess this fully as there had been no admissions since the last inspection. Care plans could be more personalised although some improvements had been noted. There had also been some improvements in risk assessments, however, the steps staff need to take to minimise risks need to be more indepth. Also the documentation used to record risk analysis could be completed more effectively. There were still areas of the environment that required attention. The downstairs toilet
Care Homes for Adults (18-65 years) Page 7 of 12 floor needed repair quickly and areas of the home required redecoration. However, quotes for the toilet floor had been received and worked planned for January 2010. The redecoration and refurbishment plan had details of work and timescales for completion. We will be monitoring progress against the plan. The deep cleaning rota for the kitchen should be specific regarding the tasks staff have to complete to maintain standards. Staff supervision has started and the documentation reviewed. All care staff should have a minimum of six formal supervision sessions a year. The deputy manager has started to audit staff training records so that a comprehensive training plan can be produced. Staff recruitment processes could not be assessed as no staff had been employed since the last inspection. The requirement remains and will be checked at the next key inspection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 8 of 12 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 9 13 Risk assessments must be completed fully for areas of risk in daily living activities. This must have detailed actions required by staff to help minimise the risks. This will ensure that staff are fully informed of any risks, know what they must do to support people to minimise the risks, and will help to safeguard residents and staff from harm. Previous timescale of 30/11/09 not met but has been extended as some progress has been made. 31/01/2010 2 27 23 The floor in the downstairs toilet must be repaired. This will prevent it from becoming a health hazard to people that use it. Previous timescale of 30/11/09 not met but has been extended due to work being planned. 31/01/2010 3 34 19 New staff members must have full checks in place prior to the start of employment. 30/11/2009 Care Homes for Adults (18-65 years) Page 9 of 12 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action This will help to ensure that only suitable people are employed to work with vulnerable adults and will help promote their safety and wellbeing. This requirement remains in place and will be assessed at the next inspection. 4 35 18 Staff must have up to date 31/01/2010 mandatory training and receive service specific training in line with the identified physical, mental health and in one case learning disability needs of the residents living in the home. The training must be identified and planned by the timescale required. This will ensure that staff have the right skills and knowledge about the needs of the people they support, will help them to identify quickly when peoples mental health needs start to deteriorate and will help them to be confident in their role. Previous timescale of 30/11/2009 not met but has been extended as some progress has been made and an audit of staff training is underway. Care Homes for Adults (18-65 years) Page 10 of 12 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 9 The risk assessment documentation should be reviewed to provide staff with more space for each risk that is analysed and to prompt them to think widely about the steps required to minimise risk. The, what is important to me document regarding how people wished to be supported with personal care should be written in a more person-centred way and signed by the resident to evidence their participation and agreement. There should be catering staff available seven days a week or an extra care staff at weekends when they have to prepare meals throughout the day. This will enable staff to be able to support residents with any occupational activites at weekends. 2 18 3 33 Care Homes for Adults (18-65 years) Page 11 of 12 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 12 of 12 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
