Inspection on 12/01/06 for Pentrich Residential Home

This inspection was carried out on 12th January 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pentrich Residential Home 11/12/09

Pentrich Residential Home 23/11/09

Pentrich Residential Home 25/09/09

Pentrich Residential Home 29/05/09

Pentrich Residential Home 03/06/08

Pentrich Residential Home 04/12/07

Pentrich Residential Home 13/06/07

Pentrich Residential Home 29/06/06

Pentrich Residential Home 27/01/05

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

CARE HOME ADULTS 18-65 Pentrich Residential Home 13 Vernon Road Bridlington East Yorkshire YO15 2HQ Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 12th January 2006 09:30 Pentrich Residential Home DS0000061162.V277055.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 Pentrich Residential Home DS0000061162.V277055.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. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pentrich Residential Home Address 13 Vernon Road Bridlington East Yorkshire YO15 2HQ 01262 674010 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) Mr Olu Femiola Mrs Jean Lesley Bailey Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2005 Brief Description of the Service: Pentrich is registered to provide accommodation and personal care for a maximum of thirteen (13) younger adults (service users) who have mental health problem. Three (3) of the service users may be over the age of 65. Nursing care is not provided. Should such care be required on a short-term basis then it will provided by the community health services. Pentrich is linked double fronted property situated in a residential area of Bridlington 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 unrestricted on-road parking. The property has three floors with the service users’ accommodation located on all floors. The accommodation consists of seven double or shared bedrooms and two single rooms. One room has en-suite facilities. A dining room and two lounges, one designated for the use of service users who smoke, are located on the ground floor. The property does not have passenger lift and is consequently only considered suitable for service users who are fully ambulant. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two statutory inspections undertaken by the Commission for Social Care Inspection during this inspectoral year. The inspection was unannounced. The inspection took a total of five and a half hours including preparation time. The inspection primarily focussed on the requirements and recommendations made during the previous inspection and on those ‘key’ National Minimum Standards not addressed on that occasion. The registered manager was available throughout the inspection. The majority of the service users were spoken to either as a group or individually. Discussions were held with the staff on duty. A number of statutory records, including service users’ care records, were examined. 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. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 6 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 Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 7 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): 5 The service users are provided with a contract of residence that provides them with appropriate information with regard to the terms and conditions of residence. EVIDENCE: Following the recommendation made during the previous inspection, the service users contracts or terms and conditions of residence have been revised and now identify the room that is to be occupied. None of the other standards in this section were assessed on this occasion. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 8 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): None EVIDENCE: Not assessed on this occasion. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 9 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): 11, 16 and 17 The service users continue to be encouraged and enabled to develop their personal living skills. EVIDENCE: Subsequent to the previous inspection, the registered manager had developed a personal profile for some of the service users that identified their personal development needs and achievements. It was intended that this is going to be used in conjunction with the service users’ care plans. It was evident from discussions with the service users that the majority are encouraged to develop their life skills. Several were relatively independent and were able to go out of the home without supervision. One service user attended a local church on several days each week. Others attended the local Resource Centre and made maximum use of the local community facilities. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 10 Following the comments made in the previous inspection report, the use of punitive actions in order to modify the behaviour of some service users had ceased. In addition to this, the control of a service user’s money or, for example, their cigarettes, had been made the subject of formal agreements between the service user concerned ad the management of the home. Examples of these were available. It was evident from discussions with, and observation of, the service users and staff that the service users were treated with appropriate respect and were spoken to in an adult and non-patronising manner. It was also apparent that the service users could choose where, and with whom, they spent their time. They had unrestricted access to their bedrooms and several expressed pride in the standard of their rooms. The home did not have a set programme of activities but in general the service users ‘did their own thing’. The service users spoken to were satisfied with this approach. The menus indicated that the meals were reasonably varied and provided a balanced diet for the service users. Comments from the service users included: “The meals are great here, the cook’s good”. The cook also doubled as a carer and consequently had a good understanding of the service users’ food preferences. A record had been maintained of all food provided for the service users. One service user was provided with a special diet. The service users ate in a dedicated dining room that had the tables informally arranged. The home had a large percentage of shared bedrooms and consequently this could limit the development of the independence of the occupants of those bedrooms. Those service users who shared had done so for a considerable number of years and did not object to the arrangement. Pentrich Residential Home DS0000061162.V277055.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): None EVIDENCE: These standards were not assessed on this occasion. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 12 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 Whilst there is an acceptable adult protection policy, the protection of the service users would be further enhanced by staff training in the subject regardless of role. EVIDENCE: The registered manager provided confirmation that training in Adult Protection procedures, including the identification and types of abuse, is planned. The majority of the staff had received training on this subject as an integral part of their National Vocational Qualification training. A document on the subject was available to staff. From discussions with the staff it was evident that they had a sound understanding of adult protection procedures and they provided reassurance that they would not hesitate to report any allegation of abuse. The manager was aware of the service users vulnerability when out of the home but had achieved a reasonable balance between the independence of the service users and their safety. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 13 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 and 30 Whilst there has been an improvement to the standard of the environment, further action needs to be taken to bring it up to an acceptable standard. EVIDENCE: Following the comments made during the previous inspection a programme of refurbishment and redecoration had been started. The entrance hall, the office and several bedrooms had been redecorated. This had been undertaken by a member of staff employed in the role of maintenance person. There were still areas that required improvement. For example, the grouting in the first floor shower room was stained and the linoleum was torn. In the upstairs corridors part of the wallpaper was stained and torn. Some bedrooms did not have the recommended standard of furniture such as a bedside light. Privacy screening was available for service users sharing bedrooms but was not generally used. A maintenance programme had been implemented but according to the manager the timing had ‘slipped’. The manager agreed to provide the CSCI with an updated version of this programme. As far as could be ascertained from the records the premises met with the requirements of the Environmental Health and Fire Departments. The home had a dedicated laundry with a washer and drier. Sluicing facilities were not required. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 14 As previously mentioned in this report (Standard 11), the home had a high percentage of shared bedrooms, which could limit the independence of the occupants of those rooms. Pentrich Residential Home DS0000061162.V277055.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, 34 and 35 Whilst the staff are provided with appropriate training, the lack of financial support could undermine their goodwill and morale. EVIDENCE: It was evident from the staff rosters that there had been no regression in terms of the staffing level since the previous inspection. Over 50 of the staff had achieved, or were in the process of achieving, a National Vocational Qualification at level 2 or above. The staff confirmed that they had received training in statutory subjects and in professional subjects such as mental health. Training had been planned for adult protection and the use of restraint. On the day of the inspection the staff were attending a introductory course on nutrition. It was evident from discussions from staff that they were expected to attend training courses in their own time if necessary. There was not a budget for training and unless the training was externally funded, or free, the staff paid for themselves. The staff presented as being enthusiastic with regard to training. Those staff spoken to felt very positive with the progress made in the home particularly with regards to the internal lines of communication. They felt better informed and consequently more aware of their roles. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 16 From an inspection of the records, it was evident that the staff recruitment, selection and vetting procedures were reasonably robust. No new staff had been recruited since the previous inspection. The staff confirmed that they were receiving regular supervision from the registered manager. Pentrich Residential Home DS0000061162.V277055.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): 37, 39, 41 and 42 The registered manager would benefit from formal feedback and support from the registered provider. EVIDENCE: The registered manager was intending to start a National Vocational Qualification at level 4 within the next few weeks. It was evident from discussions with the manager that she had a sound understanding of her role and responsibilities. Whilst it was confirmed by the manager that the responsible individual regularly visits the home, there was not, however, any documentary evidence of these visits or as to what was inspected during the visit. Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 18 The home had a basic quality assurance (QA) system that primarily consisted of questionnaires completed by the service users’ relatives. There was, however, no input from health and social care professionals. There was no evidence that the QA system was based on a systematic cycle of planning, implementing and reviewing to verify that the aims of the home were being achieved. It was evident that the manager regularly reviews the home’s policies and procedures to ensure that they remain relevant and accurate. On the day the inspection the Service Users’ Guide was in the process of being amended. Those statutory records inspected, including the accident and fire records, were complete and up to date. The manager had taught herself to use the home’s computer and a number of records had been, or were going to be, transferred onto it. The home was not, however, registered under the Data protection Act 1998. The manager did not have access to the Internet. Pentrich Residential Home DS0000061162.V277055.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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X x LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 2 X 1 3 X Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 (2) (b)(d). Requirement A programme of refurbishment and redecoration, along with timescales, is to be provided for the Commission for Social Care Inspection. The registered person must ensure that the staff receive appropriate training and are provided with suitable assistance to undertake that training. They should, for example, have at least five (5) paid training days per year. In addition to the training and development plan, the home should have a dedicated staff training budget. The registered provider must undertake an unannounced visit of the home at least every month. A written report of this visit must be provided for the registered manager and, if requested, the Commission for Social Care Inspection. Timescale for action 01/03/06 2 YA35 18(1)(c) 01/03/06 3 YA41 26 01/03/06 Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 21 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 YA11 Good Practice Recommendations Consideration should be given to reducing the number of shared bedrooms by, for example, making them single accommodation when vacated by one of the present occupants. Training in Adult Protection, including the types and indications of abuse, should be provided for all staff regardless of role. The registered manager should achieve a National Vocational Qualification at level 4 in both management and care. The quality assurance monitoring process should be reviewed to ensure that it genuinely and accurately verifies that the aims and objectives of the home are being achieved. 2 3 4 YA23 YA37 YA39 Pentrich Residential Home DS0000061162.V277055.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Pentrich Residential Home DS0000061162.V277055.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. 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!