Inspection on 17/07/07 for Pepenbury

This inspection was carried out on 17th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pepenbury 16/07/09

Pepenbury 24/01/07

Pepenbury 21/02/06

Pepenbury 05/10/05

Pepenbury 27/01/05

Pepenbury 29/06/04

Pepenbury 19/06/03

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Pepenbury Cornford Lane Pembury Tunbridge Wells Kent TN2 4QU Lead Inspector Ruth Burnham Key Unannounced Inspection 17th July 2007 09:30 Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 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 Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pepenbury Address Cornford Lane Pembury Tunbridge Wells Kent TN2 4QU 01892 822168 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) www.pepenbury.info Larkfield Hall Limited Mr Steven John McDermott Care Home 70 Category(ies) of Learning disability (70) registration, with number of places Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Pepenbury stands in extensive grounds on the outskirts of Tunbridge Wells, the site includes the main administrative premises, eleven detached houses providing service user accommodation, day activities facilities, a swimming pool and a woodland area. The centre of Tunbridge Wells is approximately two miles away and local facilities are available in the village of Pembury. Items produced by service users who live on the site and who attend for day care are on sale to the public. Two of the houses provide semi-independent living accommodation and two others are dedicated to providing a service to people with behavioural difficulties. Staffing levels vary across the houses depending upon the level of need of the residents. Fees range from £504.00 to £1220.00 per week. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over seven hours and was undertaken by Regulatory Inspectors Ruth Burnham (lead) and Debbie Sullivan (Link inspector). The inspection focussed on five of the eleven houses on the site. Time was spent speaking with service users, house managers, senior support staff and support staff and with the Executive Director and Operations Manager. Care plans and other documentation were read. The Registered Manager is on sabbatical until September. Throughout the day staff and residents were helpful in supplying information, staff spoken with demonstrated commitment to providing a professional service and there was good interaction between staff and service users. Information was also gained from the pre inspection questionnaire completed by the service; Surveys were not used during this inspection. The Provider completed the Annual Quality Assurance Audit which was also used as a source of information for this report. What the service does well: What has improved since the last inspection? Care plan recording is up to date and information in service user and induction files includes information from the most recent review and any change in needs. All service users are provided with adequate support with their personal care needs. Standards of hygiene in Hawthorne and Cornford have greatly improved There are sufficient staff to prevent service users from harming each other and to provide adequate supervision at night Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 6 The management has established an effective system for maintaining and evaluating the quality of the services provided to people who live at the home. All areas have been assessed including radiators to minimise risk of harm. 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. The summary of this inspection report can be made available in other formats on request. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 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 Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 Quality in this outcome area is good. People who are thinking about moving into the home have good information and opportunity to try out the service. Good admission policies and procedures to ensure that the needs of people who are considering living in the home can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who are considering moving into the home are provided with information about what life will be like there. They are able to visit the home and spend time with staff and residents. The service user’s guide and statement of purpose is made available on disc and in a pictorial format. Individual files contain a copy of the guide, statement of purpose, and a signed individual statement of terms of conditions. Good admission policies and procedures to ensure that the needs of people who are considering living in the home can be met. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 – 10 Quality in this outcome area is good. People who live in the home can be confident that their independence is promoted and confidentiality is respected. Care plans provide clear guidance to staff to promote a high standard of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home have individual care and support plans for staff to follow, the quality of those seen were good. Care plans provide clear guidance for staff to promote a consistently high standard of care for residents. Those seen showed evidence of recent reviews and reflected changes in needs. People who live in the home are encouraged to participate in the running of their houses. They are supported to make individual choices and decisions and are encouraged to achieve as much independence as possible. Houses hold weekly service users’ meetings. People are protected from harm in their daily living activities through risk assessment, such as accessing the community, using public transport, personal care and also in relation to particular individual activities or behaviours. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 10 The management of personal finances was not inspected during this visit. It was noted at a previous inspection that residents are encouraged to participate in managing their own personal finances and transactions made with and on behalf of residents are recorded on financial record sheets. The confidentiality of residents’ personal information is maintained through the secure storage of records. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11 – 17 Quality in this outcome area is good. People who live in the home, benefit from opportunities to take part in a wide range of activities. They are supported to maintain contact with family and friends. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home enjoy a range of daily and weekly activities, agreed with them and appropriate to their interests and abilities. These include day activities on site such as woodwork, gardening and swimming. Residents are also supported to become involved in activities in the local community and more able residents can become involved in voluntary work. They are also supported to attend clubs and groups and take part in social outings. House notice boards contain information about community activities such as the cinema or theatre. Residents are able to access very local facilities such as the bank or shops independently or with support Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 12 People who live in the home are able to personalise their bedrooms, those seen reflected personal interests and hobbies ranging from a collection of toy cars, football and music. Links with families and other contacts are supported, there were family photographs and greetings cards displayed in bedrooms. People who live in the home are involved in meal planning and choice of menu. Their health is promoted through the provision of sufficient and nutritious food. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 – 21 Quality in this outcome area is good. The health and welfare of people who live in the home is promoted. Personal and healthcare care needs are met in accordance with their wishes and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The health and welfare of people who live in the home is promoted. Care plans contain clear information is available to staff to enable them to understand and support residents with personal and healthcare needs according to their wishes and preferences. People who live in the home are well supported. They have access to specialist support from a variety of health and other professionals who reassess as needs change and provide staff with guidelines to manage health or behaviours. Personal records contained evidence of assessment and in some cases ongoing involvement from such agencies as occupational therapists, community learning disability team nurses and district nurses. People who live in the home are provided with support to access optical and dental appointments. Health is monitored through weight charts. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 14 People are protected through clear policies and procedures for the safe handling of medication. Medication is administered by staff who have been trained to do so safely. Guidelines are in place to protect people who have medication which is only given when required. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 – 23 Quality in this outcome area is good. People who live in the home are protected from harm through sound recruitment procedures and improved management of challenging behaviours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home are encouraged to offer comment or complaint. There is a clear complaints procedure provided in written and pictorial format. People can be confident than any concerns will be taken seriously. Complaints are logged, investigated and responded to within the given timescale. People who live in the home are protected from abuse through sound recruitment procedures. All staff are checked through the Criminal Records Bureau before working at the home and they all receive adult protection training. Guidelines are put into place and training is given to staff working with service users who exhibit challenging or self-harming behaviours, to minimise risk to themselves and others. There has been a significant reduction in the number of incidents reported to the Commission where there has been some form of assault by one resident on another. Records examined demonstrate considerable improvement in managing these situations through a variety of strategies. The management are working hard in conjunction with the local Authority care management team to ensure that there is adequate funding to support higher staffing levels where needed. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 16 Improvement has also been made in communication between the home and Local Authority care managers to ensure that information reaches the relevant people when incidents occur to ensure that people are supported appropriately. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 – 30 Quality in this outcome area is adequate. People who live in the home benefit from the generally well maintained, comfortable environment. Their safety would be improved through further improvement in food hygiene and infection control practice and kitchen repairs in a few areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home are accommodated in a variety of houses or bungalows. These are generally clean and reasonably decorated providing a homely environment. Two houses which had been in very dirty condition at the previous inspection have greatly improved and now provide a clean and homely place for people to live. The manager said that there are plans to further improve these houses through refurbishment of the kitchens. There were still some concerns in one of the houses where there were still areas which were not being adequately cleaned and some practices relating to food storage and hygiene could place people at risk of infection. All areas of the Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 18 home have been assessed to minimise risk of harm and maintain the safety and security of residents. People who live in each house have access to their own small garden and patio. Residents have personalised their bedrooms to differing degrees to reflect their individual taste and interests. Each house has sufficient bathrooms and toilets for the number of residents and rooms in Linnets have en suite facilities. People who have physical disabilities benefit from the adaptations and specialist equipment provided. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 36 Quality in this outcome area is good. People who live in the home benefit from the support of a committed, well trained and enthusiastic staff team. The heavy domestic workload of staff in one of the units is reducing the amount of time they have to spend with the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home benefit from the support of a staff team who are enthusiastic and committed to promoting their welfare. The staffing structure within the houses varies depending upon the needs of the service users. Residents are protected through rigorous recruitment procedures. Records examined during the inspection showed that at least two written references are taken up and previous employment history is explored. A small number of agency staff are employed for one to one work, the same agency staff are used to provide consistency. Some discussion took place about the deployment of care staff. People in one of the houses have profound multiple disabilities and do not take an active part in running the home. This means that care staff have a heavy workload in terms of domestic and ancillary tasks. It was noted Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 20 that staff on duty on the morning of the site visit were too busy to spend any time with a number of people who were in the lounge. Staff are clear about their roles and those spoken with showed a high level of commitment to service users and understanding of their needs. Staff and residents interacted well. People who live in the home benefit from the support of a well-trained staff group. The recruitment and training manager is responsible for co-ordinating induction and all other training; house managers provide information on training needs identified during supervision and appraisal meetings. Monthly development days were introduced in 2005 focussing of different topics. Supervision is given six weekly with six monthly appraisals, documentation is in place to record full supervision sessions and briefer meetings. A comprehensive training programme is on offer and Pepenbury continues to promote National Vocational Qualification training. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 – 42 Quality in this outcome area is good. People who live in the home benefit from the support of a strong management team. Internal quality assurance systems have improved to promote the health and wellbeing of residents and ensure the continued development of the service in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home benefit from the combined knowledge and experience of a well qualified management team. Responsibility for the day to day running of Pepenbury is shared between the registered manager and senior management team, overseen by the Executive Director. The views of residents are taken into account and they are consulted about the running of the home. The atmosphere throughout the home was open and friendly. Staff Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 22 and management at all levels demonstrated a commitment to act in the best interests of residents. The homes internal quality assurance system has been improved with the addition of a formalised system for monitoring all the residential units on a more regular basis. The manager completed the Annual Quality Assurance Audit for the Commission which shows plans for future development of the service to further improve the quality of life and increase opportunities for the people who live there. Staff receive training in safe working practices and all installations and equipment is regularly serviced. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation Requirement Timescale for action 31/08/08 2. YA30 23(2)(b)&(d) The registered person shall ensure the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; Specifically where kitchen units are damaged. 31/07/07 16(2) (j) & The registered person shall (k) having regard to the size of the care home and the number and needs of service users make suitable arrangements for maintaining satisfactory standards of hygiene in the care home; keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste; Specifically ensure that food storage meets food safety standards and the kitchen and service users bedroom on the ground floor in the Pines are clean. Also in the Pines, clinical waste must be handled appropriately. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 25 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 YA33 Good Practice Recommendations It is strongly recommended that additional ancillary staff are employed in Briars to release care staff from domestic tasks and free them up to spend more time with the people who live there. Pepenbury DS0000023975.V343178.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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