Inspection on 21/02/06 for Pepenbury

This inspection was carried out on 21st February 2006.

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 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

Pepenbury 16/07/09

Pepenbury 17/07/07

Pepenbury 24/01/07

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 Debbie Sullivan Announced Inspection 21st February 2006 09:30 Pepenbury DS0000023975.V277033.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 Pepenbury DS0000023975.V277033.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. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 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.V277033.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 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. Pepenbury changed its name from Larkfield in 2005. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over eight hours and was undertaken by Regulatory Inspectors Debbie Sullivan (lead) and Gary Bartlett. The inspection focussed on four of the eleven houses on the site, two of which were the more challenging behaviour units. Time was spent speaking with service users, house managers, senior support staff and support staff and with the Executive Director and senior management team. Tours of the houses visited took place, and care plans and other documentation were read. 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. At the time of the inspection there were no service user vacancies. Information was also gained from the pre inspection questionnaire completed by the service; comment cards returned from service users and a small number of relatives and health and social care professionals. A small number of comment cards included additional comments. From service users: • • “I’m happy with the house” “I’m happy in (house) and like to go shopping” From Health and Social Care professionals: • • “Staff have been receptive to advice given” “If the staff group remains constant there is usually a good follow through of recommendations in my experience” What the service does well: The assessment process ensures that service users are only admitted if the home can meet their needs in a house that offers an appropriate peer group and staff with relevant experience. Staff are knowledgeable about individual service users needs and abilities, are well supported and committed to providing a professional service. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 6 There is good liaison and co working with outside professionals. Service users are encouraged and enabled to be as independent as possible and individual interests are developed. Service users are able to participate at different levels in decisions about the service and their houses. What has improved since the last inspection? What they could do better: Care plan recording needs to be kept up to date and information in service user and induction files must include information from the most recent review and any change in needs. Personal care provided by staff or visiting professionals must be given in private. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 7 Directions for the administration of prescribed medications on MAR sheets must be typed by the pharmacy and not handwritten by staff. Worn and uncomfortable furniture on the houses should be replaced and all radiators must be made safe. Risk assessments need to include an assessment in relation to ground floor windows. 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. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 8 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.V277033.R01.S.doc Version 5.1 Page 9 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): 1,2,3,4 and 5. Prospective residents are able to access information about the service in a variety of formats. The admissions process ensures that residents are only admitted if needs can be met. EVIDENCE: The service user’s guide and statement of purpose had been revised at the time of the last inspection and made available on disc and in a pictorial format. The care plans inspected contained a copy of the guide, statement of purpose, and a signed individual statement of terms of conditions. The assessment and admissions process is thorough, as much information as possible is gained on prospective residents, senior staff assess their needs and a place is only offered if the home is able to meet them. The care plan of a relatively recently admitted resident contained comprehensive information. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 10 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): 6,7,8,9 and 10. Whilst care plans contain comprehensive information they do not always reflect current needs. Service users are involved in the running of the home and independence is promoted. Service users can feel confident that information about them is kept securely. EVIDENCE: Each service user has an individual care and support plan that is held on their file and kept in their respective house. The files are indexed and information easy to access, sections include health information, risk assessments, financial record sheets, medication information and personal and background information. Each resident also has a secondary file with additional information. The care plan format was easy to read. Although staff stated that four weekly reviews take place and plans contained comprehensive information, some care plans inspected did not contain the most up to date information, provide evidence of recent reviews or reflect changes in needs. Recording was not consistent. House managers advised that a new care plan format has been Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 11 introduced and was being implemented throughout the site and each plan is to be fully updated. Some care plans in induction files containing information for new or agency staff also held out of date information on service users. Service users are encouraged to participate in the running of their houses, make individual choices and decisions and are encouraged to achieve as much independence as possible. Houses hold weekly service users’ meetings and one house manager explained that an additional menu planning meeting had been started as meal planning took up a lot of time. Evidence of choice was available on care plans and during the inspection in terms of choice of daily and social activities, meals, room décor and personal care needs. Risk assessments are undertaken as standard for daily living activities, such as accessing the community, using public transport, personal care and also in relation to particular individual activities or behaviours. Service users 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. Records are kept securely on each house or in the main management building and information is treated confidentially, one house manager gave an example of special measures being put in place to protect others confidentiality from a particular service user keen to access information. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 12 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): 11,12,13,14,15,16 and 17 Service users are able to engage in activities with a level of support to meet individual needs. Involvement in the community and contact with friends and family is promoted. Meals are healthy and varied. EVIDENCE: Service users are able to access a range of daily and weekly activities that are agreed with them and appropriate to their interests and abilities. Pepenbury offers a range of day activities on site such as woodwork, gardening and swimming; day activities available off site are also accessed and more able residents can become involved in voluntary work. Evening and weekend social outings, clubs and groups are also attended. Individual and house activity programmes were on display in bedrooms and communal areas in the houses in written and pictorial format. Service users are expected to help with the daily running of the house and rotas are displayed with daily or weekly tasks such as room cleaning and shopping. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 13 House notice boards contained information about community activities such as the cinema or theatre and service users access very local facilities such as the bank or shops independently or with support. During the inspection some service users returned from a variety of activities including shopping and swimming. Individual bedrooms reflected personal interests and hobbies ranging from a collection of toy cars, football and a karaoke machine. It was seen that one service user enjoyed having an aquarium in their bedroom. Discussion with a staff member indicated that if a service user expressed a desire to keep a small pet, an assessment would be made of their ability to look after the animal and of any associated risks. Links with families and other contacts are supported, several bedrooms seen included family photographs and greetings cards, one resident spoke of going to visit family at the weekend and relatives visiting said they were always made very welcome. Each house involves service users in meal planning and choice of menu; in the houses visited the day’s menu was displayed in large pictures. Lunchtime in one house was partially observed and service users who needed help with their meal were assisted respectfully and discreetly. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 14 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 20 and 21. The personal and healthcare needs of service users are well met and specialist advice is sought when needed. Attention needs to be given to assuring that all personal care is given in privacy. Improving medication procedures would enhance the protection of service users. Service users near the end of their lives are afforded respect and dignity. EVIDENCE: Care plans contain details regarding service user’s personal support needs and preferences. Due to the wide range of needs accommodated at Pepenbury the level of support can vary considerably. Briars, the house that accommodates service users with the most need in terms of personal care was inspected. Equipment for individual and communal use was in place such as hoists and a Parker bath; this was reflected in other houses. One resident receiving aromatherapy during the inspection was given the session in the house lounge occupied by other service users, staff and Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 15 inspectors, this was personal choice although consideration should be given to the appropriateness of this. Specialist support is sought from a variety of health and other professionals who reassess as needs change and provide staff with guidelines to manage health or behaviours. During the inspection incidents of challenging behaviour were seen on two of the houses, staff managed these well using agreed guidelines and in one case took action to protect other service users by removing them from the vicinity. Service user files contained evidence of assessment and in some cases ongoing involvement from such agencies as occupational therapists, community learning disability team nurses and district nurses. Senior staff gave examples of requests for assessment where there was concern regarding changes in the service user, such as investigation for early onset dementia. A terminally ill service user was receiving support from the district nurse and a palliative care nurse. Staff were closely monitoring needs, managing the situation sensitively and involving the family and other professionals in reviews. Files also included documentation regarding optical and dental appointments, medication and weight charts. A service user mentioned he was due to see the dentist the following day. Medication charts and storage were inspected on one house, MAR charts had been correctly completed, although there were hand written entries regarding medications and dosages, whilst one had been signed by a GP, printed instructions need to be requested from the pharmacy. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 16 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): 22 and 23. Service users are able to access the homes’ complaints procedure. Procedures in place for the recruitment and training of staff protect service users from harm and abuse. EVIDENCE: Pepenbury has a complaints procedure that is available to service users in written and pictorial format. Information given on the pre inspection questionnaire regarding complaints stated that six had been received in the last twelve months, three had been substantiated and all were responded to within the given timescale. Staffing files were not inspected on this occasion although all staff CRB and POVA checked prior to commencing employment at the home and 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 for the management of these behaviours and to minimise risk to others. An example was given of a service user who self harmed, whereby one to one working had led to a significant reduction in this behaviour. During the inspection there were several incidents of challenging behaviour. All were seen to be appropriately managed by staff. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Service users live in a comfortable, clean and well-maintained environment. Shared and individual space is tailored to needs. The comfort and safety of residents would be improved upon by replacement of any worn furniture and controlled temperature or covering of radiators. EVIDENCE: The houses visited each differed in environment in terms of the type and amount of furniture in communal areas and in general décor. Linnets and Finch were comfortably but more minimally furnished due to the nature of the service user group and need for space and a safe environment. Some of the walls in Linnets were painted with very attractive murals and furniture in all houses was of good quality although the lounge suite in Swallows was worn and needed replacing. Each house has access to a small garden and patio area. Finch was due for some refurbishment and the arrangement of facilities and furniture in Briars allowed for wheelchair users to move about the house unhindered and as independently as possible. Bedrooms were personalised to differing degrees and reflected individual interests. The occupants had chosen the subjects for murals in bedrooms. Each Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 18 house has sufficient bathrooms and toilets for the number of service users and rooms in Linnets have en suite facilities. The radiator in one bedroom in Swallows was very hot and was not covered or fitted with a thermostatic control. Environmental risk assessments of the houses are undertaken by senior staff from other houses, it is recommended that these include an assessment of any safety issues in relation to access through open ground floor windows. Throughout the houses visited a high standard of cleanliness and hygiene was observed. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 36 A competent, well-supported and well-trained staff team supports service users. Staff are clear about their roles and accountability. EVIDENCE: The staffing structure within the houses varies depending upon the needs of the service users, houses for those with more complex needs have a house manager, three members of senior support staff and support workers, other houses have house managers and support staff. Each house has a sleeping in staff member and waking night staff are on duty on site. House managers and support staff are supported and supervised by senior managers. A small number of agency staff are employed for one to one work, and the same agency staff are used to provide consistency. Staff were 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. In January a new rota was introduced for Finch, Linnets and Briars, staff had slightly mixed views about the rota that only allowed for two consecutive days off every three weeks, although it provided more consistency for service users. The management team will review the rota after it has been in operation for a reasonable period of time. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 20 The recruitment and training manager is responsible for coordinating 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; staff stated that they found these very useful. 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 NVQ training, twelve members of staff are due to commence NVQ courses. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40 and 41 The home is well run in the best interests of service users. The health, safety and welfare of service users are promoted; environmental checks need to be further enhanced. EVIDENCE: Responsibility for the day to day running of Pepenbury is shared between the registered manager, senior manager, and newly appointed operational manager, overseen by the Executive Director. The views of service users are taken into account and they are consulted about the running of the home. The improvement and development of the service is continuously being considered. Policies and procedures are reviewed regularly. The atmosphere throughout the four houses inspected was open and friendly the members of staff spoken with were keen to discuss the merits of their particular house and how they planned to work towards refining the service and practice in the best interests of service users. Safe working practices were in evidence, additional vigilance regarding environmental checks is needed to prevent potential health and safety hazards Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 22 such as the very hot radiator in a bedroom and storage of combustible items in a boiler room. Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 3 3 3 3 3 3 2 3 Pepenbury DS0000023975.V277033.R01.S.doc Version 5.1 Page 24 No 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 YA6 Regulation 15(2)(b)(c) Requirement “ The registered person shall keep the service user’s plan under review and after consultation with the service user revise the plan” In that care plan documents in use on service user and induction files must reflect current needs and be a record of the most recent review held. 2 YA20 13(2) “ The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home” 30/04/05 Timescale for action 30/04/06 3 YA42 13(4) (c) In that there should be no handwritten entries as regards changes, instruction for administration and dosages of medication on MAR sheets, these must be typed by the pharmacy. “ The registered person shall 30/04/06 ensure that unnecessary risks to the health or safety of service users are identified and so far DS0000023975.V277033.R01.S.doc Version 5.1 Page 25 Pepenbury as possible eliminated” In that radiators must be guarded or have low temperature surfaces and environmental risk assessments be further broadened. 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 4 5 Refer to Standard YA18 YA24 YA33 YA42 YA42 Good Practice Recommendations It is strongly recommended that service users receiving any form of personal care support from visiting professionals do so in private. It is recommended that the worn three-piece suite in Swallows be replaced and houses checked for any other furniture that my need replacing. It is recommended that a review of the new staffing rota on the high dependency houses be undertaken in consultation with house staff. It is recommended that risk assessments be undertaken in respect of possible access to rooms from open windows. It is recommended that advice be obtained from the fire officer on storage of items in boiler rooms. 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