Inspection on 05/10/05 for Pepenbury

This inspection was carried out on 5th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pepenbury 16/07/09

Pepenbury 17/07/07

Pepenbury 24/01/07

Pepenbury 21/02/06

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 Unannounced Inspection 5th October 2005 09:30 Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 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.V255563.R01.S.doc Version 5.0 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.V255563.R01.S.doc Version 5.0 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.V255563.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Manager to successfully complete NVQ level 4. Do not put on certificate. 27th January 2005 Date of last inspection 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 another is 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 has recently changed its name from Larkfield. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by inspectors Debbie Sullivan (lead), Justine Williams and Gary Bartlett. The inspection lasted six hours, six of the eleven houses on the site were visited, these were, Rose, Robins, Finch, Cornford, Hawthorns and Linnets. There was opportunity to speak with a number of staff and service users during the day. Time was spent with Pepenbury’s Executive Director and Registered manager. The Recruitment and Training Manager was present for most of the time during the tour of the houses. Throughout the day service users and staff were very helpful in explaining the routines of their houses. Staff presented as enjoying their roles with a real commitment to the service users and to enabling them to be as independent as possible and providing a homely place to live. It was a very busy day on the site with a number of meetings and visitors scheduled, however senior staff that had other commitments changed their plans to allow for time to speak with the inspectors. What the service does well: What has improved since the last inspection? Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 6 The statement of purpose and service user’s guide have both been revised. There is increased staffing in Swallows due to the needs of the service user group. A Training and Recruitment Manager has been appointed and a new training programme is being implemented. Recruitment is underway for a dedicated member of staff to coordinate and monitor service user reviews. Monthly development days for staff have been introduced covering a range of topics. The laundry floor in Hawthorns has been made impermeable. 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. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 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.V255563.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Prospective residents have access to comprehensive and clear information about the service. The admissions process ensures that the needs of residents can be met by the home. EVIDENCE: Pepenbury has revised its statement of purpose and service user’s guide since the last inspection. The service user’s guide is now available on disc and in a format with symbols; the statement of purpose provides comprehensive, indexed and clear information about the service. Further information to inform prospective residents about daily life at Pepenbury is being developed, again in written and disc form. A well-established assessment and admissions procedure is in place. Senior staff assess prospective residents before a place is offered and introductory short stays may be arranged. Residents are provided with a statement of the homes’ terms and conditions that are placed on their individual care plans. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Individual needs are well documented and risks assessed. Personal information is kept confidentially. Service users are consulted about their views on the service. EVIDENCE: Care plans in Linnets were looked at in detail. The format had recently been revised so that up to date information was clear and easily accessible, with a secondary file containing less up to date, but relevant information. Each house holds it’s own care plans, discussion with senior staff and managers established that the format varies from house to house and there is a need to work towards more standardised recording. The care plans seen were thorough, easy to read and gave a very good picture of the service users’ needs and daily life. Reviews had taken place and risk assessments had been applied to a range of activities undertaken both within Pepenbury and in the community, such as using public transport or attending voluntary work. Files were stored confidentially when not in use. Service users are consulted about the day-to-day running of the home and any changes that may affect them. Each house holds a weekly residents meeting and the registered manager holds regular meetings to which all service users are invited. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 10 The Chief Executive of the service is the appointee for a number of service users, the home has written to their relatives or other representatives requesting responsibility be handed over and only retains responsibility where this has not been possible. If possible new admissions have independent appointees. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 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 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 develop skills and independence with a level of support that meets their individual needs. Choice is respected and promoted. Personal and community relationships are encouraged and maintained. Meals are healthy and varied. EVIDENCE: Service users take part in daily and weekly activities that are appropriate to their individual abilities and interests. In houses visited activity schedules were on resident and staff notice boards, where necessary pictorial symbols had been used on the information provided for service users. Pepenbury offers a variety of day activities on site and service users can also access other day services, work experience or voluntary work in the community. A member of staff spoke of work experience being provided or explored in a number of settings including a garden centre and bookshop. Activities are provided within individual houses for service users who require most support, such as art sessions. Contact with families and friends is supported by the home and service users bedrooms contained family photographs. Service users access local facilities such as the pub, shops and bank. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 12 The bedrooms seen were all individualised and contained varying amounts of personal possessions; one service user spoke of choosing the colour for the paintwork. Pictures are to be painted on the walls of one house where the needs of service users does not always allow for curtains and other items that could add to the homeliness of the environment to be in place. In each house visited there was evidence that service users are given choices within the structure of the daily routines and staff showed good understanding of the need to promote choice and independence. Service users participate in the day to day running of houses by being involved in the cleaning of their rooms, shopping, menu planning and participation at weekly meetings. In each house menus were varied and balanced and there was a good supply of fresh fruit and vegetables. Pictorial and written menus were available. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. Personal and healthcare needs are well met. Specialist support is requested when needed and acted upon. EVIDENCE: Care plans contain details regarding service users’ personal support needs, personal care is provided discreetly and the level of support determined by individual needs and abilities. As the service user group is primarily male and the majority of staff female the service is hoping to increase the compliment of male staff to ensure that there is more choice as to the gender of staff assisting with personal care, this is provided as far as possible at present. A key worker system is in place. Throughout the houses seen there was evidence of equipment being provided to aid independence. Specialist assessment from professionals is sought and provided when necessary, these include community learning disability nurses, epilepsy nurses and speech therapists. One care plan with details of District nurse and GP involvement regarding treatment post surgery was read and advice found to be followed explicitly by the relevant house. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: These standards were not fully inspected on this occasion; Pepenbury has a complaints procedure that is available in pictorial format. Staff are provided with in house and external adult protection training and are CRB and POVA checked before commencing employment. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 15 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 and 29. The environment in each house reflects and is adapted for the needs of its service user group. Staff work hard to create a homely atmosphere. Individual rooms are personalised and sufficient shared space is available. EVIDENCE: The houses visited all differed in environment, choice of furniture and decoration, the décor and type of furnishing in each is dependant to an extent on the service user group. Linnets is comfortably but more minimally furnished as is Finch. Rose, Robins and the more independent houses contained more furnishings. There are four maintenance workers and any requests for maintenance work from the houses is prioritised, the houses were generally in good condition, some kitchen tiles, work surfaces and the main fridge were being replaced in Linnets. Where any possible environmental risks were identified they were acknowledged and action was taken to rectify them during the inspection if this was practical. Service users bedrooms were personalised and the majority reflected the interests and hobbies of the occupant, this was especially apparent in the rooms of more able service users. All bedrooms were clean; one smelt strongly of smoke, a risk assessment around smoking in the room needs to be expanded upon. Only Linnets has ensuite facilities in bedrooms. Bathrooms Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 16 and toilets were cleaned to a good standard,it is recommended that bins in bathrooms and toilets have lids. Care staff are responsible for cleaning the houses this is being reviewed especially regarding houses where service users require most staff time. Each house had a choice of communal space and access to it’s own outdoor area leading onto the main grounds. There were no odours except for in Linnets due to carpet cleaning the previous day, which was unavoidable, but it is recommended this be addressed with the cleaning contractor. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35 and 36. Service users benefit from a staff group that is well trained and supported. Recruitment procedures are thorough and protect the interests of service users. EVIDENCE: Pepenbury has a very clear structure consisting of Chief Executive, registered manager, senior and house managers, senior support and support staff as well as day activities and office staff. A recent monthly development day had focussed on the staffing structure and one senior support worker stated that they had found it very useful. Within the houses staff were clear about their roles and presented as confident and competent. Photographs of staff teams were displayed in the houses. The compliment of staff in each house varies according to the needs of service users; all houses are covered twenty-four hours a day. Each house has a sleeping in staff member and waking night staff are available throughout the site. Staff observed and spoken with related well with the service users and in some cases had very in depth understanding and knowledge of needs. Commendable work has been done in compiling a system to identify staff’s individual training needs. Consequently, a comprehensive and pertinent new training plan has been devised; new care staff receive a comprehensive induction, core training programme and foundation training in their first six months. NVQ training is promoted and twenty-five staff members were registered on either level 2,3 or 4 NVQ courses. A member of the care staff Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 18 spoken with said that regular supervision takes place six weekly and training needs are then discussed. No staff member commences work without satisfactory CRB and POVA checks and the recruitment process is thorough. Service users are involved in interviewing staff for their own houses and a record kept of their involvement. A monitoring system has been introduced to track new staff through probationary and induction periods. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 19 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): 37,38,39,41and42. The health, safety and welfare of service users would be improved by additional checks on environmental hazards. Service users can be confidant that their views are sought. EVIDENCE: The day-to-day responsibility for the management of the home is shared and delegated between the registered manager and other senior staff, overseen by the Executive Director. The manager intends to recommence the NVQ 4 management course, the previous course provider having gone out of operation. Throughout the management structure roles are clear which helps with the smooth running of the service. Service users and their relatives are consulted about the running of the home in regular meetings and staff are involved in discussing ways to improve and any changes to the service during meetings, training and development days. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 20 The atmosphere throughout the houses visited was open and friendly and staff were keen to give examples of how they work with particular service users or groups, for example introducing a service user to work experience and ways of managing difficult behaviour. Records are kept safely and securely, care plans being in individual houses and staffing records in a separate office. Some potential hazards to health and safety were seen during the day and action discussed regarding the removal of hazards or replacement of equipment. Discussion about fire procedures took place, senior staff stated that these are followed and kept up to date. Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pepenbury Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 3 3 X 3 2 X DS0000023975.V255563.R01.S.doc Version 5.0 Page 22 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 9 Regulation 13.4(b) Requirement “ The registered person shall ensure that any activities in which service users participate are so far as reasonably practicable free from hazards to their safety.” In that a risk assessment be undertaken in respect of any service user smoking in their bedroom. “ The registered person shall ensure that all parts of he care home to which service users have access are so far as reasonably practicable free from hazards to their safety”. In that environmental hazards be identified by more vigilant checks on houses. “ The registered person shall provide adequate facilities for the preparation and storage of food” In that any old or unsafe storage equipment be replaced. Timescale for action 12/12/05 2 24 13(4)(a) 12/12/05 3 42 16.2 (g) 12/12/05 Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 23 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 Refer to Standard 30 37 Good Practice Recommendations It is recommended that waste bins in bathrooms and toilets have lids. It is recommended that the registered manager keep CSCI informed of progress regarding securing a new provider so that the NVQ 4 management course can be recommenced. (Action is underway to clarify if a potential new provider is available). It is recommended that environmental checks on the premises be broadened and within houses be undertaken by staff from another unit. It is recommended that additional advice be sought from a tissue viability nurse regarding service users where skin breakdown is of concern. It is recommended that the carpet-cleaning provider be contacted regarding the smell left following cleaning to see if this can be avoided in the future. 3 4 5 42 18.9 24.6 Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Pepenbury DS0000023975.V255563.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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