Inspection on 11/08/05 for Pinfold Home

This inspection was carried out on 11th August 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 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

Pinfold Home 07/01/08

Pinfold Home 14/03/07

Pinfold Home 12/12/05

Pinfold Home 10/11/04

Pinfold Home 27/07/04

Pinfold Home 25/03/04

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

CARE HOME ADULTS 18-65 Pinfold Home 35-37 Pinfold Road Streatham London SW16 2SL Lead Inspector Lynne Field Unannounced Inspection 11th August 2005 10:00 DS0000022748.V251716.R02.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 DS0000022748.V251716.R02.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. DS0000022748.V251716.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinfold Home Address 35-37 Pinfold Road Streatham London SW16 2SL 020 8769 7869 020 8677 9529 info@astrahomes.co.uk www.astrahomes.co.uk Mrs C Freeman 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) Marie Veronica Stuart Agwunobi Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places DS0000022748.V251716.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2004 Brief Description of the Service: Pinfold is a care home set in a large Edwardian building converted from two houses. They have been specially adapted and are connected internally to form spacious accommodation. The home is laid out over three floors. It is located in a residential street within a short walking distance of full community facilities in Streatham and very close to public transport. There is limited parking space available in the area. It is a privately owned home first registered in 1989 to provide long-term residential care for people with mental health problems. The home is registered for 21 residents, who are currently accommodated in 15 single and the 3 double bedrooms are being converted to single bedrooms. There are four communal areas, several toilets and bathrooms/showers, a large dining room/conservatory with wide terrace, and a well maintained secluded back garden that includes a patio, lawn and flowerbeds and an abundance of mature trees. The home has it’s own transport. The home is not designed to cater for people with physical disabilities and does not include a passenger lift. The ground floor is wheelchair accessible. DS0000022748.V251716.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the 11th August 2005. The registered manager was present and took part in the inspection process. The inspector interviewed two staff individually and met informally with two service users over lunch as well as speaking to five other service users during the course of the inspection. Comments from all are included in this report. The inspection included a tour of the home and examination of records on care plans, staff records and building maintenance records. During the inspection staff interaction with service users was observed to be very regular and conducted in a respectful manner. The home has made the three double bedrooms into single occupancy bedrooms and on the day of the inspection there were eighteen service users in residence although the home is registered to take twenty one service users. What the service does well: What has improved since the last inspection? What they could do better: The registered provider must adopt a clear policy on how it will ensure that the home meets the 50 NVQ Level 2 training target for staff. DS0000022748.V251716.R02.S.doc Version 5.0 Page 6 The registered provider must ensure that copies of reports of monthly visits to the home, made in accordance with Regulation 26 of The Care Homes Regulations 2001, are submitted to CSCI. 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. DS0000022748.V251716.R02.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 DS0000022748.V251716.R02.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): 1-4 Prospective service users’ needs and aspirations are assessed in such a way that a service tailored to their needs is provided. EVIDENCE: The inspector was shown the statement of purpose and a service user guide, which includes the complaints procedure in the service users’ guide. The home’s admissions procedure states: “care management assessments are required for all prospective service user including personal and medical histories before service users are considered”. Service users said they were invited to visit the home with family members or friends to help them decide if the home could meet their needs. The registered manager said the home then follows this up by completing an assessment based on personal history, care management assessment and a full needs assessment. DS0000022748.V251716.R02.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 Families and professionals are involved when reviews are held. Care plans are thorough and reflect service users’ needs and goals. Service users participation in the running of the home has been encouraged where feasible, though not all service users do this. Risk assessment reviews take place and are recorded. Staff have easy access to this information. EVIDENCE: Three service user files were inspected. Care plans give a thorough description of service users’ behaviours, reactions and preferences and how the service user was to be treated. Care plans are reviewed six monthly. Detailed and regular charts are kept of service users’ behaviours, household and community activities and contracts. For example, the inspector was told about one service user who has a contract with the home in which he has an agreement on how much money he would spend on cigarettes in a day. The service user and registered manager told the inspector that this was in place DS0000022748.V251716.R02.S.doc Version 5.0 Page 10 because it helped him control his smoking over the course of the week which the service user is happy about. The inspector viewed individual risk assessments, which had been carried out, monitored and reviewed by the staff with service users every six months or when the need arises. Details of any changes to the risks are recorded in the service users care plans, with details of how to manage the risk. The inspector saw evidence in the form of a placement meeting report, that placement review meeting are being held with care managers and include the service users family. DS0000022748.V251716.R02.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): 12,13,14,15,16,17 Service users are able to take part in age, peer and culturally appropriate activities, leisure activities and are part of their local community. They are actively encouraged to develop daily living and social skills by the registered manager and staff of the home. They are able to maintain relationships with friends and family. Meals are varied and enjoyed by service users. A healthy diet is provided and mealtimes are relaxed and flexibly timed to fit in with individual activity plans. EVIDENCE: The registered manager told the inspector that service users are encouraged to make decisions concerning their daily activities. The home has an activities coordinator who works with the service users in developing their daily living skills and social skills. This is done individually or in a group. DS0000022748.V251716.R02.S.doc Version 5.0 Page 12 Service users have individual activities programme, which includes household chores and responsibilities. During the tour of the home the inspector spoke to two service users who where cleaning their rooms and doing their laundry with the support of the staff. One service user said he did not mind cleaning his room and helping around the home as it was his home. The one service user who was cooking her own lunch under the guidance of the activities coordinator, said that she was able to choose activities she enjoyed doing. The activities coordinator said this type of activity helped service users develop daily living skills in an enjoyable way. It helped service users learn about budgeting and nutrition. Some service users would invite another service user to share the meal they cooked and this helped develop social skills. Another service user told the inspector about the various jobs he had which kept him occupied for most days of the week and how they had helped him develop skills and self esteem. The home provides information on local services and facilities in the community so service users are able to choose what they take part in. The inspector joined two service users for their lunchtime meal. They said they enjoyed the food served at the home. They said they could choose from the menu or if there was not anything on the menu they wanted, the cook would make them something of their choice. DS0000022748.V251716.R02.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): 18,19,21 Service users receive personal support, in the way they prefer. Medication is being handled safely. Ageing, illness and ascertaining service users wishes in the event of the death is being handled with sensitivity and respect by the registered manager at a time appropriate to the service user. EVIDENCE: Care files contain information for staff on service users who need personal support with their preferred personal care routines and details of how much help an individual requires with different personal care tasks. A key worker system is in operation, with each service user having a member of staff from within the team to co-ordinate their support and care planning. The record of health appointments attended indicated that each service user is supported by staff if this is what the service user requires, to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. DS0000022748.V251716.R02.S.doc Version 5.0 Page 14 Service user medication is stored securely in a locked medication cabinet in the staff office. A measured dose system is in place, provided by the local pharmacy. Staff induction includes medication training and medication administration records. Information about the medications in use and medication stocks checked were in order. The registered manager said she has tactfully discussed issues of illness and death with the family members of the majority of service users, but acknowledges some families do not want to discuss this issue and if this is the case will try to find the right time to approach the family. Information recorded on the service users file as to who needs to be informed and what arrangements will be made. DS0000022748.V251716.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service user’s views are listened to and acted upon and there are safeguards in place to protect them from abuse, neglect and self-harm. EVIDENCE: The home has a complaints policy, a copy of which is in the service users’ guide. The inspector noted that in the minutes of a service users meeting there had been a discussion reminding service users they are entitled to complain about what ever they want and how complaints can help improve the service. The complaints book was seen by the inspector and confirmed that no complaints have been recorded since the last inspection. There is an adult protection policy and procedure in the home as well as a copy of the local authorities POVA policy and procedure. The two staff told the inspector they are aware of abuse and protection policy and how to deal with cases of suspected abuse by reporting any suspicions to the registered manager to deal with. The home safeguards service user finances with appropriate recording systems. The inspector was told each service user has a finance book in which all financial transactions are recorded and signed by the service user and the member of staff. Five were inspected and were found to be in order. The registered manager said one service user goes to collect his money with a member of staff but makes his own decision when he will go and negotiates a time with the member of staff. DS0000022748.V251716.R02.S.doc Version 5.0 Page 16 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): 24,25,26,28,30 The home is bright, clean, comfortable and safe. Service users rooms are comfortable and are decorated to reflect their personalities. The ground floor communal areas and bedroom are accessible to people with mobility needs. EVIDENCE: The home consists of two large adjoining Edwardian houses that have a style and ambience of their own and that reflect the purpose of the home. The home has continued with the planned maintenance programme. It was observed that attention is paid to maintaining a safe and comfortable environment. The home is laid out over three floors. Stairs accesses upper floors only. It is unsuitable for individuals with impaired mobility, except the ground floor. One service user with restricted mobility has been allocated a bedroom on the ground floor. Suitable adaptations in the form of handrails have been provided to ensure and enable service users to mobilise independently. DS0000022748.V251716.R02.S.doc Version 5.0 Page 17 The number of service users has been reduced to eighteen to make all rooms into single occupancy. Bedrooms are personalised and reflect the taste and interests of the service user. Service users spoken to said they are happy with their bedrooms. The registered manager showed the inspector a number of bedrooms that have been redecorated and the flooring in one bedroom, which has been replaced since the last inspection. There is a large conservatory across the back of the house, which is used as a dining room. This leads directly on to the garden, which has recently been landscaped to provide several patio areas and secluded out door seating areas. There are two lounges, one on the ground floor and one in the basement area, which is for smoking. In the basement area is a recreation room where service users do activities such as artwork or play games. DS0000022748.V251716.R02.S.doc Version 5.0 Page 18 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): 32,33,34,35,36 In general, good practice is applied in recruiting, inducting and training staff. Service users individual and joint needs are met by appropriately trained, supported and supervised staff. EVIDENCE: Files for five of the members of staff were inspected. The home operates a good recruitment process, which includes formal interview, taking up two references, CRB checks and POVA checks prior to appointment. All staff have an employment contract which include details of their terms and conditions of employment. The files indicated that staff receive adequate training to equip them to meet the needs of the residents of the home. The two staff the inspector spoke to, said they had access to a range of training and come on a three-month trial basis. One member of staff, who had recently started at the home, described her induction programme, which was confirmed by the records in her personal file. Staff confirmed they had recently attended Fire Training, Food Hygiene, Infection Control, Health and Safety Training and had had Medication Training. The home staff team are making good progress in attaining the required percentage of NVQ qualified staff. Four staff had recently completed NVQ courses, and two others were undertaking the course in September 2005. A requirement is made for the home to continue the good progress to achieve DS0000022748.V251716.R02.S.doc Version 5.0 Page 19 the 50 of staff with an NVQ in Care at level 2 or 3, as set out by the National Minimum Standards. Staff commented that they feel adequately supported and that they receive frequent supervision from the registered manager. Supervision records examined indicated that supervision meetings are held regularly. The home’s records show that there have been no referrals under POVA to date. DS0000022748.V251716.R02.S.doc Version 5.0 Page 20 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): 37,38,39,40,41,42,43 The registered manager is qualified and experienced and runs the home well. The calibre of the manager has ensured that the aims and objectives of the home have been achieved and she is open and supportive in her management approach. Accounting and financial procedures in the home are adequate and safeguard service users interests. EVIDENCE: Staff and service users all said the registered manager is approachable and well respected by staff and service users. Her strong leadership skills combined with her commitment and drive has ensured that policies and procedures of the home are adhered to and that the terms and conditions of the contracts issued to service users are fulfilled. Staff and service users made it clear that the home is managed in a positive and open way. DS0000022748.V251716.R02.S.doc Version 5.0 Page 21 Staff said they felt they are able to influence the way the home is run via staff meetings and supervision. It was confirmed in the minutes of the service user meetings and through speaking to service users, they feel they are able to influence decisions via key working sessions and service user meetings. The health, safety and welfare of the service users is promoted and protected. As at the last inspection it was noted that records of monthly visits by the registered provider have not been submitted to the CSCI. The registered provider must ensure that copies of the reports of monthly visits made to the home, in accordance with Regulation 26 of The Care Homes Regulations 2001, are submitted to CSCI. DS0000022748.V251716.R02.S.doc Version 5.0 Page 22 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 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 3 3 DS0000022748.V251716.R02.S.doc Version 5.0 Page 23 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 YA32 Regulation 18(1)(a) (b)(c) 26 (5)(a) Requirement The registered person must have a clear policy on how it will achieve the 50 NVQ Level 2 training target. The registered person must ensure that copies of reports of the monthly visits made to the home, in accordance with Regulation 26 of The Care Homes Regulation 2001, are submitted to CSCI. Timescale for action 30/12/05 2 YA42 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000022748.V251716.R02.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022748.V251716.R02.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. 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. 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