Inspection on 12/12/05 for Pinfold Home

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 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 11/08/05

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 12th December 2005 10:00 Pinfold Home DS0000022748.V272009.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 Pinfold Home DS0000022748.V272009.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. Pinfold Home DS0000022748.V272009.R01.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 Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2005 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. Pinfold Home DS0000022748.V272009.R01.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 12th December 2005. The registered manager was present and took part in the inspection process. The inspector spoke to the registered manager at length about how the home was developing and the pressures of staffing a home such as Pinfold where service users were expected to access community activities with support when necessary. During a tour of the home the inspector met four service users, who said they liked living at the home. All the homes communal areas and bedrooms had recently been redecorated. The inspection included a tour of the home and examination of records on care plans, medication records and the complaints book. Two members of staff were out supporting service users at their activities in the community. The cook had called in sick. To cover this shortfall until replacement cook could be found, the registered manager had started to prepare lunch for the service users. 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: Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 6 The needs of the service users must be reassessed and staffing levels must be at levels appropriate to meet those needs. Care plans must be up-to-date, meet all the needs of service users, and be followed. Medication record keeping is poor at the moment and must be improved. 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. Pinfold Home DS0000022748.V272009.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 Pinfold Home DS0000022748.V272009.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): 1,2,3,4,5 Prospective service users’ needs and aspirations are assessed in such a way that a service tailored to their needs is provided. EVIDENCE: The home has a statement of purpose and a service users’ guide, which includes the complaints procedure in the service users’ guide. Each service user is given a copy in their room. The home’s admissions procedure states: “care management assessments are required for all prospective service users including personal and medical histories before service users are considered”. The manager told the inspector she had visited the service user who had recently been admitted to the home to carry out a full assessment before they decided to live at the home. The service users are invited to visit the home with family members or friends to help them decide if the home could meet their needs. The service users’ file had copies of the assessment based on personal history and a full needs assessment. The home holds assessments by health and social services professionals which it uses to demonstrate how needs can be met, and plan for the care of service users. Pinfold Home DS0000022748.V272009.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 Care plans are thorough and reflect service users’ needs and goals, but several need to be reviewed. EVIDENCE: The file of the service user who has been admitted since the last inspection in August 2005 was inspected. Care plans give a thorough description of service users’ behaviours, reactions and preferences and how the service user was to be treated. The registered manager told the inspector the service users’ assessment had identified they needed one to one support to meet their needs during certain activities and a member of staff was allocated to do this. On the day of the inspection the service user was out with her carer so the inspector was unable to speak to her, but the registered manager said she had settled well into the home and had a full programme of activities outside the home. Two other care plans were inspected and give a thorough description of service users’ behaviours, reactions and preferences and how the service user was to be treated. The inspector noted they needed to be reviewed. The registered manager said there was great pressure on homes to have service users take part in outside activities in the community but there was a limit to the number Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 10 of staff the home could feasibly employ. She explained that there are several service users who need staff support in activities on the same days and as a manager she has to prioritise and this leads to things within the home not being done. See Standard 33. Pinfold Home DS0000022748.V272009.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): 12,13,14, 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. EVIDENCE: These standards were fully examined and considered met when examined at the previous inspection. Service users have individual activities programmes, which includes household chores and responsibilities. The home employs an activities coordinator who helps service users develop daily living skills in an enjoyable way. On the day of the inspection most of the service users were out following their various planned and unplanned activities. Service users are free to come and go as they please and might decide to go out to the shops or for a cup of coffee. The inspector saw four service users. One was cleaning their room and Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 12 changing their bed linen. Two others were relaxing in the lounge and another was sitting in the smoking room. All said they liked living at the home and felt comfortable there. The registered manager said other service users were out following their activities programmes either on their own or with the support of staff. Pinfold Home DS0000022748.V272009.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): 20 Medication administration was found to be improperly documented. Service users administer and control their own medication where appropriate and are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Service user medication is stored securely in a locked medication cabinet in the staff office. One service user gets his own medication prescriptions from his GP and fills his own dosset box. Another service user has a weekly blood test and gets a weekly supply of medication, which he collects. The GP and the supplying pharmacist monitor this. Not all medication was being recorded when it comes into the home and medications checked did not agree with medication administration charts. Pinfold Home DS0000022748.V272009.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): 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 complaints book was seen by the inspector and confirmed that no complaints have been recorded. The home has a complaints policy, a copy of which is in the service users’ guide. There is an adult protection policy and procedure in the home as well as a copy of the local authorities POVA policy and procedure. These standards were fully examined and considered met when examined at the previous inspection. Pinfold Home DS0000022748.V272009.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): 24,25,26,28 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. The inspector noted that attention is paid to maintaining a safe and comfortable environment. There is a large conservatory at the rear of the house, which is used as the dining room and the inspector was told the home have just replaced all the dining tables. The last of the decoration of the bedrooms has taken place since the last inspection and the layout of one bedroom has been changed to make a small sitting area. Another bedroom has had a shower room installed. All the toilets Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 16 and bathrooms have been redecorated in recent months. All the bedrooms seen during the tour of the house were individual and homely. The home is laid out over three floors. All the stairs and landings have been decorated and carpets have been replaced making the home look warm and homely. 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. Pinfold Home DS0000022748.V272009.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): 32 Service users individual and joint needs are met by appropriately trained staff. Staffing levels need to be reviewed to ensure there are enough staff on duty to meet the assessed needs of the service users. EVIDENCE: The home staff team are continuing to make good progress in attaining the required percentage of NVQ qualified staff. A requirement made for the home to continue the good progress to achieve the 50 of staff with an NVQ in Care at level 2 or 3, as set out by the National Minimum Standards, has been met by the home continuing to support staff work towards achieving the NVQ award. The registered manager said she had to prioritise her work because of the pressure and expectations of organisations and CSCI that all service users would have access to community activities. See Standard 6. The home must review the staffing levels and make sure they reflect the assessed needs of the service users. Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 18 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): 38 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. EVIDENCE: At the previous inspection in August 2005 both staff and service users said the registered manager is approachable and well respected by staff and service users. From speaking to the inspector it was evident 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. The registered manager said the last few months had been more difficult because of the disruption the refurbishing and redecorating had caused within the home as well as the increased expectations that service users must access Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 19 community activities. For example, in the past, 21 service users would have been supported in the home by three staff and the manager per shift, which would have been adequate to meet their needs within the home. Now with the possibility of two or more service users needing to be supported at different venues in the community at the same time have stretched the staffing resources of the home. The registered manager is prioritising her workload because of her commitment to the service users to ensure their needs are met. See Standard 32. The registered provider of the home must review and assess how the registered manager can best be supported. 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 is now doing these inspections and sending copies of the reports of monthly visits made to the home, in accordance with Regulation 26 of The Care Homes Regulations 2001, are being submitted to CSCI. Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 20 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 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X 3 X x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pinfold Home Score X X 2 x Standard No 37 38 39 40 41 42 43 Score X 2 X X X 3 X DS0000022748.V272009.R01.S.doc Version 5.0 Page 21 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 2 Standard YA6 YA20 Regulation 15(2)(b) 13(2) Requirement Timescale for action 01/04/06 3 YA32 18(1)(a) 4 YA32 18 (2) The registered person must keep the service user’s care plan under review and up-to-date. The registered person must 01/04/06 ensure that all medication is being recorded when it comes into the home. The registered person must 01/04/06 ensure that at all times there are staff in suitable numbers to meet the needs of the service users. The registered person must 01/04/06 ensure the registered manager has the support to assist her during this period of change. 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 Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 22 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 Pinfold Home DS0000022748.V272009.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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