CARE HOMES FOR OLDER PEOPLE
Ponsandane Chy-an-dour Penzance Cornwall TR18 3LT Lead Inspector
Stephen Baber Announced Inspection 11th October 2005 09:30 X10015.doc Version 1.40 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 Ponsandane DS0000009091.V250720.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 Older People. 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. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ponsandane Address Chy-an-dour Penzance Cornwall TR18 3LT 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) 01736 330063 01736 332343 Swallowcourt Limited Mrs Lynda Jane Ellis Care Home 58 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (58), Physical disability (18), of places Terminally ill (22) Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th May 2005 Brief Description of the Service: Ponsandane is a private care home providing personal care and accommodation for fifty-eight elderly people in need of residential and nursing care. The home is registered under the terms and conditions set out in the Care Standards Act 2000 and Care Homes Regulations 2001. The home is situated on the outskirts of Penzance town and is a short distance away from the main London to Penzance railway station. The bus route out of Penzance runs past the home and this makes getting to the home easy if you haven’t got a car. There are panoramic views of St Michaels Mount and the bay from the front of the home. Some of the rooms have ensuite facilities and there is one shaft lift that serves ground to first and second floors as well as two chairlifts to aid the more dependent service users who find getting to their room difficult. The home provides a large day centre and there are several rooms where people can meet with their visitors including their own rooms. The home has its own mini-bus, which is enjoyed by the residents especially when trips out are arranged. This service is free to the residents. Medical care is provided by several General Practitioners practices with the manager and staff working closely with all community professionals to provide a high quality nursing and residential care experience to the residents. The Managing Director who is the Responsible Individual for Swallowcourt visits daily and offers support, guidance and supervision to residents, management and staff. As representative of the Company she writes a monthly report on the conduct of the home. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection as part of the home’s annual inspection programme on 11th and 13th October 2005. The inspection commenced at 13:30 the first day and 8:35.am the second day and finished at 16:20 each day. The manager completed a pre-inspection questionnaire with all the information provided in readiness for the inspection. The following activities were carried out to complete the inspection. Inspection of records, including assessment information and care plans. Discussion with the manager of the home on how it operates on a day-to-day basis. An inspection of the building and interviews with several members of staff, residents and relatives. Observation of the daily life of the home. This is a well-run care home that has excellent standards of care and residents and relatives are fully consulted about all aspects of service provision. The service provides a well maintained home set in lovely surroundings. It is clean, warm and comfortable. I spoke with newly admitted residents who told me that they were very happy in the home and staff were kind and caring. The manager said that some residents declined to participate in the care planning due to their age and general frailty but relatives were kept informed. Residents are treated with respect and dignity and their privacy is upheld at all times. A recreation assistant is employed and she arranges a variety of daily social and leisure activities, which are enjoyed by the residents. Free transport is provided and trips out and entertainers are arranged. Visitors and family are welcome and it was noted the number of visitors who visited the home over the two day inspection. There are sufficient staff on duty each day with a skill mix to meet residents needs. A qualified nurse is on duty at all times and there is competent waking night staff on duty in sufficient numbers to meet the needs of the residents. The company employ a training manager who organises staff training to ensure a well-trained staff group. I spoke with staff that said they are keen to study and update their skills and one member of staff was very proud to tell me that she has recently achieved her NVQ level 3. Staff meetings and supervision sessions enable the staff to contribute to the running of the home. What the service does well:
The home is well-organised and managed and residents and their relatives are consulted and involved in their care appropriate to their preferences and wishes.
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 6 The home have put in place comprehensive care planning arrangements to ensure that residents needs are fully met and they not placed in any situations of harm or risk. Prospective residents are provided with written information about the home and the services and facilities provided. Flexible arrangements are also in place for prospective residents and their relatives or representatives to visit the care home. This helps the individual concerned to decide if it is a suitable place to reside. Further work must be completed on the Service User Guide to make it available for all prospective residents. Residents who have recently moved to the home said they found the information about the home helpful and were positively welcomed by the staff and other residents. The residents also said how well the management of the home treated their relatives. The dining room overlooks St Michaels Mount and the attention to detail in the dining room makes for a pleasant dining experience for the residents. A varied menu is provided which reflect the individual residents preferences and choices and specially prepared meals are done for the residents who cannot eat solid food. The Environmental Health Office inspected the kitchen on the 11th October 2005 and found everything satisfactory. Refreshments such as squash, fresh juice, tea and coffee are regularly provided throughout the day and additional drinks are available when required. The relatives told me that they are made to feel comfortable and afforded hospitality when they visit Residents commented they were very satisfied with the quality and variety of the food provided. Ponsandane provides a high standard of accommodation and I noted that the decorators were in the home improving the environment. I spent a lot of time talking with the residents and some of their relatives who said that they were very satisfied with the accommodation and that they were comfortable. The residents said that the staff were courteous and kind and caring and were readily available when they required assistance or support. Staffing ratios through the day and night are in sufficient number to meet the needs of the residents. The staff are well supported by the manager and nursing team and staff morale appeared good. The company wish to have a corporate approach to all its homes, which means that the manager of Ponsandane is looking at her policies and procedures to be in line with this approach. What has improved since the last inspection?
The care plans have been improved since the last inspection with all residents having had a full continence assessment. The care plans are very impressive and clearly detail all interventions on the best way to provide the care and support required. The plans are regularly reviewed with the full involvement of the residents only if they wish to
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 7 participate. Residents and relatives I spoke with said they were satisfied with the care and support they received from management and staff. The residents and their relatives said that the manager was very understanding and were happy to approach her about anything. The nurses are hands on and offer support, guidance and direction to staff. 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. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Prospective residents must be given A Service User Guide to enable them to make a decision about where they wish to live. Each prospective resident has an assessment of their needs, which ensures all needs are taken account of and support is provided in the manner preferred by the resident. EVIDENCE: The Service User Guide is being updated and is not available to prospective residents. This was a requirement in the unannounced inspection of May 2005 and is now a second notification. The manager assesses each prospective resident and the assessments also take account of the views of any professionals that are involved with the person concerned. This is undertaken to make sure the persons needs can be met by the home. Wherever possible the manager also consults with the prospective resident and their relatives or representatives about the care and support required. The manager and staff now fully involve the prospective resident and their relatives in the assessment process, only if they wish to be involved. I spoke with newly admitted residents and they told me that they
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 10 had been given satisfactory information and had received a warm welcome from the staff and other residents. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. The care planning arrangements are very detailed and comprehensive ensuring that the needs of the residents are fully met. The medication at the home is well managed and in a safe manner that promotes good health. EVIDENCE: The manager, nurses and staff have improved the care planning to ensure that all aspects of health, personal care and leisure needs are identified and planned for. The care plans inform and direct staff on the most appropriate ways of providing the care and support required. The plans are regularly reviewed with the residents and amended when required. The medication system is well managed and ensures the safety of all residents. A physical check and count of the medication system confirmed the security and safety of all prescribed medication to be good. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 and 15. Social and leisure activities are creative and provide daily variation and interest for people living in the home. Dietary needs of residents are appropriately catered for and a varied menu is in operation that meets with the residents’ preferences and choices. EVIDENCE: The company employ a recreation assistant who works four days a week. She has compiled individual files for each resident with a range of activities provided to residents within the home and the local community. The activities reflect the interests and hobbies of the residents and individual preferences are detailed in the residents file. In addition she is currently working on a Life History for each resident. On the first day of the inspection some of the residents went for a trip to Redruth for fish and chips lunch. When the residents came back they said how much they enjoyed the visit. There is also a lot of cross visiting between the homes and the residents said how much they enjoyed seeing the other homes. A number of residents were spoken to and everyone commented on the food said how good it is and that they welcomed the daily choices offered. Meals can be taken in individual rooms or in the dining room. There are individual tables that seat up to four residents and the tables are presented with
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 13 attention to detail with small vases of flowers, linen table clothes, napkins and good quality cutlery and crockery. The residents said they were very satisfied with the meals provided and commented upon the quality of the meals they received. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has an open approach to concerns or complaints and any issues are dealt with efficiently and promptly. Suitable records have also been established that detail the action taken and the conclusion. This ensures that residents can feel confident their views are listened to and acted upon. Satisfactory arrangements are in place to protect residents against any form of abuse and keep them safe but staff training and policies and procedures must be reviewed and updated to protect the residents from harm. EVIDENCE: A record is maintained of all concerns and complaints that are raised with the manager with the action and outcome taken. The manager stated that she has an open approach to complaints and is keen to resolve concerns. Residents and relatives said they felt able to discuss any complaints they have with management and staff. A detailed complaints policy and procedure is in place that has been distributed to residents. The procedure details the routes that can be taken and the time scales for the resolution for complaints. Also, the Statement of Purpose details the complaints procedure. The policy and procedure for responding to any allegations of abuse must be reviewed and updated. Staff must receive training in Adult Protection to protect residents from harm. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 15 Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26. Ongoing improvements to the home continue to be undertaken to provide the residents with a safe, comfortable surroundings. EVIDENCE: Residents said to me that they were satisfied with the facilities provided. At this present time upgrading work is taking place in one of the lounges and in other parts of the home. The premises are well maintained both internally and externally to a high standard in both decor and furnishings. The company has given a great deal of thought to providing ample equipment to assist residents in their everyday living and aid staff in performing their duties. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. Staffing levels meet the needs of the residents and staff morale is good. The standards of vetting and recruiting new staff are satisfactory but POVA checks must be carried out before management offers employment to prospective staff. This will not place residents at risk. EVIDENCE: There has been movement in the staff team with the head carer/training officer terminating her employment. Her departure has prompted the manager to review the senior staff structure and instead of one staff taking on responsibility for training and supervision, the manager has delegated this responsibility to her four senior care assistants. Staffing levels are flexible to meet the needs of residents. The Registered Manager is a qualified nurse with many years experience of management and care to her credit. Staffing numbers and skill mix of staff is appropriate to the assessed needs of the residents at all times. There is a registered nurse on duty at all times. There are designated maintenance, housekeeping and catering staff. Sixty percent of the staff are qualified to NVQ level 2 and above. Throughout my discussions with residents and observations of the staff it is clear the staff treat residents with dignity and respect and that positive relationships have been established.
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 18 Staff said there was a good communication between the staff group and the manager and she found there was a good level of staff morale and mutual support. The company have established arrangements to recruit vet and select new staff. The recruitment documents that were sampled for new staff showed that an application form and two references were taken up. There was evidence that POVA checks were not completed before the staff commenced their duties. The manager is going to put this right immediately. There was evidence that new staff undertake a period of induction when they commence employment. An experienced member of staff takes a lead role in the induction arrangements under the guidance of the nurses and steps are taken to make sure the new staff members have the skills and abilities to meet the needs of the residents. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35 and 36. There is leadership; guidance and direction to staff to ensure the residents receive consistent quality care. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. Service users money is managed well safeguarding their financial interests . EVIDENCE: Ponsandane are applying for the Investor In People Award, which commences in November 2005.The Registered Manager carries out a quality assurance exercise for the home and produces a report of the outcomes. The manager is appreciative of the daily support given by the Managing Director. A report is completed monthly by the Managing Director on the conduct of the home. The home is arranging for all residents to pay by standing order. The representatives of the residents manage personal finances of the residents and
Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 20 only personal allowance is held for three residents. Their accounts were in sufficient detail and up to date. There has been a change in senior staff which has meant that supervision is running a little bit behind. This has now been put right with the creation of the four senior staff In line with the corporate approach new policies and procedures have been established to promote safe working practices for residents and staff. The equipment and services at the home are regularly maintained and serviced and suitable arrangements are in place to promote the residents’ safety and well being in the event of a fire. The next fire training was taking place on the 19th October 2005. Ponsandane DS0000009091.V250720.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 3 10 x 11 x x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x 3 3 3 x x Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP11 Regulation 5 Requirement The Service User Guide must be completed and made available to service users and their representatives. Second notification Training in Adult Protection must take placeto prevent service users being harmed. Second Notification. Timescale for action 30/03/06 2 OP1818 13 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 29 Good Practice Recommendations POVA checks should be carried out before employment commences. Ponsandane DS0000009091.V250720.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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