Care Home: Pelican Court

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What the care home does well There is an open and friendly atmosphere in the home, which is run in the interests of people who live there. The care is very person-centred and individuals` needs and wishes are met as far as is practicable. Care planning at the home is good and individual care plans are well presented, kept in good order and reflect person centred planning. Staff working at the home have positive relationships with residents and work hard to improve their quality of life. Pelican Court offers a homely and comfortable place in which to live. Residents privacy is promoted. Staff are friendly and polite. There are lots of opportunities to socialise, enjoy hobbies and learn more skills. Residents present as being relaxed and comfortable with staff indicating they feel safe and secure with them. What has improved since the last inspection? The residents` service agreements include information about fees. Each resident is given a copy of the floor plan of the home with their bedroom highlighted. This is used instead of numbering bedroom doors to offer a more homely environment. Each resident now has a support plan that identifies care needs, personcentred-pathways and achievable goals. A signed agreement is now in place where the use of bed rails is considered necessary. Information about the funding of staff supporting residents on holiday has been made clearer. As part of their person-centred approach, the home provides secure storage facilities for medicines and small amounts of cash in each resident`s bedroom. A second member of staff now countersigns hand written Medication Administration Records as being accurate to help safeguard residents. The staff call system has been made readily accessible to all residents. The method for recording the checks made on the fire emergency systems has been improved. Records regarding the recruitment of all staff working at Pelican Court are now kept at the home in order to provide evidence a sound recruitment procedure. Parts of the home have been redecorated. What the care home could do better: Some residents would benefit from the agreement being presented in alternative formats they would find easier to understand. the forms to record cash transaction made on behalf of services users be amended so they can countersign transactions. This would be more inclusive and an additional safeguard. Whilst residents live in a clean and comfortable house, their comfort and safety would be enhanced if some necessary repairs are addressed. For example, the carpet join at the lounge/kitchen doorway must be made safe. Particular attention needs to be given to the kitchen where damaged kickboards and work surfaces in the kitchen must be replaced or repaired so as to maintain satisfactory standards of food hygiene and some of the strip lights above the work surfaces need secondary covers fitted. The patio areas must cleared of weeds so as to be safe for use by all residents. Staff training needs should be better monitored to ensure they all receive training and updates as required. The quality assurance and monitoring systems should be developed to take account of feedback from relevant health and social care professionals. CARE HOME ADULTS 18-65 Pelican Court 6 Pelican Court Wateringbury Maidstone Kent ME18 5RJ Lead Inspector Gary Bartlett Unannounced Inspection 29th April 2008 09:30 Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 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 Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 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. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelican Court Address 6 Pelican Court Wateringbury Maidstone Kent ME18 5RJ 01622 817773 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) stephen.bolton@macintyrecharity.org www.macintyrecharity.org MacIntyre Care Mr Stephen Paul Bolton Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Male Whose primary care needs on admission to the home are within the following categories: 2. 3. Learning Disability - (LD) The maximum number of service users to be accommodated is 6. The age range of service users is 37-60 years Date of last inspection 27th September 2006 Brief Description of the Service: Pelican Court is registered to provide services for up to five adults, (there is a query regarding this as the provider states they withdrew their application for a reduction in resident numbers from nine and this is currently being investigated), including one person who is over 65 years of age, with learning and physical disabilities. The home employs support workers, operating a roster, which gives 24-hour cover. There are not designated staff for catering or domestic duties. The accommodation is arranged over two floors. The ground floor is used to provide accommodation for residents with a higher dependency need (including physical disability); the first floor for those with less dependency needs. The care providers are Macintyre Care, a national organisation for people with learning disabilities. The owners of the premises are Moat Housing, who are responsible for the repair and upkeep of the premises. The accommodation is purpose built. (There is other accommodation close by where supported housing is provided for more independent service users; this is not registered with the CSCI.) The home is located in a village within reach of Maidstone and other towns by public transport. There are shops and village amenities within walking distance. Current fees for the home are £ 54,612 per annum and do not include the cost of hairdressing, chiropody, toiletries, newspapers, holidays and public transport. Full information about the fees payable are available from the Manager. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Pelican Court on 29th April 2008 from 9:30 am until 3:00 pm. During that time the Inspector spoke with some residents and some staff. Parts of the home and some records were inspected and care practices observed. The Manager had completed an Annual Quality Assurance Assessment, from which information was used to inform the inspection process. Prior to this inspection and during an Annual Service Review conducted in January 2008 a small number of survey forms were received from Care Managers, two relatives of residents living at Pelican Court, a General Practitioner and a health care professional. Feedback from the latter was positive, that from the Care Managers and relatives was variable. The general consensus of Care Managers is that whilst there could be improvement in following professional guidance, Pelican Court is good at developing a personcentered approach and promoting residents’ independence and access to the community. One survey returned from a care manager gives generally positive responses to all survey questions and commented that the service “provide appropriate care for individual needs and communicate problems to care management if needed.” ”They also enhance the social life of my client”. The two surveys returned from relatives of people living in the service tell us that their experiences of the quality of care their relative receives and the quality of the contacts with the service are different. One respondent indicates they did not feel the service meets the needs of their relative. The other continues to be very satisfied with the service and the quality of care provided, saying that: “(The resident) is very happy there” and in response to a question concerning improvement they commented, “in my opinion I don’t think there is much room for improvement”. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Pelican Court prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Inspector would like to thank everyone for their contribution to the inspection. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 7 Some residents would benefit from the agreement being presented in alternative formats they would find easier to understand. the forms to record cash transaction made on behalf of services users be amended so they can countersign transactions. This would be more inclusive and an additional safeguard. Whilst residents live in a clean and comfortable house, their comfort and safety would be enhanced if some necessary repairs are addressed. For example, the carpet join at the lounge/kitchen doorway must be made safe. Particular attention needs to be given to the kitchen where damaged kickboards and work surfaces in the kitchen must be replaced or repaired so as to maintain satisfactory standards of food hygiene and some of the strip lights above the work surfaces need secondary covers fitted. The patio areas must cleared of weeds so as to be safe for use by all residents. Staff training needs should be better monitored to ensure they all receive training and updates as required. The quality assurance and monitoring systems should be developed to take account of feedback from relevant health and social care professionals. 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. The summary of this inspection report can be made available in other formats on request. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ aspirations and needs are assessed before admission to the home. EVIDENCE: The Manager described how prospective residents are only admitted to the home after a full assessment of needs, the “Getting to Know You” assessment. These are inclusive of relatives and health care professionals and are the starting point for residents’ individual support plans. The records sampled included assessments of personal support, health care needs, religious and cultural needs and social activities. The Manager confirmed the home offers residents a ‘settling in’ period to ensure the home is the right place for them and they are compatible with people already living at the home. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 10 Each resident has been provided with a statement of terms and conditions about what they can expect in terms of their rights and responsibilities relating to the care provided. The service agreement is easy to read and since the last inspection has been amended to include the information about fees. Some residents would benefit from the agreement being presented in alternative formats they would find easier to understand. Each resident is given a copy of the floor plan of the home with their bedroom highlighted. This is used instead of numbering bedroom doors to offer a more homely environment. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems for care planning to identify residents’ needs and how they are to be met. Residents are enabled to make decisions about their lives, as far as is practicable, with assistance as needed. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Each resident has an individual support plan and a daily diary, “My Support, My Way” being the core document. These are clear, holistic, person-focused and easily audited. Those seen are well presented, comprehensive in content and regularly reviewed. Residents are involved in their care planning and make their own individual personal records, which include their activities, likes, dislikes and steps to obtaining their aspirations and goals Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 12 The home operates a link-worker system to promote consistency of care and support. Residents are supported to take risks as part of maximising their independence. This risk assessment process is recorded for hazards, individual needs and activities, such as holidays and trips out. Information seen is up to date and reviewed. Discussion with staff indicated that residents are enabled to make decisions about their lives with consideration being given to risk management and group living. A risk assessment for one resident needing bedsides is recorded and a signed agreement is now in place. A regular residents’ meeting is held about decisions such as meals, activities and holidays. Health and safety issues are included within the meetings and residents can watch appropriate videos about fire and adult protection. Personal records are maintained and stored in such a way as to be available only to appropriate and authorised people. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy individual lifestyles and are supported to develop their life skills. They have the opportunity to experience a variety of social, educational and recreational activities. EVIDENCE: From observation, discussion and records it is clear that residents benefit from opportunities for personal, emotional and social development and are supported towards independent living skills, tailored to their abilities. Residents are treated as individuals and are consulted about their different interests and aspirations, which they record in their personal plans. Activities are provided accordingly. Personal development is enabled through attendance at college, Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 14 paid employment/voluntary work, day centres, leisure activities and relationships with friends and family. Residents spoken with clearly enjoyed the activities that they are involved in. Residents are part of the local community. During weekdays residents enjoy attending day centres or college, participating in social events and activities that personally interest them or to further develop their life skills. Staff at the home support their attendance and also provide activities from the home. A wide range of opportunities are available to residents including swimming, horse riding, shopping, going to the library, boat trips, cooking, bowling, discos, visits to the coast and places of interest, bingo and snooker. Opportunities are available for residents to undertake paid or voluntary work. Currently one individual works on a farm, one in a garden nursery and another with a mobile snack company. Residents are able to see their family and friends as often as they wish. Individuals can visit the home at any reasonable time. Residents spend time in the home relaxing, watching television listening to music or undertaking activities that interest them. They also receive guidance with the development of skills within the home with the support of staff. Residents are encouraged with shopping, cooking, cleaning, laundry and household tasks. If they wish, residents can enjoy privacy in their rooms and staff respect this. Staff talk with residents in a friendly and polite way. The home’s pet cat “Rugs” has an interest additional to the aquarium now that a resident has a pet budgie “Bluey”. Bluey’s care needs have been carefully documented with guidelines on how they are to be met. Residents are supported in planning holidays and have had the opportunity to go on a trip of their choice. Information about the funding of staff supporting residents on holiday has been made clearer. Residents participate in planning the menus and those seen show they enjoy a balanced and nutritious diet with a variety and choice. With support, residents are involved in the preparation and cooking of foods to the best of their ability. A resident said they enjoy the food at the home. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. EVIDENCE: Records show that staff are clearly made aware as to the type and nature of the support required for individual’s personal and intimate care needs. Staff have a good understanding of the preferred routines and varying requirements of each individual. Through discussion with the Manager and assessing the three care plans, it is evident that residents have ready access to health and social care professionals. This includes GPs, district nurse, physiotherapist, optician, Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 16 dentist, chiropodist and dietician. They are supported with any specialist appointments and/or interventions. The Manager said staff provide flexible support to service users based on individual choice and personal care is provided in private to promote the dignity of service users. Observations confirmed service users had good personal hygiene and were appropriately dressed for their activities. Guidance regarding personal hygiene is recorded in individual care plans. A procedure is in place for the administration of medication by the home, which aims to protect residents. Records show that all staff administering medications have been trained and signed off as being competent to do so. As part of their person-centred approach, the home provides secure storage for medicines in each resident’s bedroom. The administration records seen are completed appropriately. A second member of staff now countersigns hand written Medication Administration Records as being accurate to help safeguard residents. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views and concerns are listened to and receive appropriate consideration, although they would benefit from a written complaints procedure that was easier to read. Residents are protected from potential abuse, although this was not fully reflected in documentation held within the home. EVIDENCE: Residents are at ease and confident talking with staff who listen to their views and concerns. A regular meeting is held to discuss these. If residents wish to make a written complaint, postcards are available that are easier to fill in. These can be given or sent to staff, the Manager or the Area Manager. Details of complaints and their investigations are recorded appropriately. The Manager confirmed that people living in the home are protected from abuse and that satisfactory checks had been carried out on all staff via the Criminal Records Bureau and POVA. A regular residents’ meeting is held which includes health and safety issues. Residents can watch appropriate videos about adult protection. Since the last inspection there have been two Safeguarding Adults alerts. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 18 The home has a system in place, which aims to protect the financial interests of residents and holds small amounts of cash on their behalf. This is kept securely in each individual’s bedroom. Transaction records are maintained and receipts are kept for purchases made on residents’ behalf. The record forms currently being used do not have facility for the resident to countersign transactions. Being given the opportunity to do so would be more inclusive and an additional safeguard. Cash checked tallied with accounts seen. The Manager said that no one within the organisation was an appointee for any resident. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and homely environment. This would be enhanced by safer access to the back garden area and repairs being completed more promptly. EVIDENCE: Whereas the service is operated by Macintyre Care, the owners of the premises are Moat Housing, who are responsible for the repair and upkeep of the premises. The accommodation is purpose built and provides adequate recreational, communal and individual accommodation. Whilst residents live in a clean and comfortable house, their comfort and safety would be enhanced if some necessary repairs are addressed. For example, the carpet join at the lounge/kitchen doorway must be made safe. Particular attention needs to be Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 20 given to the kitchen where damaged kickboards and work surfaces in the kitchen must be replaced or repaired so as to maintain satisfactory standards of food hygiene and some of the strip lights above the work surfaces need secondary covers fitted. The kitchen work-surfaces are of a height that is suitable for residents to use whilst sitting. Staff say they are consequently uncomfortable for them and residents to use when standing. This could be addressed by the fitting of adjustable height work surfaces. Staff say there is usually a protracted delay between reporting repairs and them being addressed. An example given is the kitchen door leading to a patio area. When closed, there is a substantial gap at the top of the door. Staff described how the door can stick and be very difficult to open in hot weather. As it is a designated fire escape, this is a potential risk. Residents have access to a garden that needs some tidying and maintenance. The Manager said they are trying to locate a gardener to do this. The patios must cleared of weeds so as to be safe for use by all residents. The bedrooms seen are comfortable, furnished and decorated according to individual taste and reflect the interests of the occupant. Residents clearly like their rooms, which are personalised. They are able to choose colour schemes and how their furniture is arranged. There is not a passenger stair lift in the home so only ambulant residents are accommodated on the first floor. The ground floor accommodation is equipped to provide care for residents with physical disabilities. Currently one resident uses specialist equipment such as a hoist and reclining chair. They have been assessed by an occupational therapist. There is a readily accessible staff call system. The premises are clean and free from offensive odours. Staff say the laundry facilities are adequate for use by them and, with appropriate support, residents. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust recruitment processes are followed to ensure only properly vetted people work at the home. People living in the home benefit from the support of enthusiastic and caring staff, who demonstrate a good understanding of residents’ needs. EVIDENCE: Recent times have been problematic for the home’s staffing due to vacancies and staff sickness. Recent appointments should alleviate this when the appointees commence duties after receipt of satisfactory Criminal Record Bureau checks. Records regarding the recruitment of all staff working at Pelican Court are now kept at the home in order to provide evidence of a sound recruitment Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 22 procedure. The files of the most recently recruited staff show that appropriate checks are made prior to them commencing duties. This was confirmed by discussion with a recently recruited staff member. All new staff, including agency staff, are required to complete an induction programme. The Manager is currently collating records to update a training matrix operated by MacIntyre head office. Such a tool is not used in the home to monitor individual staff members’ training requirements. Consequently it is difficult to assess the current situation, although training certificates indicate there is ongoing training for staff. The Manager agreed to undertake a training-needs analysis for every staff member and to forward the results to the Commission. The staff rosters seen indicate staffing levels are geared to activities being undertaken by residents and staff capabilities to ensure appropriate support is available to residents when they need it. Ancillary staff are not employed at the home, the cleaning, cooking and laundry being done by residents and staff. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of residents and to promote their wellbeing. EVIDENCE: The manager was appointed in December 2005 and has relevant experience of service provision for older people and for people with learning disabilities. He has previous management experience. The manager commenced an NVQ level 4/Registered Managers’ Award in June 2006 but has not yet completed it. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 24 The Manager states he is committed to promoting an open and inclusive atmosphere in the home. From observation, residents are comfortable chatting and spending time with staff. There was discussion about the quality assurance system being used. It is not evident that it takes account of feedback from relevant health and social care professionals. This should be done so the service can make a comprehensive assessment of its performance. The accidents and incidents records seen are completed appropriately with any action taken signed off by both the Manager and Area Manager. The method for recording the checks made on the fire emergency systems has been improved and these are being done regularly. Staff spoken with have a sound understanding of emergency procedures. The Manager said all records of maintenance and safety checks are up to date. These were not inspected on this occasion. Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 3 3 X Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 13(4)(a) Requirement “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in that the external fire escape door in the kitchen must be made good so as to be easy to use at all times. To be completed by the given timescale, if not sooner. “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in that the patios must cleared of weeds so as to be safe. To be completed by the given timescale, if not sooner. “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in DS0000024003.V361127.R01.S.doc Timescale for action 30/06/08 2. YA24 13(4)(a) 30/05/08 3. YA24 13(4)(a) 30/05/08 Pelican Court Version 5.2 Page 27 that all strip lights in the kitchen must have secondary covers fitted. To be completed by the given timescale, if not sooner. “The registered person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety” in that the carpet join at the lounge/kitchen doorway must be made safe. To be completed by the given timescale, if not sooner. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, in that damaged kickboards and work surfaces in the kitchen must be replaced or repaired so as to maintain satisfactory standards of food hygiene. To be completed by the given timescale, if not sooner. “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that a detailed training analysis must be made for every staff member that includes: 1. Training they have undertaken 2. Training courses booked DS0000024003.V361127.R01.S.doc 4. YA24 13(4)(a) 30/05/08 5. YA30 13(3) 30/06/08 6. YA32 18(1)(c) 30/06/08 Pelican Court Version 5.2 Page 28 3. Details of training provider and any accreditation they may have. A copy of this must be received by CSCI by the given timescale 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 YA5 YA23 Good Practice Recommendations It is recommended the service agreement is presented in alternative formats service users would find easier to understand It is recommended the forms to record cash transaction made on behalf of services users be amended so they can countersign transactions. This would be more inclusive and an additional safeguard. It is strongly recommended the kitchen work-surfaces are of a height that is comfortable for staff and residents to work at. It is strongly recommended the home operates a training matrix or similar monitoring tool to show details of all training courses undertaken. It is again strongly recommended that the registered manager complete their NVQ level 4/Registered Managers’ Award course as soon as they are able. This was an expectation of the CSCI at the point of the Manager’s registration. It is again recommended that an effective quality assurance and monitoring systems based on a systematic cycle of planning-action-review that takes account of feedback from residents, their relatives and relevant health and social care professionals is introduced. 3. 4. 5. YA24 YA35 YA37 6. YA39 Pelican Court DS0000024003.V361127.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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