Inspection on 22/09/05 for Pegasus Lodge

This inspection was carried out on 22nd September 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pegasus Lodge 16/02/09

Pegasus Lodge 24/05/07

Pegasus Lodge 13/02/06

Pegasus Lodge 18/01/05

Pegasus Lodge 27/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Pegasus Lodge 22 Lee Brigg Normanton Wakefield West Yorks WF6 2JJ Lead Inspector Gillian Walsh Announced Inspection 22nd September 2005 02:00 Pegasus Lodge DS0000006244.V252216.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 Pegasus Lodge DS0000006244.V252216.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. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pegasus Lodge Address 22 Lee Brigg Normanton Wakefield West Yorks WF6 2JJ 01924 896713 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) Real Life Options Mrs Lorraine Burton Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6), of places Physical disability (6) Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2005 Brief Description of the Service: Pegasus Lodge is a home for six adults with special needs run by Real Life Options. There is a small and caring staff team who are experienced in providing care and support to this service user group. Pegasus Lodge is situated on the outskirts of the small town of Normanton, which has a good range of shops and community facilities. There is also good access to Wakefield, Pontefract and Leeds through local transport services and the home has its own minibus. The home is built on two floors set back from the road behind a small car park. The surrounding area is of other residential property. Each service user is provided with a single bedroom with two downstairs bedrooms being joined through a large, well-equipped bathroom, which both rooms share. There is a good sized and nicely kept rear garden, which is safely enclosed offering a pleasant area for sitting out. Service users are encouraged to access local community facilities, including attendance at college and Adult Training Centres. Pegasus Lodge DS0000006244.V252216.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 made on 22 September 2005. The visit was made by the previous and the current lead inspector for the home. Time was spent looking around the home, speaking with the manager and one staff member and examining records. Only one service user was present during the visit. Time was spent observing the positive interaction between this service user and the staff. The inspectors would like to thank the manager and staff for their assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? 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. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 6 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 Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 7 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): 2 and 3 Prospective residents individual needs and aspirations are assessed to ensure that these can be met at the home before an offer of placement is made. EVIDENCE: Information contained within a sample of resident’s files demonstrated that current residents had been admitted into Pegasus Lodge after a comprehensive assessment of their needs had taken place. The manager said that for any potential resident, she would ensure that she obtained a comprehensive assessment of their needs from the placing authority where appropriate, would also make her own assessment to ensure that the home was able to meet their needs appropriately. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 8 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 and 9 Service users assessed needs and personal goals are reflected in their individual plan of care and in their “My Life Books”. Service users are supported to take risks in order to promote their independence. EVIDENCE: Care plans were found to set out the actions, which need to be taken by care staff to make sure that the health, personal and social care needs of the service users are met. The care plans were found to contain information and records relating to the ways in which the staff promote and maintain service users’ health and ensuring access to health care services. There was no evidence within the care plan files seen that the service user or their representative had been involved in the development or review of the individual care plans and in several instances the care plans and reviews had not been signed by the person completing them. The manager explained that the company has obtained “My Life Books” which will be used to record all the essential information about each service users, their strengths, needs, goals and aspirations. ‘My Life Book’ contains information about an individual’s family history, their past, their hopes for the Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 9 future, activities, daily living skills and health. The life book is the property of the individual, but one page is returned to a 24-hour accessible location in Social Services so that in the event of an emergency it is known who has completed a life book and where it is kept. Action is taken to identify and minimise risks and hazards through the process of risk assessment and, where necessary, service users are given training about their personal safety, to avoid limiting preferred activity or choice. Potential risk is also assessed prior to admission in discussion with the service user and relevant specialists. Ways to manage any identified risk are then agreed and recorded in the service user’s individual plan, and reviewed when required. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, and 15. Service users have opportunity and are supported to engage in a range of developmental, educational, leisure and social activities of their choice. EVIDENCE: The manager said that four of the current service users attend a local training centre on either a full or part time basis; another person is attending college completing a course in life skills. Each person’s daily activity is also detailed within their care plan. Service users also take part in a range of social and leisure activities of their choice, these include visits to the cinema, shopping bowling and various beauty therapies. The manager said that she is currently looking for more services and activities within the local community that service users could access and enjoy. Recently staff and service users have enjoyed trips to concerts and an ice skating show and are currently involved in organising a Halloween party at the home. Service users are supported and encouraged to maintain family relationships and friendships with people outside of the home. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 11 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): 19 and 20. Service users health needs are met appropriately. Service users are not fully protected by current systems for recording the administration of medication. EVIDENCE: Care plan files contained evidence that the service users use ordinary community healthcare services such as GP, district nurse, dentist etc. The manager said that service users’ health is monitored and potential complications and problems are identified and referred promptly referral to an appropriate support team or specialist service. Systems for the storage, recording and administration of medications were examined. Although some service users are prescribed some medications on a PRN (as required) basis, these are not detailed on the MAR (Medication Administration Record) sheets and are therefore not recorded on the MAR sheets when they are administered. Storage systems were safe and appropriate. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 12 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): 23. Policies and procedures are in place to ensure that service users are protected form abuse. EVIDENCE: Evidence contained within staff training records indicated that staff are made aware of adult abuse awareness during induction and are aware of Wakefield Policies and Procedures for the Mistreatment of Vulnerable Adults through regular training and updates. Pegasus Lodge also has its policies and procedures to deal with suspicions or allegations of abuse. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 13 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 and 30 Service users live in a comfortable, clean and safe environment. EVIDENCE: A tour of the home showed that service users live in a homely and comfortable environment with bedrooms individually decorated and furnished to the needs and preferences of the service users. The home was clean and tidy throughout. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 14 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): 35. A staff training plan is not in place at the home and some updates are needed to meet with this standard. EVIDENCE: The manager said that due to the company’s training officer being on long term sick leave, some training had not been completed by staff at the home. This included some mandatory training including fire training updates and updates in POVA training. A current training plan has not yet been compiled. Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 15 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): 42. Policies and procedures are in place to promote and protect the health and safety of service users and staff. EVIDENCE: Evidence was available within the home’s health and safety policies and procedures to demonstrate that the health, safety and welfare of service users and staff are promoted, and that safeguards are in place. There is a written health and safety policy and the maintenance file contained evidence that appropriate environmental checks such as gas safety; electrical testing and pest control take place as required by relevant regulation. The fire alarm system is tested on a weekly basis and records are maintained. The home was found to have established suitable arrangements to reduce the spread of infection Pegasus Lodge DS0000006244.V252216.R01.S.doc Version 5.0 Page 16 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 X 3 3 X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pegasus Lodge Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000006244.V252216.R01.S.doc Version 5.0 Page 17 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 YA20 Regulation 13(2) Requirement The registered person must make arrangements for safe recording and administration of all medicines in the home. This must include all PRN medications. Timescale for action 22/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations All care plans and reviews should be signed by the person completing them. Wherever possible care plans and reviews should be signed by the service user or their representative. If this is not possible a note should be made to explain why. • The company may wish to have a member of staff from the home complete the fire trainer’s course to ensure that updates are delivered in a timely fashion. • A staff training plan for mandatory and individual training needs should be available at the home • Updates in POVA training should be arranged without delay. DS0000006244.V252216.R01.S.doc Version 5.0 Page 18 2 YA35 Pegasus Lodge Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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