Inspection on 24/05/07 for Pegasus Lodge

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pegasus Lodge 16/02/09

Pegasus Lodge 13/02/06

Pegasus Lodge 22/09/05

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 Tony Railton Key Unannounced Inspection 24th May 2007 08.50 Pegasus Lodge DS0000006244.V329362.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 Pegasus Lodge DS0000006244.V329362.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. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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) www.reallifeoptions.org 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.V329362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 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 Local Authority-run day services. On 24 May 2007 the fees for living in the home ranged between £975.70 and £1201.53. Further information regarding the service and the CSCI can be obtained from the home. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home commenced at 08.50 hours and ended at 12.30 hours. During the visit there was the opportunity to speak to the people using the service, the manager, deputy manager, senior support workers and carers. Other information regarding the service was also considered and included conversations with the local General Practitioner, visiting Physiotherapist and Social Worker. A sample of assessments, care plans, medical, financial and daily records were also seen, along with checking the medicine administration system. The daily routine of those using the service was observed along with the interaction with those caring and supporting them. It was noted that the service provides care and support for people with profound learning disabilities and physical handicaps. The inspector would like to take the opportunity to thank those using the service, the manager and her staff team for their hospitality and co-operation throughout this visit to their home. What the service does well: There is a comfortable, homely and safe environment provided for those using the service. People using the service receive specialist care and support from a highly motivated and well-trained staff team. Positive relationships were observed being fostered between staff and those using the service. Because of the profound handicaps and special needs of those using the service, staff also receive training in communication and intensive interaction to enable them to better meet people’s needs. The assessments and care plans are extremely detailed and are reviewed on a regular basis to make sure that people’s personal and changing needs are met. Discussion with the manager and their staff team found them to have an intimate knowledge about the needs of those they care for and about their conditions. Discussion with the General Practitioner confirmed this, and also found that they are very pleased with the staff team and, in particular, their insight into the needs of people living in the home. The visiting Physiotherapist said that the staff team are very good indeed and are very capable and competent. They went on to say that they have provided training and therapeutic programmes which have been followed successfully. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 6 The philosophy of the home is based on ordinary living principles and on inclusion into the local community. There is evidence to show that, despite their profound handicaps, people live full and active lives and they are viewed positively in their community. Discussion with the Social Worker found that multidisciplinary reviews are held and that the service is very good and there are no issues relating to the care and support provided. On the day of the visit, people using the service were relaxed, happy and enjoying the attention of their carers. 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. The summary of this inspection report can be made available in other formats on request. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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 Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Comprehensive and very detailed assessments show how people need to be cared for, and make sure their personal and healthcare needs are met. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: Five assessments were seen and found to be very comprehensive indeed and to contain details about how people communicate their personal likes, dislikes, and preferences. The manager said that the assessments have to be very detailed as people using the service do not have any verbal communication. The manager went on to say that the staff team have to be very skilled in non-verbal communication and knowledgeable about people’s care and support needs. Discussion with the General Practitioner and Physiotherapist confirmed the insight and knowledge of the staff team of the assessed personal care needs of those using the service. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using the service can be confident that their personal care and support needs will be met and that they will participate in all aspects of life in the home. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: People using the service were observed having confidence in those caring for them. The care plans are very detailed and contain information on how people need to be cared for and supported. Discussion with the staff team found them to be very knowledgeable about people’s personal needs and, in particular, how these are communicated. The General Practitioner, Physiotherapist and Social Worker confirmed the exceptional abilities of the staff team. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 10 The Social worker also said that people’s care and support is reviewed on a regular basis to make sure their needs are met. The reviews seen confirmed this. The risk assessments show that people are expected to take risks as part of living an ordinary lifestyle. The manager said that parents and relatives are fully involved with planning and reviewing people’s care. The minutes of the reviews, visitors’ book, and returned quality assurance questionnaires confirm this. The manager said that a person centred approach is taken to providing care and the ‘My Life Books’ and ‘Person Centred Maps’ showed this to be the case. The daily records would benefit from the increase in the use of descriptive words to reflect and show people’s choices and preferences, and to capture the good work carried out by the home. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 People using the service live full and active lives, taking advantage of ordinary community based leisure services in their own community. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: The assessments, care plans and daily records show that, despite their profound disabilities, people enjoy full and active lives. The efforts of an experienced, knowledgeable and accomplished staff team make this possible. Discussion with the staff team found them to be very knowledgeable about the special needs of people using the service and, in particular, communication and observational skills. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 12 The Physiotherapist said that some people require two carers when attending the hydrotherapy pool and the assistance given by the carers is excellent and they are professional at all times. Records show that people attend local clubs, public houses, Local Authority-run day services, holidays and outings to the coast, local shops and supermarkets. The manager said that the philosophy of the home is based on ordinary living principles and, in particular, inclusion into people’s own communities. The Statement of Purpose confirmed this. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People using the service receive personal support in a way they prefer and require and their healthcare needs are met. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: People are safeguarded and protected by the way medicines are given as the medication administration system was checked and found to be safe. Staff training records show that they are trained in how to give medicines safely. Staff also receive specialist training, as some people using the service sometimes require ‘special’ medication, which is administered rectally. The assessments and care plans are very detailed and show staff how people like to be cared for and include preferences and choices. Discussion with the staff team found them to be very knowledgeable about individuals’ care needs and the support of people with profound handicaps. People were observed responding positively to the care offered to them and staff performed their duties in a sensitive and respectful manner. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 14 The General Practitioner and Physiotherapist said that the insight into the healthcare needs of people using the service is excellent. The minutes of the multidisciplinary reviews and quality assurance report shows that other stakeholders and relatives are happy with the care and support provided. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Robust Safeguarding and Complaints Policy and Procedures protect people. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: Evidence shows that the service has not had any complaints or Safeguarding Referrals; the manager and record of complaints confirmed this. Staff working in the home have police checks and Protection of Vulnerable Adult training to make sure that people using the service are protected from any kind of abuse. The General Practitioner, Physiotherapist and Social Worker all said that they have never had any reason to complain about the services provided. The home’s Quality Assurance Report shows that parents or relatives have never had any reason to complain about the quality of the care provided by the home. Indeed, the report shows that relatives are very pleased with the service. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People living in the home are comfortable and safe. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: People were observed relaxing in a comfortable, homely, safe and clean environment. The manager said that the home has been re-decorated since the previous visit and, in particular, that the lounge has been re-decorated and has new furniture. A tour of the premises confirmed this. The manager said that health and safety checks form part of a monthly audit to make sure that people are living in safe and well maintained home. Records show that all appropriate checks are carried out to maintain a safe environment for people using the service. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 17 The quality assurance report shows that other stakeholders, parents and relatives are happy with the services provided. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 People using the service have their needs met by a competent, trained and experienced staff team, and are protected by the staff recruitment and selection process. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: The General Practitioner said that they are impressed with the background knowledge and insight into the care needs of the people using the service. The Physiotherapist said that the support offered by the home is excellent and that staff are very professional. The quality assurance report shows that parents and relatives are more than happy with the care staff and the services provided. People using the service are in safe hands as the staff training records show that staff, as well as receiving Protection of Vulnerable Adults, Moving and Handling, Fire Safety, First Aid, Infection Control and Food Hygiene training, Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 19 specialist training is also provided in Autism, Epilepsy and Intensive Interaction. Staff induction records show that all staff receive Learning Disability Award Framework training as part of their induction to give them an insight into the needs of people with learning disabilities. Discussion with the staff team found them to be very knowledgeable in the needs of people who have profound handicaps and, in particular, those with communication difficulties using the service. People using the service are safeguarded as the staff selection and recruitment records show that Police and Protection of Vulnerable Adult list checks are carried out before they are employed. The manager said that support is offered on a needs led basis and that staff are deployed accordingly. The staff rotas and daily records and reviews show that enough support is provided to make sure people’s needs are met. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using the service live in a well run home where their care and support needs underpin all self-monitoring, review and development. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: The care and support needs of the people using the service is paramount and the care management systems within the home reflect this. The assessment and care planning process is very detailed and provides a comprehensive guide to the support and care needs of people using the service. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 21 Specialist training is provided for staff to make sure that people’s special needs are met. Specialist equipment such as hoists and specialist beds and chairs are provided to make sure people are safe and comfortable. Intensive interaction and communication training is provided for staff to make sure that people receive the support and care they prefer and require. Quality assurance surveys and the report show that people’s relatives and other stakeholders have the opportunity to comment on the services provided, and show that they are happy with the care and support provided. Regular reviews are held to make sure that people’s support and care needs continue to be fully met. Records show that monthly health and safety audit is undertaken to make sure that people remain safe in the home. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 4 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X X 4 X Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA7 Good Practice Recommendations The daily records would benefit from an increase in the use of descriptive words to reflect and show people’s choices and preferences. Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Extracts may not be used or reproduced without the express permission of CSCI Pegasus Lodge DS0000006244.V329362.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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