Inspection on 21/09/05 for Pengarth

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pengarth 18/09/08

Pengarth 22/05/08

Pengarth 23/05/07

Pengarth 03/05/06

Pengarth 25/04/05

Pengarth 25/10/04

Pengarth 02/06/04

Pengarth 05/12/03

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Pengarth Windmill Hill Ellington Morpeth Northumberland NE61 5HU Lead Inspector Hilary Stewart Unannounced Inspection 21st September 2005 12:40 DS0000000545.V251512.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 DS0000000545.V251512.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. DS0000000545.V251512.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pengarth Address Windmill Hill Ellington Morpeth Northumberland NE61 5HU 01670 - 860475 01670 860475 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) Active Care Mrs Margaret Danielson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000000545.V251512.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 persons may also have a physical disability Date of last inspection 25th April 2005 Brief Description of the Service: Pengarth is a detached bungalow situated in the small village of Ellington. It is the home to five residents with severe learning and physical disabilities.A post office, shop and public house are situated nearby and a bus service is available to a nearby town centre.Offstreet car parking is available at the front of the premises and there is a large garden to the rear.The home is not registered to provide nursing care. DS0000000545.V251512.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 12:40hrs.It took place over 3 ½ hours. All of the residents were at home at the time of the inspection. The inspector spoke to the residents, two members of staff and the manager. Records and the building were examined. 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. DS0000000545.V251512.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 DS0000000545.V251512.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 5 All of the residents have had their needs assessed. This ensures that personalised care can be given The staff try to involve the residents as much as possible in developing their individual care plans. EVIDENCE: All of the residents at the home have difficulty communicating verbally. Staff described how they observe non-verbal cues such as facial expressions to understand what the residents need or if they don’t like something. The manager confirmed that all residents have an individual care plan, which shows how their needs will be met in the home. They also confirmed that the residents either had a written contract or a statement of terms and conditions. DS0000000545.V251512.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 7 All of the residents at the home have an individual plan that is reviewed regularly. The written information in the resident’s individual files needs to be updated to be accurate. This will help staff meet the needs of the residents more effectively. EVIDENCE: Individual records are kept for each resident. A sample of the files were inspected and found to contain relevant information with regards to the care of the people who live in the home. Some of the care plans do not have enough detail such as information on the reasons why there are restrictions on choice in the home. Some plans have not been reviewed as they had been written some time ago and may not be accurate anymore. For example how staff enable residents to have their meals. The manager said that the organisation that runs the home is devising new care plan forms but they are not finished yet. Risk assessments were in place but were dated 2003.The manager said that they have been reviewed but they need to be rewritten and updated. The risk assessments have not been updated to ensure that they are still accurate. Various methods of communication are used by staff to involve the resident as much as possible in the running of the home. DS0000000545.V251512.R01.S.doc Version 5.0 Page 9 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): 13 and 16 The residents use local facilities. Staff support the residents to make their own choices as much as possible. This encourages them to be more independent. EVIDENCE: DS0000000545.V251512.R01.S.doc Version 5.0 Page 10 The manager said that the residents use the local shop and pub. They go for walks around the village and most of the local people say hello and speak to them. All of the residents are registered with the local GP. Every fortnight a reflexologist comes to the home, some residents have found this beneficial. A beauty therapist and manicurist also visit. Residents use these services if they wish. DS0000000545.V251512.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): 18,19 and 20 Staff monitor the health and welfare of the residents continually as they have high care needs. Medication is managed in line with the homes policies and procedures. EVIDENCE: Details of health checks, visits to their GP and hospital appointments are recorded in the resident’s individual files. The manager said that the health and welfare of the residents is constantly being monitored. All of the residents have high care needs and are unable to tell staff verbally if they are unwell so staff have to watch for signs and symptoms. Their health and well-being is discussed during staff meetings. There is also a lot of input from Occupational Therapists and Physiotherapists. The people who live at the home looked smart and well groomed. From what the manager described the home delivers personal care to the residents well; this must be recorded in more detail in their care plans (see page 10). Procedures are followed when administering medication. The manager said that following assessment it was not appropriate for the residents to control their own medication. DS0000000545.V251512.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): 22 and 23 The home has a complaints procedure; none have been made since the last inspection. Procedures are in place to protect residents from abuse. EVIDENCE: The home has a complaints procedure. This is available to the residents their relatives and carers. Records showed that there had not been any complaints made since the last inspection. The manager confirmed this. The manager also said that staff know the procedure to be followed if an allegation of abuse was made in the home. Most staff have completed the Local authority ‘Protection of Vulnerable Adults Training’. DS0000000545.V251512.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): 24,25,28 and 30 The home looks comfortable and homely. Each resident’s bedroom has been decorated and furnished differently. More storage is needed for equipment EVIDENCE: DS0000000545.V251512.R01.S.doc Version 5.0 Page 14 The home is situated in a small rural estate in Northumberland. It is clean and well maintained. One of the homes bathrooms is being used for storage of wheelchairs and staff lockers, as there is insufficient space elsewhere. This is restricting the space available in the bathroom and it is making it look cluttered. The home is decorated to a good standard and the furnishings and fittings are adequate. A lot of effort has been made by staff to enable the residents to personalise their own rooms. The rooms had been made very individual and comfortable. DS0000000545.V251512.R01.S.doc Version 5.0 Page 15 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): 34,35 and 36 The home has a staff recruitment policy. Arrangements are in place for staff to receive appropriate training in caring for the residents. Staff need to receive individual supervision at the required intervals to enable their practice to be monitored and developed. EVIDENCE: The manager said that staff are not employed at the home until all checks, references and employment history have been verified. Staff files seen did not contain all of the relevant information to confirm this. The manager stated that staff information is kept in the company’s Human Resources department which is situated elsewhere. The manager said that staff receive the mandatory training. One member of staff has an NVQ 2 in care and another two staff are in the process of completing it. Staff do receive supervision but not at the required intervals. The manager stated that this would now happen, as the staffing levels are better. DS0000000545.V251512.R01.S.doc Version 5.0 Page 16 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): 37 and 39 The manager is qualified to run the home. Resident’s views are sought with regard to the running of the home as much as possible. There are procedures in place to promote the health and safety of the people who live in the home. EVIDENCE: The manager confirmed that they have the relevant qualifications and experience to run the home. Staff records are kept in the company’s Human Resources department so they were not inspected. Records showed that regular checks are carried out on the equipment in the home; this includes testing electrical equipment and the servicing of the central heating boiler. DS0000000545.V251512.R01.S.doc Version 5.0 Page 17 Risk assessments are carried out and records were available to confirm this in relation to fire safety. The fire logbook showed that regular fire drills and instruction are carried out. Records showed that regular training is provided for staff in fire safety, food hygiene and first aid. Risk assessments are carried out and records were available to confirm this in relation to fire safety. DS0000000545.V251512.R01.S.doc Version 5.0 Page 18 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 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X 2 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000000545.V251512.R01.S.doc Version 5.0 Page 19 Yes 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 YA18YA6 Regulation 15 Requirement The provider must improve the content of each residents care plan. (Timescale of 12/11/04 not met). Risk assessments must be reviewed and updated. Suitable provision must be made for storage. Staff must have formal recorded supervision sessions at least six times a year. (Timescale of 1/9/05 not met). The registered provider must visit the care home unannounced at least once a month a prepare a written report. Timescale for action 01/12/05 2 3 4 YA9 YA28 YA36 13 33 (2) 18 01/12/05 01/12/05 01/12/05 5 YA39 26 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000000545.V251512.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000000545.V251512.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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