Inspection on 25/04/05 for Pengarth

This inspection was carried out on 25th April 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pengarth 18/09/08

Pengarth 22/05/08

Pengarth 23/05/07

Pengarth 03/05/06

Pengarth 21/09/05

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 NE61 5HU Lead Inspector Hilary Stewart Unannounced 25 April 2005 12:00. 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 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 Stationary 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. Pengarth Version 1.10 Page 3 SERVICE INFORMATION Name of service Pengarth Address Windmill Hill Ellington Morpeth Northumberland NE61 5HU 01670 860475 01670 860475 steveac@ukonline.co.uk Active Care Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Danielson CRH 5 Category(ies) of LD - Learning Disability (5) registration, with number of places Pengarth Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/11/04 Brief Description of the Service: Pengarth is a detached bungalow situated in the small village of Ellington and is 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.Off-street 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. Pengarth Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 1200hrs.It took place over 4 and ¾ hours. Some of the residents were at home at the time of the inspection; the others had gone out with staff. The inspector spoke to the residents 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: Review the male /female staff ratio at the home. Pengarth Version 1.10 Page 6 Provide enough management time for formal staff supervisions. Improve on the content of the residents individual care plans. The homes policies and procedures should be reviewed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pengarth Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Pengarth Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Each individual has had their needs assessed. The home has developed individual plans for each resident. EVIDENCE: It is intended that Pengarth is a home for life for the residents, all of whom have lived in the home for several years. The manager stated that assessments have been undertaken with respect to all residents and this forms the basis of each individual’s service plan. Although the residents at the home have difficulty communicating verbally the manager stated that staff were able to use other methods of communication i.e. pictorial methods and non-verbal cues to find out each residents needs and references. The manager stated that all residents had either a written contract or a statement of terms and conditions. Pengarth Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8 and 9 All of the residents at the home have an individual plans which are evaluated every month. The plans need to have more detail. People who use the service are consulted as much as possible about the running of the home. EVIDENCE: Individual records are kept for each resident. A sample of the files were inspected. They were found to contain relevant information with regards to the care of the people who live in the home. Some of the care plans lacked detail such as information on the reasons why there are restrictions on choice in the home i.e. some people need to have restrictions on how their food is presented due to health needs. The files also contained information describing how the home meets the needs of each resident, any involvement with professional agencies and current reviews involving outside agencies. Risk assessments were in place but had not been reviewed since 2003. The manager stated that the care plans are being reviewed at this time. Evidence was available to confirm that various methods of communication are use by staff to involve the resident as mush as possible in the running of the home. Pengarth Version 1.10 Page 10 Pengarth Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 and 17 The people who live at the home have access to a variety of leisure activities. Meals served are varied and nutritious. EVIDENCE: The home has planned menus, which indicate that the people who live at the home are provided with a varied nutritious diet. Each resident has a weekly activities plan. The manager stated that this is adjusted as new activities are found. Some of the activities included 1. Trips to the local pub and shop. 2. Visits to a craft centre. 3. Shopping in the Metro Centre 4. Plans are being to take residents out riding on a pony and trap. The staff are continually looking for new activities. At the time of the inspection some of the residents were out at an activity with staff. It was not possible to obtain a residents’ perspective of activities due to difficulties with communication. The manager stated that family links are maintained within the home with many regular visitors. Families are always invited to the external reviews involving care managers. Pengarth Version 1.10 Page 12 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 standard(s) 18,19 and 21 The residents have regular health checks such as the dentist and opticians. Staff monitor their health and welfare continually. The dignity and privacy of residents is respected. More detail is needed in the residents car plans with regard to personal care. EVIDENCE: The residents individual records kept in the home were found to contain details of health checks, visits to their GP and hospital appointments. It was confirmed by the manager that the health and welfare of the residents is constantly monitored. It is discussed during staff meetings. The manager stated that they have a lot of input from Occupational Therapists. The people who live at the home looked smart and well groomed. Since the last inspection the manager has attempted to obtain information from families as to their wishes regarding interment, but to date there has been little response. From what the manager described the home manages the personal care of residents well; this is not recorded in detail in their care plans. Pengarth Version 1.10 Page 13 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 standard(s) 22 and 23 The home has a complaints procedure that is available to the people who live there. Procedures are in place to protect them from abuse. EVIDENCE: A complaints procedure is in place at the home and records seen were up to date. It indicated that they had not been any complaints made since the last inspection. Discussion with manager and the inspection of records confirmed that the staff team are provided with relevant training. The manager could describe the procedure to be followed if an allegation of abuse was made. Most staff have completing ‘Protection of Vulnerable Adults Training’. Pengarth Version 1.10 Page 14 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 standard(s) 24,25 and 30 The home is well presented and homely. There weren’t any offensive odours present. Written guidance is available for staff regarding Health and Safety issues. EVIDENCE: The home is situated in a small rural estate in Northumberland. It is clean and well maintained. Transport is available to residents. The home is decorated to a good standard and the furnishings and fittings are adequate. It was apparent that 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. The manager confirmed that guidance is available to staff regarding Health and safety issues. Pengarth Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 and 36 At the time of the inspection there were adequate staffing levels at the home. The home has a recruitment policy in place. Staff need to receive individual supervisions at the required intervals. EVIDENCE: The staff rota indicated that appropriate staffing levels were maintained at the home. Two members of staff are in the process of completing the NVQ 2 in care. The manager is training to be an NVQ assessor. Staff receive the mandatory training. The manager stated that all checks are carried with in relation to staff, the staff files were found to contain most of the required information but some of the staff references and confirmation of identification could not be found. Pengarth Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 and42 The home’s policies and procedures need to be reviewed and up dated. There are procedures in place to promote the health and safety of the residents. EVIDENCE: The home ‘s policies and procedures have not been reviewed and updated. The manager reported that the company are in the process of doing this. Records indicated that regular training is provided for staff in fire safety, food hygiene and first aid. The manager reported that regular checks are carried out on the equipment in the home; this includes testing electrical goods and services of the central heating boiler. Risk assessments are carried out and records were available to confirm this in relation to fire safety. Pengarth Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 x 3 x Standard No 31 32 33 34 35 Score x x 3 2 x Page 18 Pengarth Version 1.10 14 15 16 17 x 3 x 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 x 3 Standard No 37 38 39 40 41 42 43 Score x x x 2 x 3 x Pengarth Version 1.10 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 6 & 18 Regulation 15 Requirement The content of each residents care plan must be reviewed.Outstanding (timescale 12/11/04). Risk Assessments must be reviewed Documentation listed in Schedule 2 must be obtained in respect of every member of staff. Staff must have formal recorded supervision sessions at least six times a year. The registered provider must review and revise the homes policies and procedures with specific reference to the National Minimum Standards appendix 3.Documents must be referenced and dated. Outstanding (timescale 31/3/05) Timescale for action 1/9/05 2. 3. 4. 5. 9 34 36 40 13 19 18 24 1/9/05 1/9/05 1/9/05 1/9/05 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. Pengarth Refer to Standard 32 Good Practice Recommendations Continue with staff development to achieve 50 of the Version 1.10 Page 20 staff team with NVQ level 2 or above in care. Pengarth Version 1.10 Page 21 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington Northumberland 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 Pengarth Version 1.10 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!