Inspection on 03/05/06 for Pengarth

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 4 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 21/09/05

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 Key Inspection 3 May & 22 May 2006 10:40 rd nd Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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) www.flexiblesupportoptions.co.uk Flexible Support Options (UK North East) Limited Mrs Margaret Danielson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 persons may also have a physical disability Date of last inspection 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. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10:40hrs.It took place over 4 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? The living room has had new carpet laid and new furniture. This makes the building more pleasant for the residents. Staff have access to training to improve their skills and competence. This will improve the quality of care the residents receive. The manager has made sure that all staff receive regular supervisions to ensure they meet the needs of the residents. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 6 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. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 the following standard(s): 2 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents have their needs assessed at the home so individual care plans can be developed. This makes sure that the residents are getting the care that they need. EVIDENCE: The staff involve the residents as much as possible in developing their individual care plans. As the residents do not communicate with spoken words staff said they look for other ways of seeking the resident’s opinions. They observe their facial expressions and body language to inform them of their likes and dislikes. One member of staff said and example would be if a resident pushed food away this may mean that they don’t like it. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. 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. Staff enable and support residents to lead their own lives so they can be independent when possible. EVIDENCE: Individual records are kept for each resident. All of the residents have an individual care plan that is reviewed regularly. A sample of the files were inspected and found to contain relevant information about 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. Also some plans have been written some time ago and may not be accurate anymore. Further work is needed to make sure that the information Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 10 kept in the residents care plans is kept up to date and is accurate. This will help staff meet the needs of the residents more effectively. Some of the care plans have been rewritten and made up to date. Some of the risk assessments have not been updated to ensure that they are still accurate. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 the following standard(s): 12,13,15,16 and 17. Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents use local facilities so they can be involved with the community. Staff support the residents to make their own choices as much as possible. This encourages them to be more independent. Social activities are well organised, creative and provide stimulation and interest for people using the service so they can become more confident. Meals are nutritious and balanced and offer a varied diet for residents to maintain their general health and interest. EVIDENCE: 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. On the day of the inspection two residents went to the community centre for lunch. All of the residents are registered with the local GP. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 12 The Home’s menus are based on the known likes and dislikes of the service users. One member of staff described how they observe residents when they try new meals to see if they look as though they like them, one resident pushes food away if they don’t like it another uses facial expression to let staff know their opinion. Staff said that they are always trying to find new menus to see if the residents like them and to provide interesting things for them to try. At least two hot meals are provided on a daily basis. Some residents are involved with the shopping. Special diets can be catered for. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents get personal support when they need it so they can be as independent as possible. The staff monitor and promote the health of residents who live in the home. This helps to ensure their well-being. 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. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 14 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. Staff have been trained in the safe administering of medication and the medication procedures are followed in the home. The manager said that following assessment it was not appropriate for the residents to control their own medication. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. Complaints are dealt with so any problems are taken care of quickly which helps good relationships to be maintained. Staff know about adult protection procedures so the residents are kept safe. 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 and staff said that all of the staff know the procedure to be followed if an allegation of abuse was made in the home. Staff have completed the Local Authority ‘Protection of Vulnerable Adults Training’. A copy of the Local Authorities adult protection procedures is in the office at the home. When spoken to staff knew what to do if they suspected abuse. The home has a Whistle Blowing policy procedure and the manager said that staff have been told about this. Records are made of the resident’s money and what they spend it on. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28 and 30. Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is well decorated, comfortable and clean so the residents have a pleasant house to live in. Space is taken up in one of the bathrooms for storage, which reduces the space available to residents. The baths could be made height adjustable so they are easier for the residents and staff to use. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 17 EVIDENCE: The home is nicely decorated and the living room has got new carpet and furniture. One of the homes bathrooms is being used for storage and has staff lockers in it, as there is insufficient space elsewhere. This is restricting the space available in the bathroom and it is making it look cluttered. The bath in the bathroom is very large and the manager said that it is impractical to use as it needs so much water. Another bathroom is used most of the time but is not height adjustable so it is very low for staff when they are enabling residents who need to use a hoist. The manager said that plans have been discussed to change the bathrooms but they did not know when. The residents’ bedrooms looked very comfortable it showed that staff had worked hard to enable the residents to personalise their own rooms. They had been made very individual and comfortable. The manager said that water temperatures are monitored by staff to make sure the water doesn’t get to hot. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a recruitment procedure to vet staff so the residents are kept safe. Staff are supervised and get training so the residents are well cared for. EVIDENCE: The manager said and records showed that they have the relevant qualifications and experience to run the home. Records showed that staff are vetted before they are employed. The manager said that all staff have been CRB (Criminal Records Bureau) checked at an enhanced level to make sure they were suitable people to work at the home. Sufficient staff were on duty during the inspection and the manager and staff said that enough staff worked at the home. Records showed that on other days enough staff had been on duty. The manager said that 2 staff are in the process of completing the NVQ 2 in care another 3 are about to start it. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 19 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): 37,39 and 42 Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager has the experience and qualifications to run the home so the residents are well cared for. Resident’s views are sought about how the home is run as much as possible so they know they are listened too. There are procedures in place to promote the health and safety of the people who live in the home so they are protected and kept safe. A quality assurance system needs to be stated at the home so the service the residents get looked at and improved. EVIDENCE: The manager confirmed and records showed that they have the relevant qualifications and experience to run the home. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 20 Records showed that checks had been carried out on the equipment in the home; such as testing electrical equipment and the servicing the central heating boiler. Fire safety risk assessments had been completed. The fire logbook showed that regular fire drills and instruction are carried out. As all of the residents at the home use wheelchairs and would need staff to help them leave the building if there was a fire. The manager should get advice from the local fire officer about how best to manage this during the night when only one member of staff is on duty. Records showed that regular training is provided for staff in fire safety, food hygiene and first aid. The manager had written a development plan for the home. They said that the company who own the home have decided on a quality assurance system but it has not been introduced in the home yet. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 21 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 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 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 x Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 22 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 YA6 Regulation 15 Requirement The provider must improve the content of each residents care plan. (Timescale of 12/11/04 and 01/12/05 not met). Risk assessments must be reviewed and updated. (Timescale of 01/12/05 not met). Suitable provision must be made for storage. (Timescale 01/12/05 not met) The home must have a quality assurance system in place. Timescale for action 01/08/06 2 YA9 13 01/08/06 3 4 YA28 YA39 33 (2) 24 01/10/06 01/09/06 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 YA27 Good Practice Recommendations Consider putting in height adjustable baths so they are easier for the residents and staff to use. Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 23 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 Pengarth DS0000000545.V288880.R01.S.doc Version 5.1 Page 24 - 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. 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