Inspection on 06/07/05 for Pengarth Road (57)

This inspection was carried out on 6th July 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 but made no statutory requirements on the home.

Other inspections for this house

Pengarth Road (57) 07/11/06

Pengarth Road (57) 24/01/06

Pengarth Road (57) 09/02/05

Pengarth Road (57) 31/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 PENGARTH ROAD 57 PENGARTH ROAD BEXLEYHEATH KENT DA5 1DS Lead Inspector KEITH IZZARD ANNOUNCED 6 July 2005 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 ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service PENGARTH ROAD Address 57 PENGARTH ROAD, BEXLEYHEATH, KENT, DA5 1DS 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) 01622-769-1000 MCCH SOCIETY LIMITED CARE HOME 6 Category(ies) of LEARNING DISABILITY - 6 registration, with number of places PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 4/02/05 Brief Description of the Service: The home provides a long term care service for four men with a severe learning disability, who for the most part have challenging behaviour and autism. O’ Brien’s five accomplishments of community services are used as a set of standards that the home aims to provide for service users. The home provides 24 hour support with waking night staff provision. Daytime opportunities/ are provided both through day centres operated by Bexley Council and within the home. The home receives extensive input from the community learning disability team, around the area of challenging behaviour. Over the past year the home has reduced the number of residents accommodated by one and the registration certificate will be amended accordingly. The home is now jointly managed with another home for two severely learning disabled residents that is very close by. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was completed on one day over a period of 4.5 hours. Over the past year two residents moved from the home in order to better meet their assessed needs. The home was clean, tidy and safe and staff members were observed to be both caring and professional in the way they related to the resident at home at the time of inspection. This inspection included observation of the care provided and talking to staff and management. Inspecting records, safety systems and the premises. What the service does well: What has improved since the last inspection? The home now has a new manager. The home continues to provide good attention to detail in providing a caring staff team who act professionally in the best interests of residents. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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 ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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 ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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) 1-5 Adequate information was provided about the service in the statement of purpose and service user guide to enable prospective residents to make a decision to the suitability of the service. Admission procedures were in place to comply with these standards. Contracts for residents have still not been made available and this remains an outstanding requirement of previous inspections. EVIDENCE: The home had a statement of purpose and service user guide. The admission procedures in place complied with the requirement. As no new residents had been admitted since the introduction of the National Minimum Standards, the procedures had not been implemented and could therefore not be assessed in practice. The provision of contracts for residents is an outstanding requirement and has not been complied with. Restated Requirement 1. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 9 PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 10 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) 6-10 From the evidence provided and relatives’ comments received staff worked positively to meet resident’s individual care needs. EVIDENCE: Records were examined of individual planning meetings of service user’s needs and goals identified which are being reviewed regularly on a six monthly basis. Additionally, clinical meetings with CLDT have taken place regularly when specialist individual support with complex health problems such as challenging behaviour are dealt with. Interaction observed between staff members and service users provided evidence that residents are enabled by staff to exercise choice in respect of what drinks, meals they have and what activities they would like to be involved in. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 11 Residents do not have the capacity to understand that information is held about them. Nevertheless, this information is stored confidentially within the home. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 12 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) 11-17 From the evidence provided and the information obtained staff worked towards providing residents with lifestyles suited to their ability and preference. EVIDENCE: Residents are encouraged to participate in household tasks when identified as safe to do so in terms of possible challenging behaviour and in accordance with guidance in their individual risk assessments. Access is available for service user to the local day care facilities, however this is limited owing to the challenging behaviour of most of the service users, which requires a high level of staff intervention and support. It is unlikely that any of the service users would have sufficient capacity to benefit from further education or employment. Records seen showed that trips out to local shops and parks and the use of various community facilities occur on a daily basis. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 13 Service user’s families and friends are able to visit the home at any reasonable time. Staff members stated that evening or weekend events organised in the home include specific invitations for those who have active involvement with service users. No restrictions are in place in terms of contact with service users excepting any challenging behaviour that might be exhibited on occasion. The four residents benefit from the provision of a housekeeper for the home as she possesses a detailed understanding of their likes and dislikes regarding food. Menus were examined and these showed that meals are both varied and nutritious. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 14 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) 18-21 Care plans were well written showing how resident’s personal and healthcare needs were met. Medication was found to be well organised. EVIDENCE: Care plans showed the level of personal care required and how this was to be provided. Residents were supported to access health services appropriately and had these provided either in the home or attended local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to heath needs on a regular basis and that this is reviewed. Staff spoke with knowledge and confidence about resident’s individual needs and preferences. For example, around times for getting up, going to bed, whether they preferred to lie in, preferences for a bath or a shower and mood indicators. All residents were registered with a G.P and it was evident they were supported to access other health care such as dental, optical, dietician and chiropody. Specialist health care was accessed through G.P referral and very close links maintained with the local Community Learning Disability Team. The medication system was examined and was found to be well organised. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 15 PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 16 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) 22-23 Adequate systems were in place to ensure residents were protected from abuse and to manage complaints about the service. EVIDENCE: The home had policies and procedures to deal with complaints and allegations of abuse. Staff have received training on adult protection and displayed their understanding of this. Any suspicions or allegations of abuse would be referred to the CLDT for investigation under adult protection procedures, as would any unexplained injuries. Robust systems were in place to safely manage the personal finances of residents and none of the staff acted as appointee for a resident. The system had a clear audit trail and was well recorded and managed. There were no allegations of abuse made about the service to the home or the Commission since the last inspection. One complaint received about the height of the trees in the garden was responded to within timescales and the home received a complimentary note expressing gratitude for the quick response. No other complaints were received either by the home or the CSCI. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 17 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) 24-30 The premises were homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs. EVIDENCE: The inspection included a tour of the building and it was noted that the environment met the standards. All the bedrooms had been redecorated to reflect the resident’s choice. Bedrooms were furnished and arranged so that resident’s physical and personal needs could be comfortably met and to reflect the occupants interests. It was recommended that the dining/ sitting room area is, generally, considered, for refurbishment and that the outstanding order for a new sofa must be implemented as soon as possible. Recommendation1 and Requirement 2. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Staff members understand their roles, are competent and well supported and were provided with sufficient training provided to ensure the needs of residents were met. All the staffing documentation required under Schedule 2 must be retained within the home. EVIDENCE: Most of the staff are longstanding members and have a good understanding of their roles and responsibilities. A new member of staff was also interviewed and gave a very satisfactory and clear response. The level of training provided and planned for all staff was examined and met the Standard both in terms of content and frequency. However it was not clear that the home will achieve the required 50 of staff trained to Level 2 NVQ by the end of 2005. An action plan stating how this will be achieved must be submitted in writing to the CSCI. Requirement 3. The deputy manager should ensure that she receives updated training now that a manager is in post. Recommendation PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 19 The documentation required under Schedule 2 of the Care Homes Regulations that must be retained in the home to evidence the recruitment process is still not fully complied with, despite a previous requirement. Two references in relation to one new member of staff were not available in the home but in the head office of the organisation, apparently. Restated Requirement 4. Staff members were observed to be working in a caring and professional manner with residents and the supervision records examined showed that the residents’ needs were being met by staff members, who themselves were both regularly supported and supervised. It was recommended that team meetings be held more frequently as these have reduced in frequency over recent months and should be held at minimum six times per year. Also, that all staff should receive equal opportunities and disability training in line with Standard 35.4. Recommendations 2 &3. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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 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) 37-43 The manager presented as running the home in an open and inclusive manner. Records, policies and procedures showed attention was given to ensuring the safety of residents and others. Records required by regulation were well recorded and appropriately maintained. EVIDENCE: Whilst team meetings have reduced it was evident that good communication exists between the manager and staff members. This was both observed and within the daily diary / communication book. Three relatives’ questionnaires returned and one from the GP for the home commented very positively about good communication and the positive attitude of staff. Whilst the new manager is physically based in the other home, this is just up the road and therefore facilitates frequent and easy contact and a speedy response, should an emergency situation arise. Both the deputy and the PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 21 manager reported a smooth transition since the manager’s appointment. How the joint appointment works will be reviewed again at the next inspection. The home does not have a quality review system in place to record the views of residents, relatives, advocates and visiting, or involved professionals. This must be introduced, the results published and generally made available. Requirement 5. Policies and procedures are retained in the home and met the Standards as they were comprehensive and are readily available to all staff members. A sample of the records required to be retained to evidence health and safety checks and routine inspections were seen and found to be up to date and comprehensive. The deputy manager reported that the local Fire Officer was due to visit the home the following day, any recommendations or requirements made arising from this inspection must be implemented without delay. The deputy manager agreed to seek advice regarding door fireguard mechanisms, as this was the subject of a partial requirement made at the previous inspection and still to be complied with. Requirement 6. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 PENGARTH ROAD Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 23 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 5 Regulation 5 Requirement The Registered Person must ensure that a written contract is provided for each service user and includes a copy of the service user care plan.Restated Requirement (previous compliance dates of 1.06.04, 1.12.04 ansd 1.05.05 not met). The Registered Person must ensure that the sofa in the dining/ lounge area is replaced as soon as possible. The Registered Person must ensure that an action plan is submitted to the CSCI clarifying when the required 50 NVQ level 2 staffing will be achieved. The registered Person must ensure that all documentation required in Schedule 2 is retained in the home and available for inspection. The Registered Person must ensure a system is in place to review and improve the quality of care provided in the home. Outcomes on the quality assurance reviews must be made available to residents, relatives the Commission and others. The Registered Person must G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Timescale for action 1st November 2005 2. 24 23 1st November 2005 1st November 2005 1st November 2005 1st nonember 2005 3. 32 18 4. 34 19 5. 39 24 6. 42 23 1st Page 24 PENGARTH ROAD Version 1.30 implement any requirements or recommendations arising from the Fire officers report and seek clarification regarding the use of door fire guards. November 2005 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. 2. 3. 4. Refer to Standard 24 36 35 Good Practice Recommendations The Registered Person should redecorate and refurbish the loounge/ dining area. The Registered Person should ensure that team meetings are held at least six times per year. The Registered Person should ensure that all staff receive training in equal oportunities and disability awareness,in accordance with this Standard. PENGARTH ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection SIDCUP AREA OFFICE RIVER HOUSE, 1 MAIDSTONE ROAD, SIDCUP KENT DA14 5RH 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 ROAD G51-G01 S37816 Pengarth Road V223307 06--0705 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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