Inspection on 11/08/08 for Pennine Care Centre

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Pennine Care Centre Off Turnlee Road Glossop Derbyshire SK13 6JW Lead Inspector Susan Richards Unannounced Inspection 11th August 2008 09:00 X10015.doc Version 1.40 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 Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pennine Care Centre Address Off Turnlee Road Glossop Derbyshire SK13 6JW 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) 01527 594030 Canterbury Care Homes Ltd Manager post vacant Care Home 64 Category(ies) of Dementia (64), Old age, not falling within any registration, with number other category (64) of places Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service user who can be accommodated is 64 New registration (change of ownership) as of 15 February 2008). 2. Date of last inspection Brief Description of the Service: Pennine Care Centre is a large converted property with a purpose built extension. It has operated as a registered care home for many years and has recently undergone a change of ownership, resulting in the registration of Canterbury Care Homes Limited as the registered provider as of 15 February 2008. This is therefore their first inspection. The home is situated on the outskirts of Glossop accessed via a private road, set back from the main road, bus route and local amenities. Accommodation is provided in two adjoining units, served by a central kitchen and laundry. Pennine Suite provides personal care for up to 36 older people aged 65 years and over with accommodation and facilities provided over two floors. Pennine Suite has 30 single and 3 double bedrooms. One single and one double have en suite facilities. There are dedicated dining and lounge facilities, including a small quiet room. There is a garden /patio area with seating off the main drive, which is accessible to service users. Moorland Suite is a purpose built unit providing personal care for up to 18 older persons with dementia and 10 places for persons aged 50 years and over with dementia. Accommodation and facilities here are also provided over two floors. Moorland Suite has 28 single bedrooms. All bedrooms except for one room have en suite toilets and hand washbasins. There are dedicated lounge and dining facilities, with a choice of lounge areas. An enclosed rear garden/patio area with seating is accessible to service users. Communal bathroom and toilet facilities are provided on each unit, including shower facilities. Each suite has a team of care and hotel services staff and a unit manager led by the service manager, who is newly appointed, having commenced her Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 5 employment at the home the week before our inspection. Fees charged by the home as at the date of this inspection are as follows: Funding via local authority arrangements: £364.31 standard rate. Funding via individual private contract agreement: £440.00. This information is provided by the administrator at our visit of 11 August 2008. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This is the first inspection of the service since registration of Canterbury Care Homes Ltd in February 2008 following a change of ownership for the home. For the purposes of this inspection we have taken account of the information we hold about this service. This includes our annual quality assurance assessment questionnaire (AQAA), which we asked the home to complete in order to provide us with key information about the service. We also received survey returns from two people who use the service (out of a total of twenty surveys sent out) and also five staff who work there (out of a total of ten surveys sent out). At this inspection there were fifty-four residents accommodated at the home. We used case tracking as part of our methodology, where we looked more closely at the care and services that three of those people receive. We did this by talking with people, direct observation of staff interactions with them, looking at the written care plans and associated health and personal care records and by looking at their private and communal accommodation. We spoke with staff about the arrangements for their recruitment, induction, training, deployment and supervision and we examined related records. We also spoke with the acting manager and the administrator about the arrangements for the management and administration of the home and we examined associated records. The acting manager commenced her employment at the home the week before our inspection. All of the above was undertaken with consideration to any diversity in need for people who live at the home. At the time of our visit all people accommodated are of British white backgrounds, with the exception of one of other European. All of Christian based religion (either practising or non-practising). We received a number of comments from people who use the service, some of which are included in this summary below. What the service does well: Overall people live in a comfortable environment, which for the most part suits their needs. (Although overall standards of repair and renewal are variable – the home’s commenced programme for the upgrading, repair and renewal of the home should ensure a more consistent and improved quality throughout). Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 7 People’s health and personal care needs are reasonably well met. Comments received include: ‘Staff is very good, kind and caring.’ ‘They always help me as necessary, but let me be as independent as I can.’ ‘I am well looked after.’ People can usually choose from a range of activities provided in the home and for the most part their daily living routines are upheld. People receive sufficient and nutritious meals, (although opinion varies as to the quality). Comments range from: ‘The food is good.’ ‘You get enough. ‘The food is OK,’ to ‘the quality varies.’ People are supported and protected by staff that are effectively recruited and reasonably well trained. People can be confident that the service will address any concerns they have and policy and procedural guidance for staff promotes their protection from abuse. What has improved since the last inspection? What they could do better: Develop the content and format and ensure accuracy of the information that people are provided about the service within the statement of purpose and service guide, including as to the actual range of fees charged per week and what they cover. Ensure that records that must be kept in the home relating to individual’s care or those concerned with the management of the home are consistently and accurately maintained in accordance with recognised standards for care and practise in respect of records and record keeping. Consider the implications for practise in the home in respect of the Mental Capacity Act 2005. Review practise in respect of table setting at mealtimes with a view to providing suitable table linen and placemats and ensure that formal consultation is regularly undertaken with people to ascertain their satisfaction with the quality of meals provided at the home. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 8 Ensure there is a full written programme in place for the commenced and planned upgrading, repair and renewal of the home, with identified timescales for achievement. Ensure that good infection control measures are always applied. Continue to review staffing arrangements to ensure that these are sufficient to meet people’s needs in accordance with any identified changes. Further review and develop the home’s staff induction and training plan to ensure it meets with recognised standards. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 & 3 (NMS 6 is not applicable to this service). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose/service guide document does not best or always accurately inform people. For the most part people’s needs are met by the home, although individual needs assessment records do not always account for practise. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they say that they people are provided with key service information and written contracts/terms and conditions to assist them in the admission process. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 11 They also tell us that people’s needs are fully assessed before they are admitted there and that they are encouraged to visit the home before making a decision. They say they could improve their assessment and admission process further and intend to do this over the coming months by liaising more effectively with key agencies and with people themselves or where applicable their relatives. Survey returns did not provide us with information as to whether they received a written contract or enough information about the home on their admission, being left blank. One person commented that although no information was provided, they did not ask for it and their family dealt with the contract. People case tracked could not recall receiving a copy of the home’s service guide or any key written information about the home. Copies of the home’s statement of purpose/service guide document were available in the home located in the residents seating and notice board area. However, this contains some misinformation, including under the heading ‘ range of Service and Facilities, that the home is registered for 64 clients needing nursing care. This is not so, as the home is registered under the Care Standards Act 2000 to provide personal care and support only. The guide also contains a number of detailed staff policies and procedures as opposed to clear user friendly information suitable for people for whom the guide is intended., including that relating to how to complain. Information about fees in the guide is general and focuses on national trends and guidance, rather than specifying clear information as to the home’s fees, what is included and what is not. A copy of a standard form of contract/terms and conditions is included. All people case tracked had copies of their purchasing contracts via local authority arrangements in place, although only two had individual terms and conditions between themselves and the home. The manager and administrator advised that these were being drawn up, although one of the people had lived at the home since December 2007. The other was admitted more recently. The guide is in standard print, with some parts in very small print. There is no information as to whether it can be provided in other formats, such as large print. The acting manager was completely aware of the failings of the guide and advised us of her intention to review/revise this. For the two people we case tracked accommodated on the Pennine Suite, there were significant omissions of recording in their needs assessment (and care planning documentation). We were advised at our visit, that the home is in process of introducing revised standardised needs assessment and care Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 12 planning documentation for each service user and that transfer to these is completed on the Pennine Suite for approximately two thirds of the client group there. Discussions with the manager and senior care indicated that the focus has been on the transfer of information onto the revised format. These were sampled indicating reasonable progress to date. We discussed with the manager, the need to ensure that people’s needs’ assessment information is fully recorded, and kept up to date, whichever format it is kept in. The recorded needs assessment information we looked at for the person case tracked on the Moorland Suite was mostly well documented and up to date. We spoke with the senior staff there about the changing needs of the client group on Moorland Suite Staff spoken with is conversant with the needs of people we case tracked and people who use the service told us that they usually receive the care and support they need. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are reasonably well met, although omissions in record keeping mean that practise is not always best accounted for. EVIDENCE: In our annual quality assurance questionnaire completed by the home they detail a comprehensive approach to ensuring that people’s healthcare needs are met. This includes promoting a person centred approach to people’s care, operation of a key worker system, ensuring care plans and care practises are reflective of and in accordance with recognised standards of practise concerned with the care of older people (falls, nutrition, pressure ulcer prevention etc), in ensuring access to outside healthcare professional, including for purposes of routine health care screening – all aspects and end of life care and support for people. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 14 They tell us they are currently updating people’s written care plans onto Canterbury Care standardised care planning documentation, that they are actively involving people and their representatives in the care planning process and in training staff in respect of best practise. They say they intend to improve further over the coming months by full introduction of Canterbury’s Care’s care planning documentation, obtaining comprehensive life history details for each person accommodated and fully accounting for people’s end of life wishes in consultation with them. They also say that on completion of care planning documentation they intend to invite people’s relatives in to discuss these on an individual appointment basis. They do not refer to consultation with people themselves about their care plans. We discussed this with the manager at our inspection visit with regard to Data Protection and the requirement to obtain people’s individual consent to consult with relatives as to their care plans and the implications of the Mental Capacity Act 2005 for care homes. The manager is aware of the existence of the Act and advised that neither she nor staff to date have received training or instruction in respect of this, although stated that she intended to secure this. People told us that they usually receive the care and support they need, that staff always listen and act on what they say and that they always receive the medical support they need. Comments received included: ‘Staff is very good, kind and caring.’ ‘They help me as necessary, but let me be as independent as I can.’ ‘I am well looked after.’ Comments made under Section One of this report in respect of omissions of record keeping in the needs assessment and care planning records of people case tracked on the Pennine Suite also apply here. Again staff were working hard on ensuring up to date needs assessment and care planning information is recorded onto the company’s newly introduced standardised format for each resident, with almost two thirds of these completed. However, in the process, for one person case tracked whose original ones remain as current working documents. They have not been kept up to date, with significant omissions and in respect of another new admission, there were none recorded. As stated under Section One of this report, we discussed these with the manager. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 15 Overall the arrangements for the management and administration of medicines for those people we case tracked are satisfactory. However, for one person whose medicines instructions were hand written on their medicines administration record (MAR) sheet, these were not signed and dated by the staff member copying these into the MAR sheet, nor countersigned by a staff member witnessing these. Occasional gaps in recording were also seen on two people’s MAR sheets where staff responsible for administering medicines had not signed these as given nor entered the appropriate code determining the reason why they may not have been given. One person that we case tracked told us that staff retained their medicines on their behalf, with the exception of a prescribed cream, which they kept themselves. There was no recorded risk assessment in place in respect of this and although the medicines policy contained guidance for self-administration of medicines there was no standardised risk assessment tool in place in respect of this. During our tour of the building we observed prescribed out medicines to be left out in two people’s own rooms, which were removed immediately by staff, that advised us that the people accommodated there did retain or administer their own medicines. However, although not all bedrooms are provided with lockable storage facilities, should people wish to retain and administer their own medicines and be safe to do so, this is being addressed via a programme of refurbishment and upgrading underway. (See also the Environment section of this report). Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14, & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can usually choose from a range of activities, although known lifestyle preferences in respect of access to the local community could be improved for some people. Record keeping does not effectively account for individual’s capacity where decisions about their care, (and their daily lives and treatment) is made on their behalf. People receive sufficient meals, although regular quality review and monitoring of these and table settings should ensure people’s expectations are better accounted for. EVIDENCE: Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 17 In our annual quality assurance questionnaire completed by the home they say that they encourage and promoted people’s inclusion in respect of making daily living choices and decisions about their lives, including in respect of their daily living arrangements, activities, visitors and meals in accordance with their beliefs. They say that where a service user has not got the capacity to make a choice about their life or treatments that they encourage advocacy from relatives. They also tell us that they provide people with regular opportunity to engage in activities and that people receive appetising and nutritious food in accordance with their individual choices and assessed needs. They have identified key improvements recently made, which include a review of their activities co-ordinator role and visiting arrangements, in consultation with people who use the service. They feel they could improve their recording of people’s choices and preferences and by promoting better access to the local community for people. They say they aim for further improvements in respect of people’s daily living experiences by way of ongoing established consultation with them, staff training and via individual’s care plans. People surveyed and spoken with told us that there is usually activities organised by the home, which they can join if they choose. One person, case tracked told us they go out to a day centre to play dominoes, once a week and also go to the local pub for lunch on occasions and usually choose to spend their time in their own room later afternoons/evening, where they like to watch TV. Another also liked to spend time in her room reading, although stated that she could join activities if she choose. Many people told us that their preferred routines and daily living choices are usually upheld and that they were able to bring in their own personal possessions into the home when they moved there. (See also comments made under the Staffing section of this report in respect of some people accommodated on Moorland Suite and their lifestyle expectations with regard to community access). People also told us that they receive sufficient food at the home and can choose to eat in their own rooms if they wish. Comments received as to the quality were variable and included: ‘The ‘You ‘The ‘The food is OK.’ get enough.’ quality varies.’ food is good.’ Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 18 We observed lunches being served in the main dining room on the Pennine Suite. There were no tablecloths, napkins or place mats provided and a large number of people were pushed to the table in their wheelchairs and remained in these to eat their lunch. We also observed a staff member assisting a resident with their eating and drinking who also sat in a wheelchair. However, complete new dining furniture and chairs were delivered to the home and the dining room re-furnished during the afternoon of our inspection visit. Menus are displayed and are provided on a four weekly rota. People told us that their friends and relatives are able to visit at any time they wish them to. There is capacity within the homes’ standardised needs assessment and care planning format for staff to record information about people’s social needs and daily living routines and preferences, although for two of the people we case tracked this information was not recorded. There was some information detailed in respect of the third person, accommodated on the Moorland suite, although their social history profile had nothing recorded there. Where decisions are made in respect of people’s care and treatment on their behalf, individual needs assessment and care-planning records did not clearly account for their individual capacity in accordance with the Mental Capacity Act 2005. We discussed this with the acting manager who advised that she would seek to source training for staff in respect of this. Information is provided about daily activities offered within the service guide and posted onto the residents’ notice board. These include gentle exercise activities such as soft ball games, outdoor/indoor skittles, carpet bowls, a range of board games, sing-alongs, videos, newspapers and magazines and periodic entertainment. There is also a visiting hairdresser. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People may be confident to address any concerns they have about the home and policy and procedural guidance for staff promotes their protection from abuse. EVIDENCE: In our annual quality assurance questionnaire completed by the home they say that they advise people as to how to complaint via their service guide. Also that they record and act on all complaints received and encourage suggestions and comments by way of an open comment book. They also tell us that people are protected from harm and abuse and that staff are suitably trained and instructed in this area in accordance with key policy and procedures. They say that since their registration they have improved the systems and arrangements for service users monies and the recording of complaints. However, they feel they could improve further in respect of individual care planning and staff training with regard to dealing with any challenging behaviours and by raising people’s awareness further as to how to complain. They aim to do so over the coming twelve months. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 20 They told us that they have received three complaints, none of which were substantiated and one safeguarding referral. At this inspection people told us that they know how to speak to if they are not happy or have any concerns. This was usually either by way of their key worker or the senior carer on the Pennine Unit. However, people did not know how to make a formal complaint, although said that they never need to as matters raised are usually dealt with. Information about making a complaint is displayed on the residents’ notice board area on Pennine Suite, at the main entrance to the home and also within the service guide. There is also a comments book openly available on each unit. However, the procedure requires review to ensure that the role and contact details of the Commission are accurate. Records are in place of four complaints received by the provider about the home, since its registration in February 2008 up to the date of our inspection visit, including one, which is currently under investigation. These related to the following areas: Change of smoking policy at the home Standards of personal care x2 Laundry service x2 Details of their investigation, outcomes and action are also recorded. There are comprehensive policy and procedural guidance in place concerned with recognising abuse and safeguarding people. Staff spoken with is aware of the existence of these and what action they should take in the event of any witnessing or suspicion of abuse. However, safeguarding is not included in the home’s formal induction process and current training plan. We discussed this with the acting manager (see Staffing section of this report), who is in the process of securing this. The person case tracked accommodated on the Moorland Suite had a written care plan in place in respect of their aggression/challenging behaviour, although this was not clear in its reference to the use of restraint. Senior staff there advised that they did not employ physical restraint, and described a satisfactory approach in utilising diversionary and de-escalation techniques with that person. They said that most but not all staff had received training in dealing with violence and aggression/challenging behaviours, although understood that this was planned. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall people live in comfortable environment, which for the most part suits their needs, although the overall standards of repair and renewal are currently variable. However, thorough completion of their upgrading, repair and renewal of the home should ensure that that people benefit from improved environmental standards throughout. EVIDENCE: In our annual quality assurance questionnaire completed by the home, they say that the home is undergoing a refurbishment programme, with all people’s own rooms to be completed. That the home provides people with homely, clean and single room accommodation in an attractive setting, adapted and Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 22 equipped to suit people’s needs, including those who may have mobility problems. They say that since their registration they have improved the tidiness and maintenance of the external grounds, reviewed the internal cleaning programme and commenced a redecoration and refurbishment programme. They say they could improve further by completing decoration and refurbishment needed, including all people’s bedrooms and in ensuring that staff act promptly in respect of odours and that they intend to address these over the coming months. At this inspection people told us that the home is always fresh and clean and the communal areas we inspected and the bedrooms of those we case tracked were clean, personalised and adequately furnished and equipped, although one room (occupied), which we randomly inspected was in need of a thorough clean. The acting manager advised that a programme of upgrading, repair and renewal had commenced on Pennine Suite and recent minutes of a staff meeting showed an agenda item discussed with staff regarding cleanliness within the home. A number of areas of redecoration and renewal had been completed, to empty bedrooms, ground floor corridor and communal areas. However, there is no full written programme available for this. There are some areas, which service users access, which do not have radiator covers/guards and hot water from one bathing outlet was cold. We were advised at our visit of work that has commenced in respect of these, which we discussed with the maintenance person responsible for this work. They advised us of work undertaken to date and that the latter should be completed within the next few weeks. The acting manager advised us of satisfactory measures to ensure safe bathing at the home, whilst this work is being undertaken. Many bathroom areas are tired and in need of redecoration, although the first floor shower room on the Pennine Suite was in the process of being retiled/refitted. There are a number of windows in the home, which require repair. Waste bins in many areas were not fully occlusive or fitted with lids and the first floor sluice room on the Moorland Suite is also being used for activities personnel and staff to store materials and records concerned with activities. Having a desk and filing cabinet located alongside the hand sluice. The Environmental Health Officer of the local authority had inspected the kitchen/catering facilities on 05 February 2008 and made a number of recommendations and the Fire Officer from the Derbyshire Fire Authority carried out a fire safety inspection on 05 February 2008 who also made a Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 23 number of recommendations. The administrator advised us of work undertaken to date in respect of these. We are advised by the home that the recommendations of the Environmental Health Officer are achieved and that some of the Fire Officer’s is achieved with works underway to ensure compliance with those remaining. . Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported and protected by staff that are effectively recruited and reasonably well trained. Although staff deployment arrangements do not consistently promote people’s daily living expectations and lifestyle preferences. EVIDENCE: In our annual quality assurance questionnaire completed by the home they say that staff are effectively recruited, inducted, trained and deployed. And, that they have reviewed all systems and procedures with regard to the above with a view to ensuring these are in accordance with best practise. They tell us that they could improve further by revising and implementing their staff induction and training programme, which they aim to do following their analysis of staff training needs. They also tell us in the AQAA that induction training meets with nationally recognised standards. That twenty-six staff have achieved at least NVQ level 2 with nine undertaking at least NVQ level 2 (out of thirty-two people). And that 100 catering staff have food hygiene and handling training and 0 care staff. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 25 At this inspection people said that staff listen and act on what they say and are usually available when they need them. They also said that staff are respectful in their approaches towards them and we observed the same during our visit. Staff described mostly satisfactory arrangements for their induction, training and recruitment and for the most part staff records reflected this. Although in staff surveys some commented that there are not always enough staff. Particular reference was made to the Moorland suite during the afternoon, which was stated as having three care staff for twenty-five people. Observations of the client group accommodate and examination of records along with discussions with senior staff on Moorland identified that there have been significant changes over the last twelve months in terms of the individual needs, expectations and age range of the client group accommodated there. This has resulted in a demand for increased access to the local community for named individuals, in order to accord with their daily living preferences and expectations and capacities. Current staffing levels do not consistently accommodate this. The unit leader there advised that they are liaising with individual’s placing authorities in order to negotiate additional support for community access for people. Monthly meetings with residents and their relatives/representatives had recently been introduced. Matters arising included that relating to insufficient staffing levels in the home. At the time of our inspection visit care-staffing levels had been increased to provide four care staff to each unit throughout the day in response to this. This included the use of agency staff, although full details of agency staff were not recorded onto the duty rotas. The hours worked by the new acting manager were also not recorded onto the rota. A number of new staff starters recently had been recently recruited subject to satisfactory clearance checks. A full staff training needs analysis had been undertaken and training plan formulated and a formal approach to staff induction is also in place. However, these did not provide for safeguarding vulnerable adults training and instruction or Mental Capacity Act 2005. The acting manager advised that she intended to secure these. We discussed the management approach to determining staffing levels with the acting manager, who advised that a formal staffing tool accounting for people’s individual dependency needs is not used to determine staffing. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recent appointment of a manager for the home should benefit people and ensure that it continues to be managed in their best interests EVIDENCE: In our annual quality assurance questionnaire completed by the home, they say that the home is effectively managed by a competent manager and describe appropriate key management and administration systems they employ to ensure this. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 27 They say that since their registration they have reviewed and improved their system for management handling of service users monies and introduced a new monthly auditing system with corrective actions identified within the records for these. They tell us that they could improve further by developing and introducing a more effective system for staff supervision and by ensuring timely transfer of all care records onto Canterbury Care’s documentation system, which they aim to do along with introducing a business plan, marketing strategy and supervision and ISO 2001 training. They also tell us that all key policy and procedural guidance is in place, which was last reviewed 2007 and the information they gave us about their arrangements for the maintenance of equipment in the home is up to date. At this inspection we spoke with the acting manager for the service, having been in post since the previous week. The previous registered manager had been absent from the home since April 2008 and recently left employment there. During that time temporary interim management arrangements were employed up to the employment of the current acting manager. The acting manager advised us that she intends to pursue an application for registered manager with the Commission and also told us about some of the training she has undertaken relevant to this role. She demonstrated an awareness of the need to continue to keep up to date with practise, promote safeguarding and to improve and develop systems that monitor practise and compliance with the plans, policies and procedures of the home. Staff expressed positive views about the changes in the home and described satisfactory arrangements in respect of their management and supervision. The manager told us about their quality assurance and monitoring systems, which included monthly visits to the home by a representative of the registered provider and we looked at the report of those visits, which accord with required practise. We also looked at the standardised format in place for the monthly home assessment/audit, which to be introduced, along with an annual plan for the home. Monthly meetings with residents and their relatives/representatives had recently been introduced. (See also the Staffing section of this report regarding an area of matters arising). Residents and relative satisfaction surveys were also being introduced. As identified under the Staffing section of this report there were omissions in record keeping in the home in respect of people’s needs assessment, care Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 28 plans and medicines records. Staff duty rotas also did not give details as to agency staff used and the hours worked by the acting manager. Staff described satisfactory arrangements in respect of ensuring safe working practises at the home and staff-training arrangements are satisfactory in respect of these. There are satisfactory arrangements in place for the maintenance of systems and equipment at the home. (Matters relating to environmental upgrading, repair and renewal, including hot and cold water systems maintenance is referred to under the Environment section of this report). There are satisfactory systems in place for the reporting and recording of accidents and incidents in the home and staff is conversant with procedures to follow in respect of these. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 2 2 Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation Requirement Timescale for action 31/10/08 2. OP1 3. OP1 4(1)(c) S1 The statement of purpose must be amended to accurately detail the range of needs the care home is intended to meet. The detail that the home provides nursing care must be removed. This is to provide accurate information for people as to the home’s registration category. 4 (1)(a) The statement of purpose must 30/11/08 S1 be developed so as to inform people about how needs of people accommodated on the Moorland Suite are to be met in respect of their dementia, this should include aims and care philosophy and staff training. 5 The service guide must detail the 30/11/08 total fee payable in respect of the services and provision to service users and the arrangements in place for charging and paying for any services additional to those stated above where necessary. So as to ensure that people are provided with up to date, open and transparent information about fees charged by the home DS0000071418.V370168.R01.S.doc Version 5.2 Pennine Care Centre Page 31 4. OP3 14 5. OP7 15 6. OP9 13 in accordance with Regulation 5 (amended 2006). People’s needs assessment 01/10/08 records must be effectively recorded, kept under review and revised at any time when it is necessary to do so. Written care plan must always 01/10/08 be in place in respect of each service user after consultation with them, which clearly specify as to how their risk assessed needs in respect of their health and welfare are to be met. Care plans must be kept under review and revised in accordance with any required changes to their care as necessary. This is necessary to promote consistent and safe practise and to effectively account for individual’s care. There must be suitable 31/10/08 arrangements for the recording, safe keeping and safe administration of medicines in the home as follows: Gaps of recording must not be left in people’s medicines administration record sheets. Staff responsible for their administration must either sign for their administration or enter the coded reason for their nonadministration. For people who wish to retain and administer their own medicines suitable lockable storage must be provide in their own rooms and there must be a recorded risk assessment in place in respect of this, which is regularly reviewed. Medicines must not be left out in people’s bedrooms. They must be stored safely in accordance with recognised practise. DS0000071418.V370168.R01.S.doc Version 5.2 Page 32 Pennine Care Centre 7. OP16 22 8. OP19 13 & 23 9. OP26 13 10. OP27 18 This is to ensure that: People receive their medicines as prescribed or that where these are omitted the reason for this is effectively accounted for and monitored. To reduce the risk of misuse. That people who wish to retain and administer their medicines are safe to do so. The complaints procedures must be reviewed to ensure it provides accurate information as to the role and contact details of the Commission. A full written programme for the commenced and planned upgrading, repair and renewal of the home must be forwarded to the Commission, including timescales of and for achievement. This must include: confirmation as to the action being taken to ensure that all bathing outlets as provide hot water emitted close to 43 degrees centigrade. Suitable arrangements must be in place to promote good infection control. As follows: Waste bins in toilets and bathrooms must be fully occlusive. The sluice room on Moorland Suite must not be used for any other purpose. There must be at all times suitably qualified, competent and experienced staff working at the home in such numbers as are appropriate to meet people’s needs. This is with particular reference to enabling those residents accommodated on the Moorland suite to consistently access the local community in accordance 31/10/08 11/10/08 11/10/08 31/10/08 Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 33 11. OP37 17(2) S4 with their individually assessed needs, preferences, rights and lifestyle expectations. The duty roster of persons working at the care home must be accurately kept and record whether the roster was actually worked. 31/10/08 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 OP1 Good Practice Recommendations The service guide should be reviewed and developed to ensure that it provides key service information for people in suitable and alternative formats as may be necessary and which provides clear and user friendly information. It should also include service users views of the home. People’s recorded needs assessments should always be fully completed and kept up to date to cover their social interests, hobbies and religious (and cultural) needs and their daily living preferences and routines. The home’s medicines policy should be reviewed and a standardised formal risk assessment tool provided for staff to use in conjunction with the self-administration policy. People’s needs assessment and care-planning records should clearly account as to people’s capacity where decisions about their care and treatment are made on their behalf in accordance with the Mental Capacity Act 2005. A review of practise should be undertaken in respect of table setting at mealtimes, with a view to providing suitable table linen and placemats. (NMS 33 also applies here). Formal consultation should be regularly undertaken with people to ascertain their satisfaction with the quality of meals provided at the home. Ratios of care staff to service users should be determined according to people’s assessed needs with a formal system operated for calculating staff numbers required in accordance with guidance recommended by the DS0000071418.V370168.R01.S.doc Version 5.2 Page 34 2. OP3 3. 4. OP9 OP12 5. 6. OP15 OP15 7. OP27 Pennine Care Centre 8. OP30 Department of Health. The home’s staff induction and training plan should be reviewed further to meet with recognised standards include that relating to safeguarding vulnerable adults the Mental Capacity Act 2005. Pennine Care Centre DS0000071418.V370168.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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