Inspection on 14/11/06 for Pennine Centre

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pennine Centre 07/01/10

Pennine Centre 27/01/09

Pennine Centre 06/11/07

Pennine Centre 08/02/06

Pennine Centre 05/10/05

Pennine Centre 03/12/04

Pennine Centre 30/06/04

Pennine Centre 27/02/04

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

CARE HOME ADULTS 18-65 Pennine Centre Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH Lead Inspector Angela Sizer Unannounced Inspection 14 & 21st November 2006 09:00 th DS0000034637.V319353.R01.S.doc Version 5.2 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 DS0000034637.V319353.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 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. DS0000034637.V319353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pennine Centre Address Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH 01482 839311 01482 839021 pat.walker@hullcc.gov.uk 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) Kingston upon Hull City Council Mrs Patricia Mary Walker Care Home 12 Category(ies) of Physical disability (12), Physical disability over registration, with number 65 years of age (1) of places DS0000034637.V319353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the intended work as stated in the action plan in regard to the premises is carried out. Pennine Centre to provide personal care for one named service user who has reached 65 years of age. 8th February 2006 Date of last inspection Brief Description of the Service: The Pennine Centre is a modern purpose built building situated on a large housing estate on the outskirts of the city of Hull. It is operated by Kingston upon Hull City Council, social services department. There is an adjacent day centre. The Pennine centre has been over the past two years subject to major refurbishment. The home is now registered for up to 12 younger adults with a physical disability on a respite/short term basis and one named resident who has reached 65 years of age. The statement of purpose and service user guide has been amended and clearly states how the needs of the residents’ will be met. Although the work has been completed the Building Control Department and Fire Department have not yet stated that the building is fit for purpose and until that time the condition of registration will remain in place. The home is secure and has it’s own well tended grounds. Public transport is accessible adjacent to the home. Although local facilities are limited, a large retail centre can be reached by a short journey. The home has a ground and first floor with a passenger lift connecting the two. There is ample communal space for the service users to access including three lounges, a visitor’s room and a large dining area. The home intends to use 4 of the bedrooms for respite care, 5 for long term residents and 1 as a step down bed with funding from the Health Authority, in addition on the first floor there are two rehabilitation bedrooms. All new residents are given a service user guide explaining what the home will provide. The weekly fees range between £25.60 and £77.42 this information was provided by the registered manager during the inspection visit on 14.11.06. Additional charges are made for toiletries, newspapers, activities and transport. DS0000034637.V319353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was part of the key inspection process and took place over two days and took a total of 8.5 hours. Prior to the visit surveys were posted out to; 12 residents and 10 were returned, 25 were sent to staff members and 11 were returned, of the 4 sent to health and social care professionals 2 were returned and 4 care management/placement officers surveys were sent out and 2 were returned. The registered manager returned the pre-inspection questionnaire and this gave some details about the service including staffing. From this information the decision was made about which staff and resident files would be looked at. A tour of the building was undertaken, some of the records looked at included 3 resident files, 3 staff files, the medication procedure and other paperwork relating to the maintenance of the home and the care of the residents. Several of the residents and six staff members were spoken to throughout the course of the two days to find out what it was like for people who live there. The previous requirements were discussed with the manager and approximately half of them have now been met. Although the refurbishment of the building is complete the home has not yet been inspected by the Building Control Department and Fire Department confirming that it is safe. A discussion with the manager occurred regarding how the residents are supported to follow their religion of choice and practise their faith. Other issues such as physical needs arising from having Parkinsons, Huntington’s and Motor Neurone conditions were talked about, the manager confirmed that if staff need to attend training sessions or seek advice from professionals then they are supported and encouraged to do so. Other training is offered in relation to epilepsy and diabetes as they have caused problem areas for staff. One staff member stated, “I was key worker to someone with Parkinsons disease and I did not feel confident about dealing with this, so I attended some training and this gave me more confidence. I feel that I understand that person’s needs better and I am not afraid to ask for help”. Equality and diversity training has been attended by all staff as the Local Authority has made this a compulsory event, this ensures that residents are not excluded because of a diverse need. The registered manager was present throughout the two days and was told how the inspection had gone at the end of the 2nd visit. An official letter was left with the manager with regard to the fire alarm system and the automatic opening doors that have sensors fitted. The Local Authority were given 48 hours to take urgent action to ensure the health and safety of the building and it’s residents and put right the requirement made by Fire Department in June 2006. DS0000034637.V319353.R01.S.doc Version 5.2 Page 6 The inspector would like to thank the residents, manager and staff for welcoming her into the home and contributing to the content of this report. What the service does well: What has improved since the last inspection? DS0000034637.V319353.R01.S.doc Version 5.2 Page 7 The refurbishment of the home as enhanced the residents stay in the home by offering an excellent standard of accommodation. Some residents commented, “I am happy with my room and the big telly is good because Sky movies are on”, “the food is great, you get to choose what you want”, “the staff are very friendly and approachable”, “the home is spotless and visitors are welcomed”. Some of the paperwork continues to improve in particular the risk assessment documentation in relation to gastric tube feeding, but there are areas that require further development. Since the last inspection a new medication procedure has being implemented and the majority of the requirements made have been achieved. More than 61 of staff have now achieved NVQ level 2 or above. The home has developed a good quality assurance system, this incorporates regular liaison with residents, family/friends, other professionals, the completion of surveys and the correlation of this information throughout the year. What they could do better: Hull City Council’s building services has not yet arranged for the home to be handed back to the registered manager and the building control and fire department have not made final visits to ensure the health and safety of the building. During the visit the registered manager explained that although a new fire alarm system and automatic doors had been fitted a problem was identified in June 06 by the Fire Department, also a formal letter was issued by the Fire Authority stating that the home must address this requirement. The doors are automatically opened when a person goes near to them and this makes the building accessible to less mobile residents, but unfortunately when the alarm is tested or activated the automatic doors do not fail safe to the closed position. An official letter was left with the registered manager and a further letter sent to the Local Authority stating that this must be put right immediately in order to ensure the health and safety of all residents and staff. Some documentation requires further development, as some files were found to be messy, with crossings out and it was difficult to find information. The care plans and risk assessments do not include specific direction informing the reader about who does what and when. Choice is sometimes compromised, two residents confirmed that they are not always able to take a bath or shower when they would like to. DS0000034637.V319353.R01.S.doc Version 5.2 Page 8 The medication recording is not always accurate. A resident who was selfmedicating was not using the locked facility provided to store the medication and therefore other residents may have had access to this. Although the home does have a complaints procedure and responds quickly to complainants, the evidence seen does not fully investigate or explain any action taken or required action resulting from the complaint been made. Whist the staffing level is appropriate for the majority of the time; sometimes it is insufficient. From speaking to four residents it was confirmed that they are kept waiting for long periods for personal care tasks to be carried out, some comments included; “I had to wait for about one hour for staff to come and help me and I complained about this”, “the last time I came into Pennine I was only able to have three baths in a week, I prefer to have one everyday”. Six staff members were spoken to during the inspection visit and the majority stated that they felt the staffing levels were not adequate. Supervision is offered ensuring that the service and support offered is safe, but this lacks consistency. 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. DS0000034637.V319353.R01.S.doc Version 5.2 Page 9 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 DS0000034637.V319353.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents know that the home will meet their needs prior to admission. Each resident is issued with a statement of terms and conditions that describes the facilities offered. EVIDENCE: The home undertakes a thorough assessment of need for each resident and from speaking to staff and some of the residents it was clear that information is gathered before the person actually stays in the home. One person confirmed that they had received a visit from the manager and that she was able to tell the manager what her needs were and also discuss any worries before going into the Pennine Centre. Another resident stated that, “I had someone come to see me in hospital to find out whether the home could look after me, they were very nice and explained everything to me”. From speaking to the manager it was clear that wherever possible the home gathers as much information as possible both before and after admission. She stated that the situation had improved with regard to the Local Authority Care DS0000034637.V319353.R01.S.doc Version 5.2 Page 11 Management teams making inappropriate referrals that had previously been a problem. Three residents’ case files were looked at, this was to find out if their needs had been properly assessed, there was evidence in place to confirm that prospective residents are visited and an assessment undertaken that would show whether the home can meet that person’s needs. On each of the resident’s file was an assessment both from the Social Services Department and one that the home had developed, these clearly define what support is required. Since the last inspection the contract or statement of terms and conditions is issued to all residents upon admission has been amended; this clearly states the room to be occupied, facilities, fees and notice to be given. The paragraph that stated “in some cases it may be necessary to allocate another room to you during your stay and the Registered Manager reserves the right to carry out this action as and when necessary” has been changed to read in extreme cases only. DS0000034637.V319353.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place, some are not specific about what staff should do and when. Choice is promoted but residents are not able to make all decisions about everyday life. EVIDENCE: Three residents’ files were looked at to ensure that the correct paperwork is held in the home, also that clear direction is given to staff about how they should help and assist the residents. All of the files contained a care plan that the home had developed and although the manager stated that these had been updated since the last inspection, it was not always clear about what DS0000034637.V319353.R01.S.doc Version 5.2 Page 13 tasks staff are required to do and when. Some care plans require further amendment and must be prescriptive giving clear direction to staff telling them what the resident requires, when and how regular. Of the three files looked at one did not contain an up to date review and the file was messy with crossings out that made it difficult to read and understand. The manager explained that a staff member was currently updating the file, but accepted that the information wasn’t easy to locate or understand. Risk assessments have been updated since the last inspection, these now cover most areas include feeding residents through a gastric tube, mobility, self-harm behaviour and epilepsy. The care plans and risk assessments do not include specific direction informing the reader about who does what and when. Since the last inspection a resident who receives food and medication via a gastric tube has had their care plan and risk assessment updated. There was also written evidence from the GP confirming that the covert administration of medication was in the best interests of the resident, family also agreed with this decision. The moving and handling of residents has been risk assessed and these are clear, detailed and describes how staff should assist the person to move. One good example was for a blind resident and the staff are directed to introduce themselves upon and talk to the person as personal care tasks are being attended to. From speaking to five staff members it was clear that they had a very good understanding of all of the residents’ needs. They all spoke about what the care plans stated and fully understood how they should move and assist individual residents. Staff also confirmed that if a resident visits the home and has a specific need then usually specialised training would be available. One staff member stated, “when a new resident who had Motor Neurone disease came to stay we were able to go on some training to understand more about the illness, it was very useful and helped us understand the needs of the person better”. 10 surveys were returned from residents 9 of them confirming that they are able to make everyday decisions, one person stated that sometimes they are able to make decisions for themselves. During the inspection visit two residents were spoken to about making choices and again they both confirmed that overall they are able to do what they choose to do and when they prefer, apart from not being able to take a bath or shower at a time convenient to them or as regular as they would have liked. Several of the residents stated that staff respect their privacy, comments included; “staff usually knock before coming into my bedroom”, “the staff are lovely, always friendly and helpful”. There is a residents’ kitchen and this promotes independence and assists with daily living skills being developed or maintained. Staff were observed during the visit to interact with residents and offer care in a sensitive and understanding way. Six members of staff were spoken to during the visit about what the residents’ needs were; all staff could clearly describe what support the residents required and how this was undertaken. The staff team is experienced, professional and caring. DS0000034637.V319353.R01.S.doc Version 5.2 Page 14 DS0000034637.V319353.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ privacy and dignity is promoted and maintained. Residents are supported to live their lives as they wish to with regard to partaking in activities, hobbies and interests, staff supported them to do this. The menu is wholesome, plentiful, varied and nutritious. Daily routines are not always supported and sometimes choice is restricted with regard to bathing times and regularity. EVIDENCE: During the visit four residents’ were either spoken to about what it was like for them living in the home, some of the comments included; “I am happy with my room and the big telly is good because Sky movies are on”, “the food is great, you get to choose what you want”, “the staff are very friendly and approachable”, “the home is spotless, staff usually come quickly when I buzz and visitors are welcomed”. From observation staff were seen to interact with DS0000034637.V319353.R01.S.doc Version 5.2 Page 16 residents in a caring and thoughtful way, chatting to residents whilst offering support. Residents are encouraged to attend education, community centres and local events, written evidence of this was present in residents’ files, but this was also confirmed when speaking to the residents themselves. Residents also confirmed that regular activities take place within the home and there is usually something occurring on a daily basis, “we played dominoes yesterday and board games today, the TV lounge has a large screen telly and we watch Sky movies on that which I really enjoy”. The home had written evidence to confirm that other outings occur and the manager spoke about trips to the Deep and for lunches out. As mentioned earlier in the report choice is sometimes compromised, two residents confirmed that they are not always able to take a bath or shower when they would like to. Some comments included; “staff do their best, but sometimes there are not enough staff on duty to have a bath when I would like to”, “I like to have a bath in the morning before I go to the day centre and I know the staff would help me if they possibly could”. From speaking to several of the residents it was evident that they enjoy their mealtimes in the home, some comments included; “the food is gorgeous and when my husband visits he is able to have a meal with me”, “you couldn’t get much better, its like a five star hotel”, “there is always a choice, if I don’t like something I just say and I can have whatever I want”. 10 residents returned the surveys confirming that staff support residents in maintaining family links, friendships and relationships inside and outside of the home. From speaking to several residents it was clear that relationships and friendships are fully supported. One person explained that their husband visited daily and was always made welcome by the staff. The manager during discussion stated that the local community is accepting of the home and residents and include them in community events. Several of the residents attend the day centre situated adjacent to the home and also attend other community events or activities that they would normally do, “I go to the day centre a few days a week when I am at my own home, but I can also go when I come into the Pennine Centre for respite care”, “I like to go out to the pub sometimes and I am able to do this here”. DS0000034637.V319353.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents physical and emotional needs are not fully met. The medication recording is not always accurate. EVIDENCE: From speaking to the registered manager and staff it was clear that residents receive personal care in a way that maintains their dignity and privacy. Staff spoken to stated; “I always ensure I talk to the residents whilst undertaking any personal care tasks”. From looking at the residents’ files it was confirmed that independence is supported and residents have some control over their lives; times for getting up and going to bed vary. As detailed earlier, residents are not always supported to bath at times of their choice and therefore independence is restricted. One survey returned from a resident stated that a mobile hoist should be purchased, “it would be nice not to sit in my wheelchair all day”. When the DS0000034637.V319353.R01.S.doc Version 5.2 Page 18 manager was spoken to about these comments she confirmed that once the home’s refurbishment is completed and is approved by building control and the fire department an assessment of the building and adaptations will be undertaken by an Occupational Therapist. From looking at three of the residents’ files it was clear that regular health care checks are undertaken and appropriate records are kept. Since the last inspection a new medication procedure has being implemented and the majority of the requirements made have been achieved, these included ensuring that the quantity of medication is recorded upon admission, the medication administered correlates to the prescribed amount displayed on the printed label, any changes to come via the GP or Pharmacist and all medication must have a printed label detailing the persons name, date of dispensing, name and strength of medicine and dose and frequency of medicine. Temazepam is now stored and recorded as a controlled drug and there is a controlled drug register, there are two staff signatures for each entry. From checking records during the visit it was noticed that the amount of medication received into the home is not carried forward onto the Medication Administration Record, therefore making it difficult to audit what stock had been received and what had been used. The requirement is in relation to one resident being administered medication covertly in food has now been addressed and there was written evidence from the GP stating that this procedure was in the best interests of the resident, the family had also requested that this procedure was undertaken. One resident spoken to confirmed that she held her own medication, “I look after it at home and want to do the same here”. The home enables the resident to self-medicate and has a policy stating how they should do this, it was observed that the resident’s medication had been left out and from speaking to the resident it was clear that she had requested this. Before the inspection visit finished the inspector requested that the medication be placed in the locked facility provided in the resident’s room. DS0000034637.V319353.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that meets the resident’s needs who feel their views are listened to, but the written documentation requires expansion to include what action is required and by whom. A vulnerable adults procedure is in place, staff have undertaken the POVA training and demonstrated sound knowledge of the procedure. EVIDENCE: The home does have a complaints policy and procedure in place and from speaking to residents it was clear that concerns and complaints are listened to. One resident said, “I complained recently about not being able to take a bath when I chose to because of low staffing levels”. When asked if a satisfactory outcome had been reached the resident responded, “I am not sure the manager told me she would look into it, but I don’t know if this has been sorted out”. From looking at the written records it was clear that complaints are listened to and recorded, but it was less clear about what action was required if any and a response was not always given in written form to the complainant. The home has a multi-agency policy and procedure for the prevention of abuse, staff demonstrated a good understanding of this and training is DS0000034637.V319353.R01.S.doc Version 5.2 Page 20 mandatory. Two staff members were spoken to and they confirmed their knowledge about what the Protection of Vulnerable Adults procedure entailed, all staff have undertaken the training. Staff were able to talk about different types of abuse, signs and symptoms and what they would need to do about it. Financial records were looked in relation to the residents’ and these were all found to be up to date and accurate. DS0000034637.V319353.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is comfortable, homely and meets the general needs of its residents, but the health and safety of the residents is not ensured due to the problems with the fire alarm system and automatic doors not working correctly. The home is clean, fresh smelling and hygienic. EVIDENCE: A tour of the building was undertaken and overall the standard of accommodation, equipment and furnishings is of a very good standard. Unfortunately, Hull City Council’s building services has not yet arranged for the home to be handed back to the registered manager and the Building Control DS0000034637.V319353.R01.S.doc Version 5.2 Page 22 and Fire Department have not made final visits to ensure the health and safety of the building. During the visit the registered manager explained that although a new fire alarm system that has automatic doors had been fitted a problem was identified in June 06 by the Fire Department, also a formal letter was issued by the Fire Authority stating that the home must address this requirement. The doors are automatically opened when a person goes near to them and this makes the building accessible to less mobile residents, but unfortunately when the alarm is tested or activated the automatic doors do not fail safe to the closed position. An official letter was left with the registered manager and a further letter sent to the Local Authority stating that this must be put right immediately in order to ensure the health and safety of all residents and staff. Individual bedrooms have an electronic sink, which enables people with a physical disability to maintain their independence; one bedroom has an ensuite shower. There is a bathroom and disabled access shower room both are assisted, there are four communal toilets available to the residents. New signs have been placed upon bathroom, toilet, lounge and kitchen doors and these are in picture, written and Braille format. The hot water temperature is taken on a regular basis and recorded. The previous problem of the water being too hot has now being corrected. The carpet in the main entrance and hallway has been cleaned, but the Registered Manager stated that she is awaiting quotes for the replacement of the carpet. The beds are the electronic profile type and they move up and down, residents spoken to confirmed that the beds were comfortable and assist with their independence. There is a ceiling track hoist in all bedrooms apart from one smaller bedroom that is designated to residents who do not require assistance to move. It was noted that Room 12 did not have a lock on the door. Rooms 7, 9 & 11 did not have handrails in the shower area. An Occupation Therapist has assessed one half of the building that has been refurbished and there are suitable aids and adaptations in place including grab rails, assisted walk-in shower room and an assisted hydro-bath. One resident spoke about the hydro-bath, “it is lovely and very relaxing”. There is a ceiling-tracking hoist fitted in most of the bedrooms and bathrooms. Once the refurbishment is completed an occupational therapist will need to re-assess the whole of premises. Room 7 the light in the shower area was not working and requires attention. The home was clean and hygienic and there no malodour was detected. Disinfectant gel is situated in various places around the home and from speaking to staff it was confirmed that they had received training in relation to infection control. Ten surveys were returned from residents all of which were very complimentary about the cleanliness of the home, some comments included “the home is lovely and clean”, “its like a hotel, I cannot fault it”. Four DS0000034637.V319353.R01.S.doc Version 5.2 Page 23 residents were spoken to during the site visit about the environment and some of the comments were; “I love my room, I have everything I need, the bed is comfortable”. DS0000034637.V319353.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are insufficient at times and therefore residents may not receive the support they need. The home operates a robust recruitment procedure that ensures the residents receive support from properly vetted staff. EVIDENCE: During the inspection visit six staff members were spoken to about their roles and responsibilities. It was evident that the home has a varied and experienced staff group ensuring that the residents’ needs are on the whole met. Some comments from staff included; “the training opportunities are excellent, I have requested to go on Motor Neurone training because I wanted to learn more about the illness and how staff here can help people who have it. DS0000034637.V319353.R01.S.doc Version 5.2 Page 25 I was fully supported to undertake the training and feel more competent when dealing with the resident now”, “I have attended training for various things including Epilepsy, Parkinsons, Huntington’s disease all of these have helped me gain knowledge that makes me more confident”. From speaking to the staff members it was clear that they had a good understanding of the residents’ needs and could express what care was offered and the way in which the care tasks were undertaken, ensuring the privacy, dignity and independence of the residents. It was clear that the ethos of the home is to offer a very high standard of care in a sensitive and has adapted a person centred approach. Since the last inspection staff who administer medication and PEG feeding have updated their knowledge by attending training courses in these areas, there was written evidence to confirm this. More than 61 of staff have now achieved NVQ level 2 or above. Whist the staffing level is appropriate for the majority of the time; sometimes it is insufficient. From speaking to four residents it was confirmed that they have in the past been kept waiting for long periods for personal care tasks to be carried out, some comments included; “I had to wait for about one hour for staff to come and help me and I complained about this”, “the last time I came into Pennine I was only able to have three baths in a week, I prefer to have one everyday”. Six staff members were spoken to during the inspection visit and the majority stated that they felt the staffing levels were sometimes inadequate. Staff surveys received also stated that staffing levels are low when the home has higher level need residents who require two or more staff to assist with personal care. The service provider needs to critically examine the staffing level to ensure that all the needs of residents can be met. From looking at written records it was confirmed that staff receive supervision, but this is not always as regular as it should be. Staff confirmed that the manager and shift leaders are approachable and offer informal support on a daily basis. One staff member said, “I have only had three supervision sessions since April 2006”. DS0000034637.V319353.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s quality assurance programme is comprehensive and qualitymonitoring systems are based on seeking the views of all stakeholders, but an annual report is not currently produced. Residents’ health and safety is not always safeguarded, the fire alarm system requires attention as directed by the Fire Department. EVIDENCE: From speaking to several residents it was confirmed that the management of the home is approachable and usually any problems are dealt with quickly. Six DS0000034637.V319353.R01.S.doc Version 5.2 Page 27 staff members were spoken to about the general running of the home and they stated, “the manager is always available to talk to”, “the manager operates an open door policy”. The home has developed a good quality assurance system, this incorporates regular liaison with residents, family/friends, other professionals, the completion of surveys and the correlation of this information throughout the year. The home does not produce an annual report highlighting both positive and corrective action, a copy of which must be made available within the home and a copy forwarded to the CSCI. A newsletter has been produced informing the residents of events, activities, stories and staff news, it is well presented, colourful and interesting to read. All complaints and compliments are recorded. Unfortunately the Building Regulation or Fire Department has not yet approved the building work that has been undertaken. During the inspection visit it was highlighted that the Fire Officer had visited in June 2006 and stated that the fire alarm system required attention, an official letter was sent to the home on 16.06.06 stating that the doors fitted with automatic sensors should fail safe to the closed position upon the operation of the fire alarm system and that this was a requirement stipulated during the building regulation consultation phase of the recent refurbishment. This is to enable less able-bodied persons to leave the premises when the fire alarm system is activated. A push pad or break the glass override facility was recommended by the Fire Officer. During the inspection visit on 21.11.06 an official letter was issued stating that the fire alarm system must be made safe in accordance to what the Fire Officer has requested and action must be undertake within 48 hours. Following the inspection visit two telephone calls and two emails were made to the Commission confirming that the work has been assessed and will be carried out on the 5.12.06. A further telephone call and written confirmation was received stating that all but one door had had a push button mechanism fitted; the remaining door requires an additional part, which has been ordered. Unfortunately the problem remains when the fire alarm is tested and further work to the system is required. At the time of writing this report the risk remains that in the event of a fire the doors may fail to remain closed and could potentially spread a fire and therefore place the residents at risk. Documentation in relation to the maintenance of the building was in place to evidence that regular checks have been carried out. These included gas, electrical wiring certificate, the water system was checked on 9.2.06 and Legionella was not detected. The hoists and lifts were all up to date and evidence was seen confirming this. All of the mandatory training is offered to the staff including moving and handling, fire safety, first aid, health and safety, the protection of vulnerable adults and infection control. Evidence was seen on the staff files to confirm this and from speaking to the staff members it was clear that they undertook DS0000034637.V319353.R01.S.doc Version 5.2 Page 28 appropriate training and was fully supported to do so. Therefore the residents receive support from a well-trained and experienced staff group. A discussion with the manager took place with regard to the diverse needs of residents and how the home are able to meet those needs. The manager stated that currently none of the residents have a different ethnic background or culture. She did state that the cooks have looked at alternative menus in the event of the person from a different culture being admitted. Also that equality and diversity training is mandatory and therefore all staff have been trained appropriately and should be aware of differing needs the residents’ may have. The home offers support to a varied age group (18-66) and has appropriate aids and adaptations that would maintain independence. Some staff have also undertaken training in relation to Huntington’s and Parkinson’s disease, Diabetes and Epilepsy. DS0000034637.V319353.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 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 2 30 4 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 2 X X 1 X DS0000034637.V319353.R01.S.doc Version 5.2 Page 30 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 YA6 Regulation 15,17 Requirement All care plans must give clear direction to care staff. (Previous timescale – not met 05/01/06 & 8/04/06) Residents are able to make decisions about everyday life in particular when they choose to have a bath or shower. Risk Assessment should be made more specific, detailing any action to be taken and regularity of intervention. Previous timescale – not met 08/04/06) See standard 12. See standard 12. Medication stock must be carried forward onto the Medication Administration Record in order to provide a clear audit trail. Residents who selfadminister must use the lockable space provided to store their medication. Timescale for action 21/03/07 2 YA7 12 21/03/07 3 YA9 13,14,17 21/03/07 4 5 6 YA16 YA18 YA20 12 12 12,13 21/03/07 21/03/07 21/03/07 7 YA20 12,13 21/03/07 DS0000034637.V319353.R01.S.doc Version 5.2 Page 31 8 YA22 22 9 YA24 23 A record of all complaints must be kept, details of any investigation, action taken and the outcome. The registered person must ensure that the premises are fit for the stated purpose. Confirmation required that Fire Department and Building Control Department have inspected the building. (Previous timescale not met - July 04 & 08/04/06) All shower areas must have grab rails in place. Bedroom 7 en-suite light not working. Bedroom 11 & 12 require locks on doors. Dining room tables must be accessible to wheelchair users. Once the refurbishment is completed, an occupational therapist or similar will need to assess the building. The registered person must critically examine the staffing rota and ensure that the staffing levels are appropriate at all times in such numbers as are appropriate for the health and welfare of the residents. Supervision must be offered to all staff at least 6 times per year. (Previous timescale not met 05/11/05 & 8/4/06) 21/03/07 21/03/07 10 YA24 23 21/03/07 11 YA29 12,13,16,23 21/03/07 12 YA34 17,19 21/03/07 13 YA36 17,18 21/03/07 14 YA39 17,24 The quality assurance system 21/03/07 must be further developed DS0000034637.V319353.R01.S.doc Version 5.2 Page 32 15 YA42 12,13,16,23 and an annual report must be produced and the content shared with all stakeholders including a copy to be forwarded to the CSCI. The registered person must ensure that the fire alarm system ensures the safety of the residents, in particular the automatic opening sensors on the doors must fail sail to closed position upon operation of the fire alarm system – the home must liaise with the Fire Department. Immediate requirement issued – 48 hours given for action to be taken. 23/11/06 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 2 Refer to Standard YA6 YA24 Good Practice Recommendations Care Assistants who are also key worker or link worker to residents should attend reviews. The carpet in the main entrance hall and hallway will require deep cleaning or if unsuccessful will need replacing. DS0000034637.V319353.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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