Inspection on 27/01/09 for Pennine Centre

This inspection was carried out on 27th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 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 06/11/07

Pennine Centre 14/11/06

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Pennine Centre Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Angela Sizer     Date: 2 7 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Pennine Centre Pennine Way North Bransholme Kingston upon Hull East Yorkshire HU7 5EH 01482839311 01482839021 pat.walker@hullcc.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Kingston upon Hull City Council Name of registered manager (if applicable) Mrs Patricia Mary Walker Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: That the intended work as stated in the action plan in regard to the premises is carried out. To provide personal care and accommodation for three service users with physical disability who have reached 65 years of age. Date of last inspection Brief description of the care home The Pennine Centre is a modern purpose built care home situated on a large housing estate on the outskirts of the city of Hull. It is owned and run by Kingston Upon Hull City Council. There is an adjacent day centre, which people staying in the home can use if they wish to. The Pennine Centre has been subject to extensive refurbishment and is registered for up to 12 younger adults who have a physical disability. The home offers care and accommodation mainly on a short term and respite basis. The statement of purpose and service user guide has been amended and clearly states how the needs of people staying there will be met. The home is secure and has its own well Care Homes for Adults (18-65 years) Page 4 of 30 care home 12 Over 65 1 12 Brief description of the care home tended grounds. Public transport is accessible adjacent to the home and there are some local facilities nearby. The home has a ground and first floor with a passenger lift connecting the two. There is ample communal space for people, including three lounges, a visitors room and a large dining area. The home intends to use 8 of the bedrooms for respite care, one for long term and one as a step down bed with funding from the Primary Care Trust, in addition on the first floor there are two rehabilitation bedrooms. People are given a service user guide explaining what the home will provide. The weekly fees range between GBP46.34 and GBP315.50, this information was provided during the inspection visit. Additional charges are made for toiletries, newspapers, activities and transport. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This site visit took place over one day and took a total of 9 hours. A regulation inspector visited the home as part of the process. Prior to the visit surveys were posted out to people living in the home and staff members, information was gained from these and this has formed part of the evidence. The Annual Quality Assurance Assessment was returned to the CSCI prior to the visit taking place. Care Homes for Adults (18-65 years) Page 6 of 30 We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Several of the people living in the home were spoken to throughout the day about the care they receive and what it is like to live in the home, some of their comments have been included in this report. Two files of people living in the home and three staff personnel files were looked at during the site visit. One staff member was spoken to this was to find out what it was like working in the home and what training support and supervision was offered to them. A tour of the premises was undertaken and a number of records were looked at to ensure that the correct maintenance has been undertaken. The manager was given feedback after the visit. What the care home does well: What has improved since the last inspection? What they could do better: Risk assessments would benefit from being more descriptive and specific, as this would ensure that people have risk managed or reduced to a minimum. People who use the service receive a good level of personal and healthcare support. However, errors continue to occur when medication is administered, therefore people using the service do not always receive their medication in a safe way. People are not always protected from possible harm or abuse, due to medication being administered incorrectly and incidents not being referred appropriately. Care Homes for Adults (18-65 years) Page 8 of 30 Training and supervision are not undertaken as regular as they should be, this would ensure that staff have the skills and knowledge to meet the needs of people they care for. Incidents are not always reported and recorded in accordance with procedure and therefore peoples health and safety may be placed at risk. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have their needs fully assessed and have the opportunity to visit the home before they decide to move in, this means choice is promoted and people can make an informed decision about whether to move into the home. Evidence: Prior to the inspection visit taking place information was gained from the home and service users, confirming that people have their needs assessed prior to and following admission. Surveys were received from people who live or stay at the Pennine Centre and some comments included, I am able to make choices at Pennine and I decide when to come in for respite. The home completed an Annual Quality Assurance Assessment (AQAA), which details how the home can meet peoples individual needs it also stated that customers have an assessment of their needs undertaken either by way of a community care assessment or a daily living assessment. Prospective customers are visited at home and given information about what facilities are offered. During the site visit two care files were looked at confirming that an assessment of Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: need is undertaken prior to admission and also that the home further develops this with the use of the daily living assessment. The manager gave an update with regard to specific training and confirmed that some staff have now attended transgender, physical disability, learning disability and difficult to manage behaviour courses. From speaking to people living in the home, a relative and staff member it was clear that staff have a good understanding of more diverse needs. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can make their own decisions in life with risk assessments being put into place where necessary. However, risk assessments would benefit from being more descriptive and specific as this would ensure that people have risk managed or reduced to a minimum. Evidence: Prior to the inspection visit the AQAA was received stating that all people have care plans that meet individual need and risk assessments are in place. Staff have attended training around the Mental Capacity Act giving staff an understanding of peoples rights to make their own decisions. During the visit it was confirmed by speaking to people using the service, staff and a relative that care plans are developed and shared with the person. People could confirm what support they received and how staff would assist them if they needed this. One person said, staff come and help when I need it. From looking at written Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: evidence it was confirmed that the care plans are informative and give direction to staff they also look at the short term and long term objectives for that person. There is a risk management process that minimises or manages risk, however, the files that were looked at did not cover all risk. For example one person is undergoing an intensive rehabilitation programme and there were no risk management plans in relation to the activities undertaken both inside and outside of the home. The plans that were in place did not contain the level of risk and how the decision had been reached and some did not have signatures and review dates on them. From speaking to people living or staying for respite in the home it was clear that choice, participation and independence are all promoted. Some comments included, yes I choose when I get up and go to bed, I go out when I want to, I choose when I have a shower and staff come and help me when I need them. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are enabled to take part in appropriate activities and education, they are encouraged to maintain outside links with family and friends and the menu offered is of an excellent standard. Evidence: Prior to the visit the AQAA was received and stated that all customers are encouraged to attend the adjoining day centre and one customer, who has a part time job at a community centre is assisted to continue to do this whilst in respite. We took part in the Fresh Air Challenge and this focussed on getting people out into the fresh air. We organised a trip to the park, rugby match and shopping. We have links with a local group Bransholme Enterprise, who have an allotment and customers have taken part in tidying up and re planting the homes garden. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: During the visit some of the people living in the home were spoken to and some comments included, its been nice here, all of the staff are very nice they come and ask if I want to join in with activities, but they leave me alone if I dont want to, they are really good I go to the gym Monday, Tuesday and Wednesday, as this is a big part of my life, we go out shopping and to the pictures. From speaking to a relative it was confirmed that people living in the home have the option to take part in outings or activities. People are encouraged to attend day centres or community groups. Written evidence in case files confirmed this. Visitors are made welcome at any time, this was confirmed from speaking to one relative and a visiting district nurse who commented that they are always made welcome and that, the staff are friendly, courteous and polite. The home continues to offer a varied, healthy and nutritious menu and from speaking to people living in the home, it was clear that choice is offered and the quality of the food is very good. Some comments included, the food is good and there is plenty of choice, the meals are good. The home has achieved the Heartbeat Award for the eighth time and has also gained a score of A with the Environmental Health Department. Six surveys received prior to the inspection visit confirmed that people are happy with the menu and food offered. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive a good level of personal and healthcare support, however errors continue to occur when medication is administered therefore people using the service do not always receive their medication in a safe way. Evidence: Prior to the visit taking place an AQAA was received and stated that all of the health care needs of people were being met and there had been some improvements made to the medication procedure following two incidents where people had received incorrect medication. During the visit two files of people who live or stay on respite in the home were looked at, written evidence was in place confirming that healthcare checks have been undertaken. From speaking to people using the service it was clear that they are supported to attend hospital, GP and other healthcare appointments. It was also confirmed that staff offer support in caring and sensitive manner some comments included, the staff are very good, the staff are caring they are really good. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: Prior to the inspection visit taking place two incidents occurred, resulting in two people being administered the incorrect amount of medication. Although the incidents were reported this was two months later and the manager had not made a safeguarding referral until prompted to do so by the CSCI. The investigations have concluded and were upheld the following recommendations were put in place; all staff to undertake medication training, a full audit of the medication procedure to be undertaken, a new procedure for the booking in of medication to be implemented. During the inspection visit the medication process was looked at and the records were of an adequate standard. However, mistakes continue to occur and would appear to be happening at the point of booking in the medication. One person who had arrived at the home on that day had 64 paracetamol booked in and it was recorded that they were not required for that day, however only 62 remain in stock. Another person had 84 Baclofen upon arrival at the home, 17 recorded as administered however, 71 remained instead of 67. Another person had been out of stock of Lactulose since 21.1.09. From speaking to the registered manager and staff, it would appear that the recommendations made in the audit have been implemented as there are always two members of staff who sign when the medication is booked in and a third check is undertaken by the night senior on duty. Gaps in recording are checked by the night senior and reported via the communications book. From speaking to a care assistant it was clear that some training had been given in relation to checking the prescription was correct and for the right person this is currently done on an informal basis. However, there is no procedure for homely remedies in place. The home has a returns procedure, which detailed the name of the person the medication was for the medication prescribed and dosage. The medication is stored in a locked medication room and within that room there are several locked cabinets and a controlled drugs cabinet. There is also a medication trolley. The home has a refrigerator to store medication and evidence was seen confirming that the temperature is taken on a daily basis. Controlled drugs are stored securely and records show that two staff always sign when given. From speaking to a staff member it became evident that there is a lack of consistency when administering the medication. All staff must follow the same procedure for example, the person who is witnessing the administration must observe the procedure from start to finish, counting and witnessing what has been given and recording this in the controlled drugs register, as this would ensure people receive their medication in a safe way and eliminate any potential problems. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are informed about the complaints procedure and are able to express their concerns in an open culture. People are not always protected from possible harm or abuse due to medication being administered incorrectly and incidents not being referred appropriately. Evidence: The home has a complaints procedure and it was confirmed from speaking to people living in the home and staff that complaints are listened to and acted upon. One person said, I have no complaints, but I would know who to go to if I had, Minor issues have been dealt with quickly in the past. There had been four complaints since the previous inspection visit. Written records confirmed these were dealt with and responded to appropriately. A written outcome letter was also forwarded to the complainant. The home has a multi agency policy and procedure for the prevention of abuse. Staff undertake mandatory training in this area. Since the last inspection there have been three safeguarding referrals made to the Local Authority Safeguarding team. There were two incidents of medication being administered incorrectly, one in May and one in June 2008, however, the required notification was not received by CSCI until July 2008 and at that point the home was contacted to ensure that the appropriate referrals had been made to the Safeguarding team. The manager confirmed that safeguarding Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: referrals had not been made CSCI advised the manager to do so immediately. The safeguarding referrals were also completed by CSCI resulting in two investigations being undertaken by the Local Authority, both of which were upheld and recommendations put in place to ensure that medication is given out in a safe way. The third safeguarding referral involves two people living in the home. One person alleges that another person has sexually assaulted them this is currently being investigated and CSCI are awaiting the outcome. The manager gave an update and confirmed verbally that the investigation has been completed. However, from looking at written evidence there was no risk management plan in place that would ensure the individual and others living in the home were safe whilst this investigation was ongoing. The home has a policy and procedure for dealing with peoples monies and financial affairs. Records for maintaining the personal finances were looked at and on the whole were in order. However, there was only one signature from a staff member for two transactions and the Local Authoritys procedure clearly states there should be two staff signatures in place. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is maintained to an excellent standard and the environment is clean, hygienic, comfortable, homely and meets the general needs of people living there. Evidence: A tour of the building was undertaken and the standard of accommodation and cleanliness was excellent. The health and safety of people living in the Pennine Centre is maintained and promoted. Since the last inspection all of the requirements have been met. The lift controls are now clearly identifiable, grab rails have been fitted to all toilet and bedroom doors. An occupational therapist has undertaken an assessment of the building aids and adaptations and the manager stated that the majority of the recommendations have been implemented. The manager said, most of the recommendations have now been met and with regard to the rehabilitation kitchens, the occupational therapist advised us to use the lower table with people who use wheelchairs. The report stated to fully equip the rehab kitchen with both normal and adapted utensils, pots and pans, but overall it stated that at the present time the Pennine unit would pass all the requirements of Standard 29, however, the recommendations would optimise the units safety factors. Individual bedrooms were decorated to a high standard and were personalised with Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: pictures, posters, dvds and belongings. Six surveys were received from people living in the home and all confirmed that the home is clean and tidy. Some comments included, very clean, Pennine is a good run home and the carers do an outstanding job, it is a very nice place. The home was clean, hygienic and had no offensive smells present. Staff receive training in relation to infection control and there are clear guidelines set down to staff to follow if there are any infectious diseases. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home recruits staff in a safe way and staffing levels are sufficient to meet need. However, training and supervision are not undertaken as regular as they should be. This would ensure that staff have the skills, knowledge and guidance to meet the needs of people they care for. Evidence: Prior to the visit taking place an AQAA was received and stated that staff attend mandatory core training. Currently 74 of staff have achieved NVQ level 2. It also confirmed that regular staff meeting takes place and since the last inspection a new staff rota has been implemented, which can be supplemented with casual staff when needed. As a respite unit the customers who are staying here change regularly and staffing levels are reviewed to reflect the need. The recruitment is in accordance with the LA procedure, two references and a CRB check are seen before appointment is offered. Training is in accordance with the Hull City Council training tower for adult services. Specialist training re physical disabilities and conditions are provided in house. Surveys received from people living or staying at Pennine Centre confirmed that the staff are approachable, caring and professional. Some comments included, the Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: Pennine Centre is a very nice place to stay when I am on respite, the staff are very friendly and caring. A visiting District Nurse was spoken to and commented that the homes staff were always, welcoming and friendly also that they took direction well and sought advice when they needed to. One relative was spoken to during the visit confirming that visitors are made welcome at any reasonable time and commented, yes I am always made welcome by staff. I am happy with the overall care my son receives I know he is content when he is here and that is my main concern. During the inspection visit three staff files were looked at confirming that the recruitment procedure is followed. All files contained a CRB check, references and an application form these are held at the Personnel Section. Each person had undertaken an in-house induction and a more thorough corporate induction that meets the skills for care specification. Supervision is offered to all staff and from looking at written evidence it was confirmed that this is not as regular as it should be. One person commenced employment in April 2008 and has received one formal supervision and another staff member received three supervisions in 2008. The recommended minimum is six per year as this would ensure good practice is being followed and staff receive sufficient support, supervision and guidance. As stated the AQAA staff must undertake mandatory training, however it was evident that not all training is up to date. Two out of the three files looked at confirmed that staff had not undertaken or kept up to date training in relation to safeguarding adults, moving and handling, basic first aid, fire awareness and infection control. The manager confirmed that all staff are to undertake equality and diversity training and from looking at three files it was confirmed that diverse needs of people are looked at and training sought. Some staff had undertaken training in relation to the following eating and drinking difficulties, values and attitudes, continence and catheter care, learning disability awareness, physical disability awareness, alcohol awareness. One staff member was spoken to and she commented, the care offered is of a high standard I enjoy the job, it is a lovely home. When discussing training the staff member said, personally I think it is excellent, diverse need would be looked at and in house training is given at times. From speaking to the people living in the home, staff and the manager and from surveys received, it was clear that the staffing levels are sufficient to meet the needs of individuals. It would also seem that they have been reviewed and increased since the last inspection visit. People confirmed that they can choose when to receive personal care and that usually staff attend to them quickly. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately run and values the views of people living there. However, incidents are not always managed, reported and recorded in accordance with procedure and therefore peoples health and safety may be placed at risk. Evidence: Prior to the inspection visit the AQAA was received giving details about how the home is managed. It stated that the quality assurance system had been improved, surveys are now sent to service users, staff, relatives and other professionals and an action plan is completed showing any corrective action required. A newsletter is produced and includes contributions from staff and customers. Surveys received from staff confirmed that the manager offers support and comments included, her door is always open, Pat is very approachable. During the visit the quality assurance system was looked at and evidence was seen confirming that surveys are sent to various stakeholders, including people living in the Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: home, staff, relatives and other social and healthcare professionals. The results are gathered and analysed and presented in a report format this is shared with the people living in the home and ways of improving the service are developed. The home has also developed a newsletter that incorporates the views and stories of people living in the home and staff also contribute. All compliments and complaints are recorded. From speaking to people living in the home it was clear that their views are listened to. One person said, I feel that I can speak my mind and if I had a problem or comment then this is listened to. Health and safety is ensured by having all of the appropriate maintenance certificates in place, regular checks on these take place and evidence was seen confirming this. Staff undertake all health and safety courses within the first 6 months of employment ensuring that the staff are knowledgeable and have the necessary skills to deal with emergencies. However, some mandatory training is out of date and not all incidents are reported and recorded appropriately in particular safeguarding issues that have not been referred through the appropriate route. Regulation 37 notices are forwarded to the Commission for Social Care Inspection, but this has been two months after the event. Equality and diversity is promoted by staff from speaking to people who live in the home it was confirmed that staff respect and promote dietary requests or needs. People are able to attend religious meetings of their choice. Some of the staff have attended training in relation to values and attitudes, alcohol, physical and learning disability awareness. From speaking to the manager it was evident that the local authority regard equality and diversity training highly, as this is a mandatory course for staff. She said, the induction at Pennine is to give the person a flavour of what it is like in the home understanding different physical conditions. For example, Multiple Sclerosis, Huntingtons or Parkinsons disease or having a stroke. The manager also said the Local Authority offer understanding a physical disability, this is a new course but eventually all staff will undertake this. Several staff have undertaken challenging behaviour following a head injury. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Medication must be administered as prescribed, accurate records must be kept for all medicines. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. 12/05/2009 2 23 13 Incidents that place people at risk or have an adverse effect upon them must be reported appropriately. To ensure that people receive their medication in a safe way and are protected from harm or abuse. 12/05/2009 3 42 13 Incidents must be managed and reported in accordance with procedure and regulation, this would ensure that peoples health and safety is promoted. 12/05/2009 Care Homes for Adults (18-65 years) Page 28 of 30 To ensure that all incidents affecting people are reported and dealt with appropriately. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Risk assessments would benefit from being more descriptive and specific, as this would ensure that people have risk managed or reduced to a minimum. Training should be offered and updated on a regular basis, as this would ensure that people have their needs met by appropriately trained staff. Supervision should be offered to staff a minimum of six times a year, as this would ensure that staff receive the support and guidance to carry out their responsibilities and good practice is promoted. The registered manager should manage incidents/accidents in an effective manner, ensuring that policy and procedure is followed. This would make sure that people live in a wellrun home. 2 35 3 36 4 37 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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