Inspection on 10/03/06 for Pennine Lodge

This inspection was carried out on 10th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pennine Lodge 26/06/07

Pennine Lodge 06/06/05

Pennine Lodge 15/11/04

Pennine Lodge 10/06/04

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

CARE HOMES FOR OLDER PEOPLE Pennine Lodge Burnley Road Todmorden Lancashire OL14 5LB Lead Inspector Lynda Jones Unannounced Inspection 10th March 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pennine Lodge Address Burnley Road Todmorden Lancashire OL14 5LB 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) 01706 812501 01706 817555 Mr Barry Potton Miss Denise Christine Terry Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Pennine Lodge is a care home providing personal care and accommodation for 40 older people with dementia. The home is situated in Todmorden, on a main bus route and not far from the town centre. There is ample parking space within the grounds for visitors and the house is surrounded by well maintained grounds. Thirty six of the bedrooms are single and two rooms are double. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk The last inspection of the home was unannounced and took place on 6 June 2005. This was an unannounced inspection carried out over 3.5 hours. The main purpose of the inspection was to make sure that the home continues to provide a good standard of care for the people who live there. The findings of the inspection are very positive. This is a well run home providing good quality care. The accommodation is good, the home is well maintained and residents are well cared for and comfortable at the home. The methods used at this inspection included looking at a sample of care records and staff records. A tour of the building took place and time was spent talking to residents, the registered manager, the company deputy chief executive and some of the staff on duty. As many of the standards were assessed at the last inspection, this report should be considered together with the report from 6 June 2005 What the service does well: There is a strong management team and a dedicated staff team who are all committed to providing a good quality service. All admissions to the home are carefully planned. The care plans are of very good quality and evidence shows that the care of all residents is regularly reviewed. Recording systems are excellent. Staff are vigilant, they make sure that residents health care needs are met. Staff consult with, and take advice from a range of health care providers. The home has a robust recruitment policy and appropriate checks are carried out on staff before they commence employment. Adult protection issues are high on the agenda of the home and all staff receive training in this area, with regular updates. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 6 There is the possibility of career progression within the home for all staff and excellent training opportunities are available. Induction and foundation training is provided and a mentoring scheme is in operation. All staff receive NVQ training. There is very little turnover of staff. Strategic planning is a strength at this home. Staff and management strategy meetings are planned in advance and there is a clear development plan for the home. High standards are maintained within the home in terms of hygiene and cleanliness. The domestic team provide an excellent service. The home is decorated and furnished to a high standard in the communal areas and in the bedrooms. There are very pleasant, secure and well maintained gardens that the residents can enjoy in safety. There is a generous budget for activities. There is plenty of choice of social and stimulating activities, visiting entertainers and organised trips out take place. The records demonstrate that health and safety matters are given high priority within the home. A pro-active approach is taken to identifying, assessing and as far as possible eliminating possible risks. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 All prospective residents have their needs fully assessed prior to them moving into the home. This ensures that their care and support needs are planned for and can be met. Prospective residents or their relatives are encouraged to visit the home so they can assess the suitability of the facilities for themselves. EVIDENCE: The home has a good procedure that ensures that no individual moves into the home without being properly assessed. The manager or deputy chief executive carry out pre-admission visits to prospective residents and they complete the assessments to make sure that their needs can be met at the home. Prospective residents and their relatives are invited to visit the home to view the accommodation and to meet the staff before any decision is made about moving in. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 9 The terms and conditions of residence document clearly states what is and is not included in the fees, the room to be occupied, fees payable, notice periods and insurance cover. These documents have been signed by residents and/or their representatives together with the manager. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents’ needs are thoroughly assessed and the home has a good approach to promoting the residents health care. The care plans are completed to a very good standard and give clear guidelines to the staff on how to meet the individual resident’s needs. Residents’ medication is well managed which promotes good health. EVIDENCE: A sample of case files was examined, each file was found to contain full care plans, detailing health, personal and social care needs. Individual care plans also include risk assessments. There was written evidence showing that plans are drawn up with the full involvement of residents’ families and with residents themselves, as far as their individual abilities allow. Through the examination of case files, it was possible to track the care provided from assessment of need to the development and review of detailed care plans and the monitoring of the care provided. Care plans and supporting documentation continue to be reviewed at least monthly or sooner if the resident’s needs change significantly. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 11 Residents have access to a wide range of services provided by a variety of health care professionals. The majority of residents are registered with the local medical centre, unless their own home was close enough to Pennine Lodge to allow them to retain their own GP. Care plans clearly document each visit by a health care professional and note the advice that has been given. The personal hygiene and oral hygiene needs of residents are clearly documented in the care plans. Case files included details of regular appointments and annual checks and there was evidence that continence issues are well managed. The home has links with a psychiatrist who holds clinics in the town and who visits residents at the home. Residents living at Pennine Lodge looked smart and well cared for. Everyone was well dressed, had their hair done and nails manicured, all the men were shaved. Personal care that was offered by staff was provided in a respectful and dignified way. Medication records are well maintained and show that residents are getting their medication at the prescribed times. The home has policies and procedures in place in relation to the dying and death of a resident and the deputy chief executive confirmed that comfort and support is offered to all parties during this very difficult period. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14. A wide range of social activities are being provided at the home to keep residents stimulated. Residents are encouraged to exercise control and choice over their lives. Residents and their relatives and are asked for their views on the service provided. EVIDENCE: The home offers a wide range of activities that take place each day. The management team recognise the importance of providing appropriate activities that meet the needs of people with dementia and they have accessed equipment through specialist providers. A generous budget has been set aside for this. Activities include a very popular tea dance, old time music sessions, painting, percussion and bell instrument sessions and sing a longs. Easy to manage equipment allows everyone the opportunity to take part in floor netball, darts and skittles. The home is very successful in sourcing outside entertainers who work well with people with dementia, shows have been performed at the home and Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 13 musicals which everyone can sing a long to, have been shown on a large screen. A sign in the entrance to the home invites residents and their guests to “A Really Old Fashioned Disco Show” The home has its own transport and trips out take place frequently in the good weather. Relatives are welcome to call at the home at any time. They are always invited to the many social events that take place throughout the year. The visitor’s book shows that there are frequent visitors to the home at various times during the day and evening. The meals provided at the home were not reviewed on this occasion. They have received very favourable comments from residents and visitors in previous reports. The lunchtime meal was observed in the main part of the house. The dining room is spacious and pleasantly decorated. Dining tables were attractively laid and condiments were available on the tables. Music was playing in the room and some people were singing along as they waited for their meals. Everyone was asked what they would like to eat, meals were served by staff from a heated trolley. Residents were shown the choice of food available to help them to decide what they wanted. The meal was enjoyed at a leisurely pace, residents chatted with each other and with staff, the event was very relaxed and dignified. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this inspection. See last report. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. The home is well maintained, with high standards of cleanliness throughout, providing a pleasant and safe environment for residents. EVIDENCE: The home is maintained to a high standard, internally and externally. The house is surrounded by well-maintained grounds, which are well stocked with trees and shrubs. There are two secure garden and patio areas, which enable people to leave the building and enjoy the garden in safety. Both areas have been thoughtfully constructed and are well used. Each is equipped with outdoor tables, parasols, chairs and benches. There is a wheelchair accessible pathway outside the house and full wheelchair access inside. There is an excellent team of domestic staff who work hard to achieve a high standard of hygiene and cleanliness throughout the home. On the day of the inspection, as on previous unannounced inspections, the home was free from Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 16 unpleasant odours. The laundry system is well organised and residents’ clothes are carefully washed and ironed. Bedrooms are brightly decorated, with residents able to exercise choice over the colour schemes of their rooms. Care has been taken to make sure the colour schemes are coordinated. The bedding is fresh and ironed and everyone has their own toiletries in their bedroom. Every room is clean and tidy. Most residents have their own personal possessions around them in their bedrooms. There are family photos, plants and ornaments and soft toys in many of the rooms. Bathrooms are clean and warm. There are assisted bathing facilities for people who need help getting in and out of the bath. The home has two hydrotherapy units which fit into the baths at the home. A choice of massage can be selected from one of the many programmes available. In conjunction, a range of specialist herbal bath products are used creating a therapeutic health spa which residents are reported to enjoy. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30. Recruitment procedures are very thorough to make sure that staff are suitable to work with vulnerable adults. The level of training made available to the staff is commendable and the skill mix within the staff team ensures that residents’ needs are met. EVIDENCE: A selection of staff files were examined to look at staff recruitment and training. Recruitment procedures in the home are robust. A minimum of two references are taken up, employment histories are explored with prospective employees and checks are made with the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register. All of this takes place before new staff start work at the home. The staff files are well organised, information is easy to access and all of the records that were examined were up to date. All files contained job descriptions, contracts of employment, copies of certain policies and procedures and evidence that staff induction training had been provided. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 18 The home has an excellent record for providing staff training. This is an area that the management team feel is very important and well worth investment. The home’s deputy chief executive is adept at securing funding and assisting staff to access courses. There is a comprehensive training plan for each member of staff. New staff sign an undertaking indicating their willingness to take part in training. Detailed records are kept of all the courses that staff attend, demonstrating that all staff have good opportunities to expand their knowledge and awareness of good care practice. All staff are enrolled on NVQ courses and the home has achieved its target of 50 of staff who are trained to level 2. The manager has completed a course in Care Management and is now working towards her Registered Managers Award. Four senior staff are on a course leading to a Certificate in Mental Health Practice. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37,38. The home is managed by an effective, caring management team. The staff carry out their duties in the best interests of residents. The health, safety and welfare of residents is protected by the robust management and administrative systems that are in place throughout the home. The home has a quality assurance system in place and continues to seek the views and opinions of residents, relatives and all health providers who visit the home. EVIDENCE: The home is well managed by a senior team with a range of different but complimentary skills. The registered manager and deputy chief executive are at the home most days and are available if anyone has any concerns they wish to discuss. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 20 There are good systems in place for consultation and forward planning. Strategy meetings take place on a planned basis throughout the year and the proprietor, registered manager, deputy chief executive, senior team, chef, domestic supervisor, maintenance person and company secretary all attend. Issues from these meetings are then taken to management meetings for final decisions regarding budgeting and to plan for any improvements that are intended. This results in the formulation of the annual development plan for the home. The administrative support for the home is of a high calibre and the presentation and formatting of records is good. All records that were examined were well maintained, detailed and up to date. Surveys are given out twice a year to visitors to the home to ask for their opinions on the service provided and to see if there are any suggestions for improvements. Records demonstrate that health and safety matters are given high priority within the home. Risk assessments are regularly undertaken and identified risks minimised. Training records show that staff undertake training in moving and handling and fire evacuation procedures. The home has a good record of compliance with any requirements that may be made by external agencies, such as Environmental Health, Fire Authority and the Commission for Social Care Inspection. Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 4 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 3 Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pennine Lodge DS0000000995.V265887.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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