Inspection on 26/06/07 for Pennine Lodge

This inspection was carried out on 26th June 2007.

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 10/03/06

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 Liz Cuddington Unannounced Inspection 10:00 26th June 2007 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.V333410.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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.V333410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 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.V333410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection of the home took place on 10 March 2006. No further visits have been made to the home since then. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Pennine Lodge. The methods I used to gather information included a visit to the home, conversations with the people who live there, their relatives, healthcare professionals and the staff I also looked in detail at the care and records of four people, examined other records and looked around the home. I spent eight hours at the home. Before visiting I sent out questionnaires for the people who live at the home, their relatives and healthcare professionals to complete. I received one back from one of the people who lives at Pennine Lodge, seven from people’s relatives and five from healthcare professionals. Feedback from these surveys is included in this report. The manager also completed the home’s preinspection questionnaire. These questionnaires provide valuable information to help me form a judgement about the quality of service offered at Pennine Lodge. I would like to thank the people who live at Pennine Lodge, their relatives and the staff, for their welcome and hospitality and for taking the time to talk to me during my visit and for completing the questionnaires. What the service does well: The person who lives at Pennine Lodge who was able to complete a questionnaire, confirmed their satisfaction with all aspects of their care and support and said they are aware of how to complain, if necessary. They said they are able to request a different meal if the choice on offer was not what they would like, and confirmed that staff are always available. They also said they enjoy the activities and receive full support with their medication and healthcare needs. The home offers a high standard of personal and healthcare to the people who live there. The healthcare professionals all confirmed this, one wrote in their questionnaire ‘Everything the home does has the clients wishes and needs at the forefront. It’s a home that is very person centred…’. One person’s relative commented that the home ‘…looks after my (relative) ….with great care…’. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 6 There is a varied programme of activities for people to take part in, or not, as they choose. All the staff take part in arranging and carrying out the activities. There is a high level of staff, which makes sure people’s needs and wishes can be met. The home is clean, fresh and well maintained. There are safe and accessible outside seating areas for people to enjoy the fresh air. The meals are well planned and the people who commented said they enjoy their food. The home’s staff make nutritious ‘smoothies’ and freshly prepared juices for everyone, as well as to tempt people who have small appetites. The staff interact well with the people who live at Pennine Lodge. One relative commented that ‘…the staff are very pleasant and co-operative’ and another wrote that they are ‘…really pleased with the care..’. There are plenty of staff on duty at all times and staff are well trained and motivated. There is a good management and leadership structure and everyone knows how each individual prefers their care and support to be given. The relative of one person who lives at the home said ‘….I have visited many care homes…..and Pennine Lodge is one of the best that I have come across’. One of the healthcare professionals wrote in their questionnaire that the home has a ‘…strong but caring management and excellent organisation. I am privileged to be involved in caring for residents in this home’. 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 Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 8 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.V333410.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Standard 6 does not apply People who use the 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 carries out a thorough assessment process for prospective residents prior to admission, to make sure the home can meet their needs. EVIDENCE: Pennine Lodge has a very comprehensive pre-admission procedure, to make sure they can meet the person’s needs. An assessment of the person’s care and support needs is carried out and used as the basis for their care plan. This is completed in plenty of time before the person arrives, to give all the staff time to read the information. Social Services assessments are also used to determine the care needs of the individual. People are welcome to visit the home before reaching a decision. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their health and well-being, peoples’ personal and healthcare needs are met. People are fully protected by the home’s medication systems. Medications are stored safely and administered accurately. To maintain their dignity, the staff treat people with respect, care and consideration at all times. EVIDENCE: I looked at three people’s care plans. They are very informative and well organised. Each plan clearly shows what the person needs in all aspects of their life, and how staff are to support them. The home’s senior staff review the plans regularly, to make sure they are up to date and reflect the Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 11 individual’s current needs and wishes. The individual and/or their family are involved in developing and reviewing the plans, wherever possible. The plans are clearly written and easy to follow. People’s health is checked regularly and any concerns are followed up with relevant healthcare staff and their advice is followed. The surveys I received from five healthcare professionals confirmed this. One person wrote that ‘They liaise well with…primary and secondary (health) care teams…’. Other comments said that the home is ‘..very good at seeking advice…’ and is ‘….pro-active in looking after and improving the healthcare needs of their residents’. Another person said that the home’s ‘Management of incontinence is …excellent’. One person wrote that the staff are ‘…active in ensuring that each individual’s health is monitored regularly…’. The care plans showed, for example, that people are weighed each month and any significant changes are referred to the person’s GP. Other comments from people’s relatives said that ‘The care given here is excellent…’ and they ‘…wish other care homes came up to this standard…’. Another relative said that the staff ‘…advise me if anything is wrong’. The medication is stored securely and safely. The Medicines Administration Record (MAR) charts are accurately completed and quantities of medicines received, in stock and returned to the pharmacy are recorded correctly. The staff that administer medication have all received suitable training. One small problem the home was experiencing, concerning disposal of medicines people had refused, was resolved swiftly and satisfactorily after taking professional advice. A healthcare professional commented that ‘The home has a strict medication policy and administer medication appropriately’. Some of the comments I received from healthcare professionals and relatives confirmed my own observations that all the staff are respectful and considerate to the people who live at Pennine Lodge, and make sure people’s dignity is maintained. One person wrote that ‘The home has good standards of care in relation to privacy and dignity’ and another said they noticed that the ‘Residents are encouraged to engage with staff to give their opinion about their wishes…witnessed on many occasions staff interacting with residents in a positive and respectful manner’. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the 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 are supported to maintain contact with family and friends. A wide range of leisure activities is provided, to try and make sure each person’s recreational needs and expectations are being met. People are offered a choice of meals and other foods, to make sure their dietary needs are met. EVIDENCE: The people I spoke to said they enjoyed the activities and my observations confirmed this. On the day I visited I saw people playing floor dominoes and quoits in one of the lounges, with assistance from two staff. In the dining room the tables and chairs had been moved back to make space for dancing. A mixture of different types of music and songs were being played and people were dancing with each other and the staff. People who did not wish to dance were singing to the music. Everyone seemed to be enjoying themselves and the people who commented confirmed this. One person’s relative wrote in their survey that ‘…activities are a regular event…enjoys a dance’. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 13 The home also arranges outings to places of interest, such as Blackpool illuminations, and brings in entertainers. Special events are celebrated, usually with a party. There are armchair exercise sessions each week. A religious service takes place every month. The home does not employ an activities co-ordinator, but prefers that all the staff take part in the activities and help to plan them. One relative commented that the ‘….staff have time for the residents….’. This was evident while I was at Pennine Lodge. The staff spent time with people not only during the time they were doing the activities, but also by just sitting and talking or going for a walk with someone. The menus are varied and special diets are catered for. People told me they enjoyed the meals and any assistance people need is offered discreetly and at the person’s own pace. Some people at Pennine Lodge have small appetites. The staff make ‘smoothies’ and freshly prepared juices to tempt people and to make sure they have a good, nutritious diet. One healthcare professional commented that ‘The food is excellent and the nutritional intake is of an exceptionally high standard. …for those that don’t eat…..”smoothy” drinks are given between meals’. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the 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 living at the home, and their relatives, are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people living at the home are safe. EVIDENCE: The surveys and the people who live at the home confirmed that people are aware of how to raise a concern or make a complaint, should they need to do so. One person wrote in their questionnaire that ‘My questions or concerns are always listened to…’. Another person said ‘….where concerns have been raised by relatives…..these were dealt with appropriately, sensitively and promptly’. The complaints procedure is clear and easily available. There is a complaints log to record any complaints or concerns, which are raised. The home deals with any concerns effectively and without delay. The staff are aware of the need to report any concerns they have about care practice and there are clear guidelines for reporting such incidents. All of the staff have had Adult Protection training. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 People who use the 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 live in a safe, comfortable, well-maintained and homely environment. EVIDENCE: The whole house is well maintained, clean and fresh. There is a refurbishment programme for the shared areas of the house. All the bedrooms that I saw reflect the person’s individual preferences and taste. There is a programme of re-decoration for the bedrooms, as well as for the rest of the house. Several bedrooms have recently been re-decorated and look fresh and attractive. The bedroom doors all have locks, and there is a lockable storage space in the rooms, which means that people can keep their belongings private and secure. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 16 One of the bathrooms has been converted into a ‘wet room’. This means that the level floor gives easy access to the shower, making showering easier. A wheeled shower chair can be used if needed. One bath has a therapeutic massage system, which can be used to help people feel more comfortable and relaxed. The home is fresh, clean, comfortable and well looked after. Everyone who commented agreed that the home is well kept. The garden is tidy and there are safe and sheltered seating areas for people to sit and enjoy the fresh air. Ramps are in place to make access easier. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. The people who live at Pennine Lodge are protected by thorough recruitment procedures, which ensure that staff are suitable to work with older people. Suitable training is provided, to make sure staff have the skills and knowledge they require to meet people’s needs. EVIDENCE: The staff rotas confirmed my observations that there are plenty of staff on duty to meet the care, social and leisure needs of the people who live at Pennine Lodge. There are seven staff on duty in the mornings and six staff in the afternoons and evenings. One healthcare professional commented that staff are ‘Always on hand’ and ‘….staff have time for the residents….’. I looked at three staff files. They all included completed application forms and two written references. The files showed that satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks have been obtained. No new staff begin work until the appropriate checks have been completed. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 18 The manager makes sure that staff have the necessary training to help them do their work as well as possible. There is a wide range of courses available and the records confirmed that the staff are allowed the time to attend. Seventeen of the twenty-eight care staff have a relevant National Vocational Qualification (NVQ) at level 2 or above. Other staff are currently taking their NVQ award. During the past year the home’s staff have taken a range of mandatory training, as well as courses on the care of medicines, continence and falls prevention. Staff receive training in the implications of the Mental Capacity Act and on the protection of vulnerable adults. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the 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 safe and well managed and people who live and work at the home can contribute to the decision-making processes. EVIDENCE: The manager has the qualifications and the skills to manage the home effectively. There is a good management structure within the home, which supports the manager and encourages senior members of staff to widen their responsibilities. Managers and trainee managers take a Certificate in Mental Health Practice at Huddersfield University. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 20 Twice a year the home sends out questionnaires to relatives, in order to gain information about how people view the service and what improvements they would like to see. The responses are analysed and any follow up action is taken. I looked at some of the questionnaires. The responses people’s relatives made reflected the comments and high level of satisfaction on the surveys I sent out before this inspection visit. The management also carry out a quarterly internal audit covering catering, housekeeping, laundry, care and administration. The policies and procedures are kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people who live at the home is promoted and safeguarded. The home looks after small amounts of people’s money, to pay for their day to day expenses. The remainder of their money is dealt with by their families, or by other appointees. Confidential information is stored securely. The kitchen had an Environmental Health inspection in March 2007. The inspector awarded the home a hygiene star rating of four, out of a possible five stars. Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 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 4 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 4 X 3 3 3 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Pennine Lodge DS0000000995.V333410.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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.V333410.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Paul’s House 23 Park Square Leeds LS1 2ND 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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