Inspection on 06/06/05 for Pennine Lodge

This inspection was carried out on 6th June 2005.

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 10/03/06

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 Cheryl Stovin Unannounced 6 June 2005 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 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 J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pennine Lodge Address Burnley Road Todmorden Lancashire OL14 5LB 01706 812501 01706 817555 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Barry Potton Mrs Mavis Morris Care Home 40 Category(ies) of DE(E) DEMENTIA - OVER 65 One named registration, with number individual under 65. - 40 of places PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 15 November 2004 Brief Description of the Service: Pennine Lodge is a care home providing personal care and accommodation for 40 older people with dementia. In July 2003 the registration was varied to allow care to be provided for one named person under 65 years of age. Respite care is also provided. 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 J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by two inspectors over six hours. Case files and other documents were examined and inspectors spoke to relatives who were visiting, to members of the management team and to residents. Inspectors were also able to speak to some residents during the course of the day and to observe the general running of the home. What the service does well: 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 J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 7 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 standard(s) 3 and 5 All prospective residents have their needs fully assessed prior to admission and visits to the home are arranged for them and their families. EVIDENCE: The home has a good procedure that ensures that no individual is admitted before a full assessment of her/his needs has been undertaken. Copies of care management plans from other agencies were available on individual case files. The home also completes its own assessment document and senior staff carry out pre-admission visits to prospective residents. The management team is very clear about the needs which can be met by the home and ensures that all service users have a plan of care for daily living. These were available on files. Prospective service users are invited to visit the home and relatives who were present on the day of the inspection, confirmed that they had been able to visit the home prior to the admission of the service user and were fully involved in the admission process. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 8 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 standard(s) 7 and 8 Service users needs are thoroughly assessed and the home has a good approach to promoting the service users health care. EVIDENCE: Eight case files were examined and were found to contain full care plans, detailing health, personal and social care needs. Individual care plans also include risk assessments. There was written evidence that plans are drawn up with the full involvement of service users’ families and with service users 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. Relatives confirmed that they have been fully involved in the admissions process and that residents are well cared for. 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. Case files examined showed details of regular appointments and annual checks and there was evidence that continence issues are well managed. Training records show that staff PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 9 undertake training in the promotion of oral care and there are links with a psychiatrist who holds clinics in the town and who visits residents at the home. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 10 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 standard(s) 14 and 15 Service users are encouraged to exercise control and choice over their lives and are asked for their views on the service provided. EVIDENCE: Service users’ files showed that they are consulted about how they wish to spend their time at Pennine Lodge and they and their families are asked for their views on the service provided. There was evidence that service users are encouraged to bring some of their possessions into the home. Bedrooms had pictures and photos on the walls and ornaments and other small possessions on shelves. Bedrooms are regularly redecorated and service users are encouraged to select colour schemes for their rooms. One resident commented that he liked having his photographs in his room. Service users and their families made very positive comments about the meals provided at the home. Relatives said that they are encouraged to visit the home for meals and that the food that is provided for residents is good. The mid day meal was eaten with residents. A choice from the menu was offered and there were vegetarian alternatives available. The meal was nutritious, well cooked and well presented. A range of drinks was made available. Special diets can be readily provided and residents are encouraged to drink plenty of fluids throughout the day. Catering staff are all skilled and well qualified. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 11 Relatives made particular reference to meals that are provided for special occasions, such as Easter and Christmas and said that service users appeared to enjoy the food. Case records showed that efforts are made by the staff team to ensure that people participate in activities which are stimulating and suit individual needs. On the day of the inspection, a tea dance had been arranged. Staff encouraged all residents to participate and a number joined in. Inspectors were also able to take part and observed that residents clearly enjoyed the music and dancing. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 12 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 standard(s) 16 and 18. The home has robust systems to ensure that service users are safeguarded from abuse and that complaints are dealt with promptly. EVIDENCE: The home has a procedure that clearly specifies how complaints can be made, details of which are contained in the service user guide. Relatives said that they had been given information about the complaints procedure and felt they could raise issues with the home’s manager and staff and believed that these would be dealt with promptly. They also said that they had not needed to make complaints. Staff confirmed that they are aware of the whistle blowing policy. Records show that all staff have undertaken training in Adult Protection. The home uses the local authority procedures and ensures that staff are made aware of their responsibilities in this area of their work. Case files contain written plans for residents whose behaviour can be challenging. Training records also contain details of the training that is undertaken by staff to help them work with and manage risk within the home. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 13 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 standard(s) 21 and 26 The home is well maintained, with high standards of cleanliness throughout, providing a pleasant and safe environment for service users. EVIDENCE: The team of domestic staff 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 offensive odours, clean and tidy, with no evidence that repairs are not attended to promptly. Bedrooms are brightly decorated, with residents able to exercise choice over the colour schemes of their rooms. The laundry system is well organised and relatives said that service users clothes and bedding is kept fresh and clean. 32 of the 38 bedrooms have en suite facilities. Additional toilets are located close to sitting areas. Bathrooms are located close to bedrooms. All facilities are warm and pleasantly decorated. Previous inspection reports mentioned the two hydrotherapy units that are in use and records on service user files showed that these are regularly used and enjoyed. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28 The home is appropriately staffed to meet the needs of the service users. Staff are well trained for their work. EVIDENCE: The duty rotas worked were examined and showed that there have been a minimum of 6 care staff on duty on each shift plus an extra member of staff on care duty from 8 a.m. to 1 p.m. Monday to Friday. This is sufficient to cover the needs of the residents. Relatives who were present during the inspection, said that they have no problem in contacting staff at the home and feel that there are always enough staff on duty to care for service users. There is a team of domestic staff and one person working in the laundry. There is one chef and one kitchen assistant and the home has recently employed two further assistants to work in the kitchen, washing and clearing up. The addition of these two staff to the team, has ensured that all care staff on duty are able to spend their time with residents. The home also employs a handyman who is available 5 days each week and a gardener who works part time. The home’s proprietor and the deputy chief executive are also available at the home on most days. The home invests heavily in training and has a comprehensive training plan for care staff. Records that were examined confirmed that staff are able and expected, to take up the courses that are offered. All staff are enrolled on NVQ courses and the home has achieved its target of 50 of staff who are trained to level 2. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38. The health and safety and welfare of services users is protected by the robust management and administrative systems that are in place throughout the home. EVIDENCE: 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. In this, as in previous unannounced inspections, records were checked and showed that there is a good 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 J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 16 The home’s deputy chief executive said that since the last inspection in November 2004, the local authority’s system for paying personal allowances to residents has changed and these are no longer paid to the home. Families and others acting as agents for individual residents, now hold all such allowances. PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION x x 3 x x x x 4 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation NONE 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. 1. Refer to Standard Good Practice Recommendations PENNINE LODGE J52_J01_s0995_Pennine Lodge_v229991_060605.doc Version 1.30 Page 19 Commission for Social Care Inspection 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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