Inspection on 16/12/05 for Pennyghael Residential Home

This inspection was carried out on 16th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pennyghael Residential Home 16/10/06

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Pennyghael Residential Home Westbourne Grove Selby North Yorkshire YO8 9DG Lead Inspector Kate Shackleton Unannounced Inspection 16th December 2005 06:30 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 Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pennyghael Residential Home Address Westbourne Grove Selby North Yorkshire YO8 9DG 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) 01757 210204 Mr Steven William Saltmer Mrs Penelope Alison Saltmer Miss Anita Yvonne Butterfield Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16) of places Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 09/06/05 Brief Description of the Service: Pennyghael provides residential, social and personal care to 16 people over the age of 65 with dementia. The home is situated very close to Selby town centre with good access to the towns sevices and amenities.The accommodation is provided on two floors which are serviced by a stair lift. There is a conservatory which overlooks extensive gardens which provide a safe area for the residents to walk about. The home recently changed ownership to Mr and Mrs Saltmer. The registered manager Miss A Butterfield remains the same. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Pennyghael changed ownership on the 29 September 2005 and is due to have one inspection before March 31 2006. The timing and nature of this unannounced inspection was prompted by an anonymous complaint alleging poor care practices. The allegations were not substantiated. The inspection started at 6:30am and finished at 12:30 mid-day. The majority of this time was spent sitting talking with service users and one visitor about life in the home whilst observing staff assisting service users with daily living. Some staff were spoken to and a few records were looked at. A tour of the house was done. This did not include looking in every bedroom. What the service does well: What has improved since the last inspection? An occupational therapist has assessed the home to make sure that it has the right disability aids and that the premises are suitable for the people living there. A new larger cooker has been provided in order to improve the cooking facilities when catering for sixteen service users. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 6 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. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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 Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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): None of these standards assessed at this inspection EVIDENCE: Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 9 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 and 10 Service users health and personal care needs are met in a respectful manner. EVIDENCE: Five service user case files were examined. Four of the five contained an up to date care plan. Regular reviews are held. The file of one service user who was admitted on the 18/11/05 did not contain a care plan. Two files did not contain completed risk assessments. Several service users and one relative spoken to said they were happy with the service provided. They said that they can see the doctor and other health care professionals as and when they need to. The community nurse visited during this inspection. One service user who was feeling unwell and had been seen by the doctor was helped to return to bed. Files demonstrated that health care needs are identified and met. Observation of medicines being given out after breakfast showed that a safe system for the administration of medication is in place. Staff were observed working with service users in a kind and helpful manner maintaining their dignity and privacy. Service users said that staff are very good and that they feel well looked after. Service users looked clean and appropriately dressed. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 and 15 Service users are content with the service they receive. EVIDENCE: On arrival at the home at 06:30 several services users were up sitting in the lounge with the television on. Some were dozing in their chairs and one service user was sitting alone in the dining room. All of the service users were asked individually whether it was their choice to be up so early. They all confirmed that they were early risers and that they could please themselves when they got up. The two night staff, one of which was the registered manager confirmed that only service users who were asking to be got up were helped to rise early. The early risers were given a hot drink before breakfast was served. The day staff were observed helping service users get up well into mid morning. There was a choice of food at breakfast. Breakfast went on for as long as it took service users to have their meal. Some service users choose to eat in their bedroom and the lounge with the majority favouring the dining room. The member of care staff cooking that day was heard offering service users a choice of meal at lunchtime. A new cook has recently been employed with new ideas and a new set of menus is being developed. The cook had rung in to say she couldn’t come in to work so care staff were preparing the meals. The cook Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 11 is aware of service users likes and dislikes. Service users said that the food was good and that they had enough to eat and enjoyed their meals. Activities are arranged and some examples given were: in house games such as Bingo, sing-a-longs and entertainers visit approximately monthly. There is no religious service held in the home because no one is asking for it. Visitors are made welcome; three were seen in the home during this inspection. One visitor spoken to said that her relative who has lived at the home for about four years is well cared for and that she is kept informed and made welcome. The visitor felt that staff “do their very best” to provide a service that meets the needs of service users. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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 the following standard(s): None of these standards were assessed EVIDENCE: Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 Some areas of the house are not clean, poorly maintained and have poor furnishings. Whilst this does not pose a risk to service users it does not create a pleasant environment to live in. EVIDENCE: A tour of some areas of the house including communal areas and some bedrooms raised the following issues • The dining room carpet and other carpets were stained. • The walls are dirty and the vanity unit stained in a first floor bathroom • Bedroom 10 smelt of urine • Two lights were not working on a first floor corridor. • A chair in the lounge has ripped arm coverings. •The conservatory lounge was cold. The heater was broken. The carpet was dirty. The low three-piece suite was in poor condition with obvious cigarette burns. A glass panel was cracked and held together with cellotape. The UPVC structure was dirty and stained resembling the colour of nicotine. A new gas Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 14 cooker was stored in this lounge. The room looked untidy and uncared for and because of the state it was in could not be used by service users. Staff explained that the carpet cleaner is broken. The first floor bathroom is due to be refurbished and they are waiting for an electrician to visit to repair the heater in the conservatory lounge. The conservatory is the smoking area. The cooker was to be fitted in the kitchen the following day. Little appears to have been done to in terms of redecoration or refurbishment in the last twelve months and the environment seems to have deteriorated since the home was last inspected. Since the last inspection an occupational therapist has assessed the building and produced a report. All the recommendations made in the report have been implemented. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 15 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): 27,28 and 29 A lack of trained staff and poor recruitment practices has the potential to place service users at risk of harm EVIDENCE: There is usually three care staff on duty throughout the day and two waking night staff. A cook and kitchen assistant work five hours each day covering the lunch time period. Care staff prepares and serve breakfast, tea and supper. One cleaner is employed to work for five hours three days a week. Outside of these fifteen hours care staff have to also do cleaning duties. This means that a substantial number of care hours that should be spent working directly/ spending time with service users are being taken up with ancillary duties. Previous comments made in this report suggests that more domestic hours need to be provided. Service users said that staff seemed to have the time to complete tasks without hurrying them and staff were observed responding quickly to requests made by service users. Four of the fourteen care staff employed have achieved National Vocational Qualification level 2. This is below the 50 average of NVQ trained staff expected to be achieved by the end of December 2005. This lack of trained staff could be detrimental to service users. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 16 The practice of employing staff without suitable safety checks has been reported at previous inspections but is continuing. A recently recruited staff member started work before a POVAfirst/Criminal Records Bureau check had been issued. Only one written reference was on file instead of the required two. A robust recruitment procedure to safeguard residents must be implemented immediately and the owners and registered manager must familiarise themselves with the Protection of Vulnerable Adults guidance. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 17 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): None of these standards were assessed at this inspection. EVIDENCE: Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 1 30 X Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Timescale for action 16/01/06 2 OP19 OP26 23 3 OP29 19 The registered manager must ensure a dedicated care plan detailing specific care interventions and developed from a comprehensive assessment of need, including risk assessment and management principles, must be developed for every service user. (Timescale of 30th March 2004 and 18th July 2005 not met) The registered manager must 16/01/06 ensure that all parts of the home are kept clean and that furnishings and fittings are replaced as they become damaged. The registered manager must 16/01/06 not employ staff before a POVA/first check has been issued. (Timescale of 21st January 2004 and the 18th July 2005 not met) The registered manager must receive two written references relating to the person before employment commences. Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 20 The registered providers and manager must familiarise themselves with the Department of Health POVA guidance and the CSCI policy and guidance on Criminal Records Bureau Checks. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 27 28 Good Practice Recommendations Consideration should be given to providing additional dedicated daily cleaning hours. More care staff should undertake training that leads to a Health and social Care National Vocational Qualification Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI Pennyghael Residential Home DS0000065116.V273625.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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