Inspection on 16/10/06 for Pennyghael Residential Home

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Pennyghael Residential Home 16/12/05

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 Brian Hallgate Key Unannounced Inspection 16th October 2006 10:15 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.V314357.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. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 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.V314357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 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 town’s services and amenities. The accommodation is provided on two floors that are serviced by a stair lift. There is a conservatory that overlooks extensive gardens which provide a safe area for the residents to walk about. A copy of the service users guide to the home is given to potential service users and their relatives. A copy of the latest Commission for Social Care Inspection Report is available for prospective service users and their relatives to read. The weekly fee on the date of the inspection was £350 per week. Additional charges are made for chiropody £11 and hairdressing £4.50. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to inform this report was obtained from the information documented in previous inspection reports, a pre-inspection questionnaire completed by the registered manager of the service, a site visit, completed survey forms and discussions with seven service users, the registered manager and four members of staff. Prior to the inspection seven survey forms were sent to service users and none were returned, four survey forms were sent to GPs and one was returned and four forms were sent to care managers and none were returned. The responses were positive. This unannounced inspection took place on the 16th October 2006, commencing at 10.15am. A number of records were inspected including service users’ assessments, care plans, medication and health and safety information. A tour of the building was made with the administrator of the home and staff were observed interacting with a number of service users. 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. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 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 the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. The assessments prior to admission are comprehensive and provide informed decisions about moving into the home. EVIDENCE: There is a comprehensive assessment completed on all potential service users before they are considered for admission to the home. Service users are admitted for a trial period of four weeks. The documentation examined showed that the necessary assessments had been made prior to admission. Intermediate care is not provided in this home. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. The health needs of service users are met with good access available to specialist medical services when required. EVIDENCE: There is a written plan of care for each individual service user that enables staff to care for people as individuals. Service users files inspected showed that the information was sufficient to allow staff to care for each person appropriately. The plans are reviewed at least monthly and the files seen had regular and up to date reviews completed. All service users are registered with a GP and access to specialist care is through the GP’s surgery. Dental appointments are arranged when necessary and those service users who need glasses have a yearly eye test. A chiropodist visits six to eight weekly. No service users are able to self medicate. A monitored dosage system is used to store medication for other service users who require medication. The medication and medication records checked were up to date and in order. Observations of staff interacting with service uses showed that they were treated with dignity and respect. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Visiting arrangements are flexible allowing service users to maintain good and regular contact with their family and friends. EVIDENCE: Visitors are welcome at anytime and service users spoken to welcomed these visits. One relative confirmed this and stated that her relative received very good care and was very happy in the home. She said, “Everything is fine here, my relative is very happy. She has experienced other homes but she is far happier here”. There are a number of activities arranged and these include chair based exercises, outside entertainers, quizzes, bingo, dominoes, cards, board games, puzzles, drawing and baking. Outside the home service users can play pitch and putt, lawn bowls and skittles. Staff were encouraging service users to throw beanbags onto lettered squares in the centre of the floor and asking them for flowers beginning with the letter that the beanbag landed on. The majority of the service users were actively taking part in this activity. There is a menu that shows service users have a choice of meals. Diets are catered for if necessary. No service user at present is on a special diet. All service users spoken to considered that the food was very good. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 10 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. There are satisfactory complaints and abuse policies and staff showed that they were aware of the correct action to take if a complaint or abuse situation was observed. EVIDENCE: No complaints have been made to the Commission for Social Care Inspection since the last inspection. One complaint has been made to the home. This was investigated and substantiated. Staff spoken to were fully aware of what action to take in the event of an abuse situation occurring. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. The standard of the environment within this home is good providing service users with a homely place in which to live. EVIDENCE: The home has been undergoing continual improvement since the present provider took over the running of the home. The home has been repainted internally and wallpaper has been applied to the interior walls throughout the building. New carpets have been ordered and the fitters have stated that they will commence fitting the carpets within the next week. Tiles have been purchased for the kitchen and arrangements are in hand for them to be fitted. The home is clean, pleasant and hygienic. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 12 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. Since the last inspection the standard of vetting and recruitment practices has improved with the appropriate checks now being carried out. EVIDENCE: There was sufficient staff on the duty rota to meet the needs of the thirteen service users living in the home on the date of the inspection. However the supervisor on the morning shift rang in sick at 7am and staff tried to obtain a replacement without success. The registered manager was in the home at the beginning of the inspection but was officially on annual leave. The administrator, who has many years experience as a carer, took charge of the shift with two inexperienced carers. The service users received the care that they needed from the staff team. One of the cooks was also on duty. There was good interaction between all the staff and the service users who were all treated with respect and dignity. Arrangements should be made that enable staff to be available at short notice to cover sickness. On this particular day as the administrator was on duty and had considerable care experience she was able to concentrate on caring instead of administration. The employment records checked were in order and up to date. The necessary checks had been made before new staff commenced their duties. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 13 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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit. There was evidence that proper attention is given to health and safety promoting a safe and secure environment in which service users with dementia can live. EVIDENCE: The registered manager is experienced in the care and management of older people with dementia. She is at present undertaking NVQ Level 4 in management. Quality assurance is undertaken by questionnaires forwarded to relatives for completion and by discussion with relatives when they visit the home. No money of service users is kept by the home for safekeeping. Relatives deal with all service users finances. Each service user has a locked cupboard in their own room to keep small amounts of money if they wish. All health and safety information checked was in order and up to date. This included fire alarm checks, hot water temperatures, gas and electrical safety certificates. Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 14 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 15 Are there any outstanding requirements from the last inspection? NO 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 Pennyghael Residential Home DS0000065116.V314357.R01.S.doc Version 5.2 Page 16 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. 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