Inspection on 22/08/05 for Pfera Hall

This inspection was carried out on 22nd August 2005.

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

Pfera Hall 16/12/08

Pfera Hall 27/11/07

Pfera Hall 05/12/06

Pfera Hall 22/06/06

Pfera Hall 10/03/06

Pfera Hall 23/03/05

Pfera Hall 02/09/04

Pfera Hall 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pfera Hall Old Ledbury Road Redmarley Gloucestershire GL19 3JU Lead Inspector Richard Leech Uannounced 22 August 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pfera Hall Address Old Ledbury Road Redmarley Gloucestershire GL19 3JU 01531 650880 01531 650833 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) Stones Holdings Ltd Mr Andrew Biddlecombe Care Home 18 Category(ies) of LD Learning Disabilities Both (18) registration, with number MD Mental Disorder Both (18) of places Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2005 Brief Description of the Service: Pfera Hall is registered to provide care with nursing for up to 18 service users with learning disabilities and mental health difficulties. It is near the village of Redmarley, between Ledbury and Gloucester. The home is set in substantial grounds and is surrounded by countryside. The home is divided into three units named Nimrod, Dorabella and Winston. Each has a lounge, kitchen, dining area and laundry as well as bathroom and toilet facilities. A separate wing houses the managers office, reception and day care facilities. The latter includes a gym, multi-sensory room, computers, training kitchen and art & craft centre. The home has several vehicles in order that service users can access facilities and amenities in the wider community. Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 10am and lasted for about four and a half hours. All three areas of the home were visited, and several staff and service users met with. Menus were checked along with daily records and activity plans. A relatively small number of National Minimum Standards were assessed during this visit since it was combined with considering an application for a variation in registration. As part of the inspection two new bedrooms (converted from one larger room) were checked. The company has applied to increase the registered numbers from 18 to 19. At the time of writing the application was being processed. 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. Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Appropriate steps are taken to ensure that the team can meet the assessed needs of people admitted to the home. EVIDENCE: In the last report a requirement was made about amending the Statement of Purpose such that it met the Care Homes Regulations. This has been done. The Statement of Purpose has a section about admissions. This includes reference to assessment, introductory visits and a three-month trial period. Care planning files for two recently admitted service users were checked. These included assessment and background material. One service user described their introductory visits to the home including overnight stays. Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 & 17 Service users are offered a range of meaningful activities in the home and community which meet their individual needs and interests. These develop their confidence and skills as well as a sense of achievement and fulfilment. Service users are supported to have contact with important people in their lives, helping them to maintain and develop their relationships. Service users are offered a varied, healthy diet which promotes their wellbeing and incorporates their choices and preferences. EVIDENCE: The Statement of Purpose describes the kinds of in-house and community activities which service users are offered. Discussion with staff and service users, as well as checking activity timetables and daily records, provided evidence that service users have varied, individual programmes which correspond to their needs and interests. A monthly magazine on display near reception included accounts of other activities such as a trip to a farm, a quiz and a sports day. The magazine and a notice board also provided information about a range of events and opportunities at different venues in the local community. Service users and staff described accessing facilities and services Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 10 in the local area such as church, the cinema, cafes, the Post Office and pubs. Recent trips included a boat ride and a visit to an animal park. The Statement of Purpose includes information about how service users are supported to stay in contact with family and other important people in their lives. Service users described regular contact with family members, including by telephone. Staff talked about how they support this contact. Service users spoken with were positive about the food. Menus in each unit were viewed. Staff in each of the three units described how menus were put together and how service users’ choices were represented. Staff and service users confirmed that alternatives are available if a person does not like something on the menu. Staff described using fresh meat and vegetables as much as possible and some service users commented on the quality of the food and cooking. Records are kept of each person’s food intake. Some did not include specific reference to vegetables served with the meal, just noting the main course. As part of demonstrating and monitoring that people are having a healthy diet staff could also record the vegetables and other accompaniments provided with each meal. Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were inspected on this occasion. EVIDENCE: Pfera Hall D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pfera Hall Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x D51_D03_S16539_PferaHall_V245908_Stage4_200805_U.doc Version 1.40 Page 17 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 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 17 Good Practice Recommendations Aim to record the vegetables and other accompaniments provided with each meal in the records of peoples food intake, as part of monitoring whether the diet is balanced. 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