Inspection on 01/11/05 for Pinegrove

This inspection was carried out on 1st November 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinegrove 03/07/07

Pinegrove 28/06/06

Pinegrove 27/07/05

Pinegrove 20/12/04

Pinegrove 21/06/04

Pinegrove 03/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Pinegrove Main Road Nether Padley Nr Grindleford Derbyshire S32 2H Lead Inspector Leslie Wilson Unannounced Inspection 1st November 2005 02:15 Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 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 Pinegrove DS0000020073.V258238.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 Adults 18-65. 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. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinegrove Address Main Road Nether Padley Nr Grindleford Derbyshire S32 2H (01433) 639784 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) Home Farm Trust Stephanie Anne McDonald Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: The home provides care and support for up to 9 younger adults with learning disabilities. It is located near the village of Grindleford, in the Peak District National Park, and set in its own large grounds and gardens. The gardens are well maintained and there are lots of parking spaces available. Accommodation is on three floors, with separate dedicated living accommodation for up to three residents on each floor. Individual living accommodation is made up of a single bedroom, kitchenette facilities, and ensuite bathroom with W/C. There is a shared lounge, dining area and kitchen on each floor. A shaft lift provides access between the floors. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and started at 1415 hrs. The visit lasted 2 hours and 45 during the afternoon and early evening. Four residents currently living at the Home and the members of staff who were caring for them at the time were consulted. Residents records were looked at and case tracking methods were used. Policies, procedures and the homes records were also reviewed. The home was well decorated and had the feel of a real house and not an institution. Staff and most residents seemed to enjoy being at the home and the two residents commented that the home was “very good”. Staff are generally well supported and there are sufficient systems in the home to ensure its smooth running, and that the needs of residents are met. However, some systems require some more improvement in order to meet the National Minimum Standards and information needs to be made accessible to all as appropriate. Equally due to low staffing pressures on staff were higher than usual, but staff should be commended for never allowing this pressure to detract from providing the best possible service to residents. 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. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 8 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 the following standard(s): These standards were not assessed during this inspection visit. EVIDENCE: Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 9 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 the following standard(s): These standards were not assessed during this inspection visit. EVIDENCE: Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 17 Menus and meals planning were conducted to ensure that residents had a full and varied choice of food available to them. EVIDENCE: From the records seen it was clear that some meal planning took place, allowing resident to exercise choice about the food that they ate. Where advanced meal planning did not take this was due to residents’ wishes to plan on a daily basis what meals they would eat, and this being respected by the staff, and incorporated into their care plans and development plans. Although the Registered Manager stated that a nutritionist did not see the menus to advise the residents, and staff, about whether the menus were balanced. Plans have been made to include this service for residents soon. Residents confirmed that they were able to choose their meals and that they could ask the staff to change the menus if they did not like a particular food. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed during this inspection visit. EVIDENCE: Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Although all complaints and concerns procedures were in place a lack of training means that staff are not always aware of systems in relation to the Protection of Vulnerable Adults. EVIDENCE: A clear policy was available for staff to follow in the event of comments and complaints being made about the services provide at the home. Residents stated that they knew who to make a complaint to and how to make a complaint. Records seen indicated that no complaints had been made about the home since summer 2004. However, it was not clear from the complaints record book, if the monthly visitor examined it. From the records of staff training seen, and discussions held with the Registered Manager, it was evident that Protection of Vulnerable Adult (POVA) training had not been given to any staff currently working in the home, and staff were left unaware of how and when to report incidents using POVA procedures. However, staff commented that they would approach the Registered Manager or ‘on-call’ person should they require guidance in relation to a POVA referral. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed during this inspection visit. EVIDENCE: Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 36 Support systems for staff are not in place to ensure that staff development needs and resident needs can be addressed and met. EVIDENCE: Training records seen indicated that although training had been provided to some staff, the training provided was not consistently applied to all staff (including relief workers) and was sparse in places. The Registered Manager stated that it was sometimes difficult to free staff for courses due to 40 vacancy level in staffing in the home. However, a recent recruitment drive should alleviate this problem in the future thus ensuring that all staff have the required training. From the records displayed in the office, and the supervision records seen, staff were given supervision every 2 months. The Registered Manager stated that staff supervision was being moved to a monthly basis; and staff were able to confirm that this took place. Although some staff felt that monthly supervision was ‘too much’ the management of the home should be commended for working to ensure that supervision is a well-defined and positive process for staff, reflecting on their work and the needs of the residents. Staff were also able to confirm that annual appraisals along with a Personal Development Plan (PDP) were in place, and that PDP’s were reviewed twice a year during the supervision process. A clear staff induction was in Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 15 place and 3 monthly and 6 monthly probationary reports were available indicating the skills assessed and achieved by new staff. Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 Although systems were in place to ensure that the views of residents and carers were gathered; further systems were required in order to ensure that the home is a safe environment in which to live and work. EVIDENCE: Records of Residents Meeting were available. The residents made some of the records with other records being made by staff. Residents confirmed that they could talk about things they liked and didn’t like about living at the home during the meeting and that their ideas would be listened to. The Registered Manager described a system of consultation with parents and carers based on their wishes to be consulted on an annual basis rather than bi-annually. The majority of Health and Safety checked had been carried out in the home and records of these checks were seen. The Electrical (Hardwiring) Safety Certificate had been issued on the 26/02/01 and was listed as requiring review on 26/02/01 whilst it was stated that the certificate was valid for 5 years leaving some confusing about the validity of the certificate. Fire and general environmental risk assessments were available within the home and risk Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 17 assessments individual to each resident were also available to ensure that residents individual health and safety needs wee identified and minimised were possible. The Gas safety Certificate for the home was out of date meaning that it was not clear if the home was safe in relation to the gas appliances within the home. Pinegrove DS0000020073.V258238.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 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 X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pinegrove Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000020073.V258238.R01.S.doc Version 5.0 Page 19 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 2 Standard YA23&YA35 YA42 Regulation 18 12 Requirement Staff must be provided with training appropriate to the work they perform. Provision must be made to ensure the health and welfare of residents and staff within the home. Timescale for action 31/12/05 31/12/05 Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 20 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 3 4 Refer to Standard YA22 YA23 YA35 YA42 Good Practice Recommendations The complaints record book should be signed by the monthly visitor to indicate that they have examined the records. Staff should be provided with Protection of Vulnerable Adults training. Staff should be provided with training as indicated throughout the National Minimum Standards. The electrician who conducted the Electrical (Hardwiring) Safety Certificate inspection should be contacted for written clarification on the validity of the certificate issued to the home. A current Gas Safety Certificate should be available in respect of the home and available for inspection. 5 YA42 Pinegrove DS0000020073.V258238.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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