Inspection on 28/06/06 for Pinegrove

This inspection was carried out on 28th June 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 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 01/11/05

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 Nancy Bradley Unannounced Inspection 28th June 2006 09:00 Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 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.V303187.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 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.V303187.R01.S.doc Version 5.2 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 Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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 en-suite 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.V303187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. The inspector spoke with the assistant area manager and members of staff on duty. During the site visit the inspector made a tour of the home and spoke with several service users. The remaining service users’ were at the local day centre or at the farm run by Home Farm Trust. The inspector observed throughout the visit how the staff were meeting service user needs. The Registered Manager has resigned since the last inspection and Brian Parsons has been appointed and he will need to apply for registration with the Commission for Social Care Inspection. Records were examined relating to the service users’ and the running of the home. The inspector had lunch with the service users’. No family or relatives were present during this visit. Since the last inspection there has been no change in the service users’ living at 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. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 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 the following standard(s): Standard 2 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. Arrangements are in place to ensure that service users needs are fully assessed and met prior to admission. EVIDENCE: The individual records of two service users were checked. The majority of the service users who are admitted to the home have their needs assessed via social worker or through the care management system, which highlights their additional needs, and the need for additional staffing hours. The assessments then form part of the service user plan compiled by the home and had been signed by the service user’s. These were comprehensive and up to date and reflected the involvement of service user and significant others. The majority of the assessments examined were of long-term service users who had been at the home for many years. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 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 the following standard(s): Standards 6,7,9 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. There is a care planning and review system in place, which ensures that service users individual needs are met. Service users are supported to achieve an independent lifestyle and participation in all aspects of the life at the home is encouraged. EVIDENCE: During the visit care plans of two service users were examined. The care plans have been compiled by the staff on each service user and evidence was seen of care plans being reviewed on a regular basis. Care plans included services users individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily records are also maintained on each service user. Care plans were personalised and had been signed by the service user or their families. All service users have access to the Advocacy service should this be required. Detailed risk assessments were in place and these included actions to be taken by staff. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 9 The service users have been resident at the home for some time and it is evident that the staff know them well. All service users access various services according to their needs, abilities and requirements. Service users spoken with during the visit talked about life in the home and the care they received, detailing their individual daily living arrangements and involvement in daily routines. As good practice and file management pervious years recorded could be archived leaving a working file. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 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): Standards 12,13,15,16 and 17 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. There were arrangements in place to enable service user to maintain and develop appropriate relationships, and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. The home provides a well-balanced and nutritious diet. EVIDENCE: During the visit the inspector spoke with service users and care staff about the activities service users were engaged in and the arrangements for these. The care records of two service user’s provided detailed needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. The service users personal goals, choices and preferences were identified and there were properly recorded risk assessments in place for each service user in relation to the activities they were engaged in. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 11 Service users spoke about the forth-coming holiday to Blackpool in September and how they would be spending their time during the holiday. The holidays are tailored to the individual needs and abilities of the service user. Information on service users’ records indicated that contact with family and friends were appropriate. The service users’ families play an important part in their lives and the home maintains very good contact with them. From examination of the menus the home is providing a healthy well-balanced and nutritious diet with some service users on special diets. Service user’s weekly weights are recorded. During the visit the inspector joined the service users for lunch. The service users are given a choice if they do not like the options on the menu. The staff were observed checking with service users as to their likes and dislikes. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 12 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): Standards 18,19,20 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The health needs of service users’ are well documented ensuring that individuals receive regular health checks. Service users receive personal support in a way, which promotes, their independence EVIDENCE: From records examined and from discussions with staff, this showed that service users’ health and personal needs were being met Service users were generally healthy and records showed that staff promptly contacted the appropriated medical services. All service users attended services within the community including optician, chiropodist, and dentist. The home operates and monitors service users medication. None of the service users are able to administer their own medication. All staff have received training on medication training procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to be satisfactory. There was a clear audit trail of all medication used at the home. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 13 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): Standards22and 23 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. Arrangements are in place to safeguard service users welfare and ensure that their concerns are listened to and acted upon. Staff training on safeguarding adults would further strengthen and support this. EVIDENCE: Their key worker makes service users aware of the complaints procedure through the service user guide. The complaints policy is in an easy to read format and is easily accessible to service users. Service users stated that they knew who to make a compliant to and how to make a complaint. Records seen indicated that no complaints had been made about the home since 2004. The monthly visitor had signed the complaints book confirming this. There has been no adult protection issue raised in the home since the last inspection. From discussions with several staff it was evident that staff had not received any up to date training in adult protection. Staff spoken with during the visit commented they would contact the on call person should they be required to in relation to adult protection issue. The staff are trained in de-escalation techniques however this does not fully cover physical intervention should this be required. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 14 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): Standards 24 and 30 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The general standard of the home and the environment are good providing service users with an attractive and comfortable place in which to live. EVIDENCE: A tour of the building was conducted and the service user accompanied the inspector. All communal areas were inspected together with the staff facilities. Several of the service users bedrooms and en suites were inspected with their agreement. Individual service users bedrooms were highly personalised. Some of the rooms on the second floor were very hot compared to the ones lower down. Although this was due to the weather the home may need to look at providing suitable ventilation. All areas of the home were seen well maintained and clean. The premises were decorated and furnished to a high standard and properly equipped. Sufficient space was provided in all communal areas. The garden area is well maintained and attractive with seating areas provided and a sun house. The service users have a small vegetable patch, which they are responsible for. individual risk assessments were in place in relation to the use of the kitchen by the service users. There are no outstanding repairs or maintenance issues. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 15 Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 16 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): Standards 32,34, 35,and 36 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The home has robust recruitment procedures and practices in place which ensure the safety and protect the service users. More importance needs to be given to the staff’s developmental needs. EVIDENCE: The home operates a key-worker sys tem and the staff spoken with during the visit where aware of the individual needs of the service users. From records examined during the visit 50 of the staff have attained a National Vocational Qualification at level 2. The Home Farm Trust have recruitment policy and procedures in place and from records examined all staff are required to have a current and valid Criminal Records Bureau check, two references and a medical clearance. All recruitment records are held centrally at Sheffield with the home holding very little information. This was discussed with the senior management at the end of the inspection with the home looking at an alternative system. From records examined during the visit 50 of the staff have attained a National Vocational Qualification at level 2 Staff’s training records were seen, however due to staffing difficulties it has not always been possible for staff to attend relevant training events. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 17 From records seen supervision was within the standard 36.4. Although the deputy area manager did state that the frequency is to be increased to once a month. This should be seen as good practice. The home conducts annual appraisals and all staff have a Personal Development Plan. A clear staff induction programme is in place with staff completing a six months probationary period. As a sign of good practice staff on their induction and probationary period should not be covering the sleeping-in duty. Staff job descriptions are in place. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 18 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): Standard37, 39, and 42 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. Systems are in place to ensure that service users have a voice and their views are listened to. EVIDENCE: The Registered Manager post is currently vacant, Brian Parsons has been appointed manager and will require registration with the Commission for Social Care Inspection. The Commission for Social Care Inspection were informed of the appointment. The assistant area manager has been is providing the dayto-day management support. The Home Farm Trust has established a service user involvement group, which meets every few months and looks at specific topics, which affects their lives. This then fits in with quality assurance systems, which operates within the home. Service users confirmed that they talk about things they like and dislike about living at the home. The majority of Heath and Safety checks had been carried out in the home, although the home insurance certificate expired in May 2006. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 19 It was noticeable the amount of electrical equipment in the staff sleeping room and the registered person was asked to investigate this under health and safety. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 2 X Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 21 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 Regulation 18 18 Requirement Timescale for action 31/08/06 3 YA42 23 Staff must be provided with training appropriate to the work they perform. All staff must be given the 31/08/06 opportunity to undertake training appropriate to the work they perform. The home must display a valid 31/08/06 insurance certificate. 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 5. Refer to Standard YA6 YA23 YA35 YA35 YA42 Good Practice Recommendations Previous years records should be archived leaving a working file. Staff should be provided with up to date training in the Protection of Vulnerable Adults. Staff should be provided with training as indicated throughout the National Minimum Standards. Staff on their induction and probationary period should not undertake sleeping in duty. The home should check on the amount of electrical equipment and wiring maintained in the staff sleeping in DS0000020073.V303187.R01.S.doc Version 5.2 Page 22 Pinegrove accommodation. Pinegrove DS0000020073.V303187.R01.S.doc Version 5.2 Page 23 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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