Inspection on 06/01/06 for Pinfold Lane

This inspection was carried out on 6th January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinfold Lane 16/08/07

Pinfold Lane 24/08/06

Pinfold Lane 08/12/04

Pinfold Lane 03/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Pinfold Lane 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE Lead Inspector Linda Trenouth Unannounced Inspection 6th January 2006 13:45 Pinfold Lane DS0000001491.V264727.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 Pinfold Lane DS0000001491.V264727.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. Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pinfold Lane Address 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE 0113 286 3691 0113 286 3691 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) Community Integrated Care Mr Richard Conyngham McGill Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Pinfold Lane is located close to the town centre of Garforth. The home was first registered in March 1997, providing care to four men with profound learning disability. The registered provider for the home is C.I.C. (Community Integrated Care) A wheelchair user is accommodated on the ground floor, where the communal sitting areas, kitchen, bathroom, shower and laundry are located. There is a specialist bath lift and hoist in the bathroom. There are two bedrooms on the ground floor and two on the first floor. All bedrooms are single rooms. Residents are encouraged to use community facilities in the neighbourhood for social activities. Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 4th August 2005. There have been no additional visits made to the home since the last inspection. This was an unannounced inspection carried out by one inspector who was at the home from 1.45pm until 6.00pm. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents. The methods used at this inspection included looking at care records; observing working practices and talking to staff and residents. Comment cards were sent to the home to provide residents and visitors with the opportunity to comment on the service. Feedback was given to the manager at the end of the visit. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of the report. What the service does well: The home undertakes good recruitment practice to induction training to make sure that the residents are well protected. Staff had regular individual supervision and meet regularly in team meetings. The management and staff as much as possible make sure that residents make meaningful decisions about their lives. Residents are encouraged and supported to take part in daily tasks within the home and participate in the community activities. All the residents had good opportunities for personal development and integration into the local community. Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 6 The residents are also supported to have friendships beyond the home and enjoy and maintain family relationships. 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. Pinfold Lane DS0000001491.V264727.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 Pinfold Lane DS0000001491.V264727.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): Not reviewed at this inspection. EVIDENCE: Pinfold Lane DS0000001491.V264727.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): 8 and 10. Residents make meaningful decision about their daily lives. EVIDENCE: The staff make sure that all residents participate in the daily decision making in the home. Staff consulted with residents on all aspects of their day, encouraging them to make meaningful choices. Residents were observed choosing what they wanted during the day and for the evening. Plans and choices were informally discussed over the mealtime and all residents were asked their opinion and encouraged to participate. Residents take part in their reviews and make both short term and long-term decisions. They choose whether they want to attend a day centres or remain at home during the week. They decide between ranges of additional leisure activities organised by the staff and a holiday or day trips. Staff support residents to live a fulfilling live outside as well as in their home. Food is also discussed and menus planned around the four residents likes and dislikes. Pinfold Lane DS0000001491.V264727.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 Service users are offered a healthy and interesting diet and enjoy their meals and mealtimes. EVIDENCE: The staff plan a weekly menu with the residents. This menu is then displayed in the kitchen. The menu allows for flexibility for meal change and a treat such as a take away meal. The home is small enough to know the residents likes and dislikes. The menu is therefore planned around their tastes and is a varied and interesting menu suitable to the age group at the home. Mealtimes are held in the kitchen and staff sit with residents to encourage and help where necessary. The mealtime is relaxed and informal and staff assist and prompt residents. Pinfold Lane DS0000001491.V264727.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): 20 and 21. Medication records were maintained but storage and disposal of medication needed to be reviewed to make sure that errors in administration did not occur. The ageing and illness of service users are handled with respect and dignity. EVIDENCE: The medication records were reviewed. The drugs records were satisfactory but there were some items of medication that were of out of date. The manager and staff must constantly review the medication and make sure that out of date medication is returned to the pharmacist for disposal. Ointments must also be dated when they are opened, as the shelf life is limited. During the last inspection the staff cared for a resident who had a high level of health and care needs, requiring district nurse support. Staff observed caring for this individual did so in a conscientious and respectful manner. When the health needs changed the staff at the home continued to care with the same high level of commitment to ensure that the transition to the next home was in the best interest of the resident. Pinfold Lane DS0000001491.V264727.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): The service user and their relative are encouraged to make their views known and they are listened to and acted upon. EVIDENCE: Relatives visiting at the inspection said that the manager had invited them to talk to him or his staff and raise requests or concerns. They felt able to talk to the manager and staff and pass on any problems. Service users make their views and feelings known through speech, expression and behaviour. The manager and staff have worked with three of the residents for some time and had a good understanding of their needs. The staff also worked closely with the day centre staff, which join in the reviews and were in contact throughout the year. Pinfold Lane DS0000001491.V264727.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): 24 and 30 The carpets in the hall and corridors and the first floor toilet did not meet a satisfactory level of cleanliness and hygiene. EVIDENCE: At the previous inspection it was raised that the hall, stairs and landing carpets were very dirty giving a poor impression upon entering the home. If this carpet cannot be effectively cleaned and maintained, then this carpet must be replaced. The single toilet on the first floor smelt of urine. The wooden/ chipboard boxed pipe area around the toilet had deteriorated and urine had soaked in. It was no longer possible to keep this area sufficiently clean and the boxed area urgently needed to be replaced. Pinfold Lane DS0000001491.V264727.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): 33, 34 and 35. Safe staff recruitment procedures are followed to protect residents. The home is staffed to meet the needs of the service users. Staff receive training and supervision to review their competence and skills. EVIDENCE: The home has been through a difficult time in the last 6 months with staff leaving to take up other employment. This has put additional stress on the existing staff team. The service has recruited five staff who are undertaken their period of induction at the home. Throughout this however staff confirmed that they have had regular staff meetings and supervision. Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 15 All new employee files were reviewed and it was evident that the home operates a safe recruitment procedure, which includes interviewing potential staff and ensuring that all checks are undertaken. All staff are issued with copies of the terms and conditions of employment and staff confirmed that they have had induction training covering manual handling, first aid, food hygiene and adult protection. The manager confirmed that staff are registered on the NVQ award after they have completed their foundation training. Pinfold Lane DS0000001491.V264727.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): 42 and 43. The home has a responsible approach to the Health and Safety of the residents by undertaking regular checks and training staff in health and safety awareness. The home has a good quality assurance system, which is appropriate to the size and needs of the home. EVIDENCE: The manager and the provider work together to make sure that the needs of the residents are met. The area manager makes regular visits to support the manager and staff at the home. The home has a responsible approach to the Health and Safety of the residents, staff and visitors. Regular checks had been undertaken in areas of Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 17 fire, electrical and gas safety. The service complies with the requirements made by the fire and environmental health authorities and has always been responsive to the previous requirements regarding health and safety at the home. Pinfold Lane DS0000001491.V264727.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 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x 3 x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 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 3 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pinfold Lane Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score x x x x x 3 3 DS0000001491.V264727.R01.S.doc Version 5.0 Page 19 yes 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. Standard Regulation Requirement Timescale for action 01/04/06 01/04/06 1 2 YA20 YA24 13 23 3 YA30 13 The manager must make sure that all out of date medication is disposed of appropriately. Clean or replace the carpet in the hall, corridor and stairs. ( previous timescale of 1.11.05 not met.) The casing of the pipes around the toilet on the first floor must be replaced. 01/04/06 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 YA32 Good Practice Recommendations The organisation must ensure that 50 of care staff have an NVQ qualification by 2005. ( 31.12.05 timescale agreed from a the previous inspection). Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Pinfold Lane DS0000001491.V264727.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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