Care and Social Services Inspectorate Wales

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1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Pen-y-Garth EMI Residential Home Pleasant Lane Brymbo LL11 5DH Type of Inspection Focussed Date(s) of inspection 10 February 2014 Date of publication 31 March 2014 You may reproduce this report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers Please contact CSSIW National Office for further information Tel:

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3 Summary About the service Pen-Y-Garth is registered with the Care and Social Services Inspectorate Wales, (CSSIW) to provide accommodation and personal care for up to 44 people over the age of 65 who have a diagnosis of dementia/ mental infirmity. This can include up to five persons under the age of 65. The responsible individual is Mr Keith Symms and the registered manager is Mrs Michele Roberts. Mrs Roberts has a management qualification and is registered with the Care Council for Wales. What type of inspection was carried out? We, (CSSIW), undertook a focused inspection on the 10 February 2014 between the hours of 6.10 am and am. The inspection took place following concerns we received about people being asked by staff to get up very early, that there were sometimes not enough staff on duty at night and that not all staff had received appropriate training. We looked at the care records of eight people who were awake, dressed and in the lounges when we arrived. We viewed the staff rota and a training record supplied by the manager at the offices of CSSIW. We spoke with five members of staff who were very helpful when the reason for the visit was explained. We also spoke to the manager. We viewed communal areas and some bedrooms. There were 43 people living in the home on the day of the inspection. This inspection report relates only to the visit undertaken on the 10 February What does the service do well? The service is expected to operate to at least the national minimum standards. Within the focus of this inspection as detailed above, we did not see any practice that exceeded this. What has improved since the last inspection? The focus of the inspection was to look at specific concerns raised with us so we did not review previous inspection findings. We are therefore unable to comment at this time about any improvements that may have been made. What needs to be done to improve the service? Non compliance notices have been issued as a result of this inspection. The home is not compliant with the Care Homes (Wales) Regulations (1) regarding all people who live at the home must have a care plan and a non compliance notice has been issued. The home is not compliant with the Care Homes (Wales) Regulations 18 (1) (c) (i) regarding all staff must have received training appropriate to their work and a non compliance notice has been issued.good practice recommendations. A photograph of the person should be kept on their care records as soon as they move into the home. This is so that people, particularly when they first move into the home, can be easily identified by staff. Regulation 17 (1) (a) Schedule 3 (2). 3

4 Quality of life Overall we found that people living at the home cannot be reassured that their wishes are taken into consideration in all aspects of their lives. This is because we saw that 12 people were awake and dressed when we arrived at 6.10 am. We spoke with several people but only one person was able to tell us that they were up early by choice. There were four staff on duty. Staff told us that this was the usual staffing level. However, we received information before we visited that indicated that sometimes there was only three staff on duty at night. We looked at staff rotas for the week of the inspection and the preceding two weeks. We saw that there were four staff on duty every night. The manager told us that if night staff had to go home due to illness, that they, (the manager) and the deputy manager immediately covered the shift themselves. This meant that we did not evidence that there were less than four staff on duty at night. We were told by staff that some, but not all, people had been offered and given a drink. One person who was dressed and sat in the lounge told us that they had not had a drink since they got up and their mouth was, yacky because of this. We saw that from 7.15 a.m. people in one area of the home were offered breakfast. One person told us that they were very well looked after by staff who they described as, marvellous. They told us that they liked living at the home and it was, the best place. People can be confident that staff providing direct care will treat them with respect and courtesy. This is because we saw that people who lived at the home were treated with kindness and respect by staff. Staff spoke to people warmly and were familiar with people s care needs. Staff told us that they knew from the staff handover which people had gone to bed early. They said that people who went to bed early tended to wake up early. They told us that people who were awake were assisted to have a wash, dressed and were taken into the lounge. Staff told us that great care was taken when offering care and support to people who lived in shared rooms if only one person was awake, not to disturb the other person. We saw that some people had then fallen asleep in the lounges. We saw that because staff were assisting people to get up, people who had been taken to the lounge were left for periods of time with little or no supervision. We were told by staff in the extension part of the home that people were not offered breakfast until day staff arrived at 8 am. We saw that this meant that some people may have been awake for at least two hours before being offered anything to eat. People cannot be confident that the home will develop a care plan when they move into the home to inform staff about their needs and how these should be met. We looked at eight care records. There was a disparity in the quality of the records with the records for the extension part of the home being more detailed and better completed. We saw that four care plans contained some information about what time people liked to get up or go to bed. However, the remaining three records did not include any advice or guidance for staff on what people s preferred routines were. This meant that we could not evidence that all of the people we saw up and dressed during the visit had chosen to do so. On two care files looked at the home had not developed a care plan. One person s care file did not contain a photograph of the person. The manager told us that a photograph had been taken but not put into their care file. The lack of a care plan for two people means that staff had not been provided with information about people s needs and how they should be met. This is a breach of the Care Homes (Wales) Regulations (1) and a non compliance notice has been issued. The manager assured us that this would be addressed as soon as practicable. 4

5 We saw that the home was very clean, tidy with no unpleasant odours. The lounge areas were decorated very nicely in a domestic style. 5

6 Quality of staffing This section was not looked at in detail during this inspection visit. However people cannot be confident that the home provides appropriate training for staff. The manager provided us with a record of training undertaken by staff. The record did not include all members of staff currently employed to work at the home. This is a breach of the Care Homes (Wales) Regulations 18 (1) (c) (i) and a non compliance notice has been issued. 6

7 Quality of leadership and management This section was not looked at during this inspection visit. It will be considered at future inspections. 7

8 Quality of environment This section was not looked at during this inspection. It will be considered at future inspections. 8

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10 How we inspect and report on services We conduct two types of inspection; baseline and focussed. Both consider the experience of people using services. Baseline inspections assess whether the registration of a service is justified and whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years. At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations. Focussed inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focussed inspections will always consider the quality of life of people using services and may look at other areas. Baseline and focussed inspections may be scheduled or carried out in response to concerns. Inspectors use a variety of methods to gather information during inspections. These may include; Talking with people who use services and their representatives Talking to staff and the manager Looking at documentation Observation of staff interactions with people and of the environment Comments made within questionnaires returned from people who use services, staff and health and social care professionals We inspect and report our findings under Quality Themes. Those relevant to each type of service are referred to within our inspection reports. Further information about what we do can be found in our leaflet Improving Care and Social Services in Wales. You can download this from our website, Improving Care and Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW regional office. 10

11 Care Homes for Older People (GIRPT01E v3.) Version 8.1 July 2012 Care and Social Services Inspectorate Wales Care Standards Act 2000 Non Compliance Notice Care homes for older people This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the timescales specified. The issuing of this notice is a serious matter. Failure to achieve compliance will result in CSSIW taking action in line with its enforcement policy. Further advice and information is available on CSSIW s website Pen-y-Garth EMI Residential Home Pen-y-Garth Residential Home Pleasant Lane Brymbo LL11 5DH Date of publication 31 March 2014 You may reproduce this notice in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers Please contact CSSIW National Office for further information Tel: cssiw@wales.gsi.gov.uk Page 1

12 Care and Social Services Inspectorate Wales North Wales Region Government Offices Sarn Mynach Llandudno Junction Conwy LL31 9RZ Home: Pen-y-Garth EMI Residential Home Contact telephone number: Registered provider: Registered manager: Pen-y-Garth Care Homes Ltd Michele Roberts Number of places: 44 Category: Care Home - Older Adults Dates of this inspection from: 10 February 2014 to: Dates of other relevant contact since Not applicable last report: Date of previous report publication: 7 February 2014 Inspected by: Sue Hale / Susan Thelwell 2

13 Quality of life Non compliance identified at this inspection and action to be taken Action to be taken The manager must ensure that all people living at the home have a care plan. This should be developed as soon as possible in conjunction with the person and their representatives if at all possible. Timescale for Regulation number completion 07/03/14 15 (1) The home is not compliant with the Care Homes (Wales) Regulations 2002, 15 (1), Schedule 3 (1) (b) regarding the requirement that all people living in the home must have a care plan. The evidence includes: We looked at the care file of a person who moved into the home on the 15 January The care file did not contain a care plan developed by the home. The information provided by the funding authority clearly detailed that the person experienced episodes of ill health but this had not been risk assessed. The care file did not contain any information about the risks or tell staff what they should do if they occurred. The information in the care record did not contain any information about the person s routine or preferences for getting up. The person was awake, dressed and in the lounge at 6.30 am. We looked at the care file of a person who moved into the home in November The care file did not contain a care plan developed by the home. The information in the care record did not contain any information about the person s routine or preferences for getting up. The person was awake, dressed and in the lounge at 6.30 am. The manager was unaware that two people did not have a care plan. The evidence indicates that the home had not taken action to develop a care plan for these people as soon as they had moved into the home. It also indicates that the manager does not have systems in place to check that a care plan is developed when people move into the home. The impact on people is that staff had not been provided with information by the manager about people s needs, likes, dislikes and preferences so that staff could meet these in a way that was person centred and appropriate. Page 3

14 Quality of staffing Non compliance identified at this inspection and action to be taken Action to be taken The registered person must ensure that all staff working at the home receives training appropriate to their work. Timescale for Regulation number completion 07/03/14 18 (1) (c) [i] The service is non compliant with the Care Homes (Wales) Regulations (1) (c) (i) regarding the requirement that persons employed at the home must receive training appropriate to the work they are to perform. The evidence includes: A member of staff started working at the home on the 29 January 2014.The training record supplied by the home on the 10 February 2014 did not include the person s name. A second member of staff started working at the home on the 28 November The training record supplied by the home on the 10 February 2014 did not include the person s name. The evidence indicates that two people working at the home have not completed any training, including induction training. The impact on people is that staff may not have the knowledge and skills to provide them with appropriate and safe care. Page 4

15 Quality of leadership and management Non compliance identified at this inspection and action to be taken Action to be taken Timescale for completion Regulation number None Page 5

16 Quality of environment Non compliance identified at this inspection and action to be taken Action to be taken Timescale for completion Regulation number None Page 6

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