Inspection on 21/09/07 for Pals Residential Home

This inspection was carried out on 21st September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Pals Residential Home 02/09/08

Pals Residential Home 28/06/06

Pals Residential Home 18/11/05

Pals Residential Home 26/05/05

Pals Residential Home 08/11/04

Pals Residential Home 10/06/04

Pals Residential Home 23/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Pals Residential Home 79 Ombersley Road Worcester Worcestershire WR3 7BT Lead Inspector Rachel McGorman Key Unannounced Inspection 21st September 2007 1:30 X10015.doc Version 1.40 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 Pals Residential Home DS0000018669.V341524.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 Older People. 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. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pals Residential Home Address 79 Ombersley Road Worcester Worcestershire WR3 7BT 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) 01905 612439 Mr Sharanjit Singh Purewal Mrs Eileen Nellie Jeynes Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14), Physical disability over 65 years of age of places (14) Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: Pals Residential Care home is registered to provide personal care for up to fourteen older people who are frail, and who may also have physical disabilities. The premises is an extended Victorian house situated in a pleasant residential area of Worcester, approximately 2 miles from the city centre. The property is well maintained and has an established garden that is accessible to residents. The home has been under the ownership of Mr Sharanjit Singh Purewal, for several years and who is also the registered provider. The Registered Manager, with responsibility for the day to day running of the home is Mrs Eileen Jeynes. The stated aim of the home is to meet the individual needs of the people who live at Pals, by providing high quality accommodation and personal care. The range of fees varies from £365 to £415 per week. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included viewing previous reports, and documents relating to the home, and considering the contacts made with the home since the last inspection. The Annual Quality Assurance Assessment (AQAA) for the service, had been completed and submitted to the Commission. Discussions were held with the registered manager, Mrs Eileen Jeynes, about her role, and the day to day management of the home. The inspector also met the proprietor, Mr Sharanjit Purewal. who was at the home for part of the visit. Relatives, and visitors to the home at the time of the inspection, were asked for their views of the service and the care that is provided, and surveys were circulated to ten people. Time was spent with several residents, discussing with them what it is like to live at the home, and observing their interactions with staff. The care records of two residents were checked in detail for case tracking purposes. During conversations with staff, comments were made about their experience of working at the home, and staff files were also seen. The records checked during the course of the inspection, included those required for the protection of residents, those relating to health and personal care, and those kept in respect of the maintenance of equipment and safe working practices. The medication administration records were also seen. A tour of the premises was undertaken, and the ongoing maintenance, improvements that have been implemented, and future proposals for the home were discussed with the management, during the course of the visit. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 6 What the service does well: A warm welcome is given to visitors, and the atmosphere is relaxed and friendly. Everyone was spoken to and said they were comfortable and happy to be living at the home. Residents confirmed that they are treated with respect and consideration at all times, that their privacy is observed, and that they receive support from staff to do as they wish. The Statement of Purpose and the Service Users Guide provide information about the service, and what can be provided, and is made available to assist prospective residents and their families to make the right decisions about their future care needs. A good standard of personal care is provided for each resident at the home, and the staff work well with other professionals and agencies, to help improve and maintain the health of residents. Activities are available for everyone living at the home, and they are able to choose, if they wish, to be involved in the many activities that are provided. Residents live in a homely and pleasant environment, where their privacy and dignity is respected, their independence is promoted, and with their personal possessions around them. The arrangements regarding the provision of food reflect the individual preferences of each person, and the provision of a nutritious and wholesome diet is helpful in maintaining their health and wellbeing. The complaints procedure is satisfactory, and enables any concerns to be expressed, although a record also needs to be maintained of all the comments made about the home, to give a more balanced view of the service. The premises are generally well maintained, and the house is comfortable, clean and warm, and nicely furnished. A pleasing environment is maintained for the people who live there, both within and outside the home, and the gardens are accessible. The National Vocational Qualification (NVQ) training programme is in place at the home, and additional care related training is also provided for staff, which should enable them to provide a good standard of care for residents. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The regular review and amendment of all documentation within the home, and dating to confirm when it was last reviewed, should ensure that accurate information is available for the people who live and work at the home. The ongoing development of care planning and risk assessment procedures should be sustained, and more detailed information to show that all risks to resident have been clearly identified, will better enable staff to provide appropriate care. Evidence of a more person centred approach to care provision will be obtained by holding more frequent meetings to gain the views of residents, and also to confirm that the home is run for the benefit of the people who live there. The guarding of the hot water pipes throughout the home must be completed without further delay, for the protection of the people who live there, and in order to maintain a suitable environment for people living at the home, repairs to equipment should be undertaken in a timely manner. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 8 The documentation relating to the appointment of staff, and information about training and performance should be maintained for each member of staff individually, to ensure the protection of residents and the efficient running of the business. A training and development assessment and profile should be provided for each member of staff to ensure that their training needs are met, that they are competent, have a clear understanding of their role and can therefore deliver the appropriate care for residents. To ensure that the home is run in the best interests of the people who live there, a quality monitoring system should be developed and implemented. Formal supervision for care staff, when fully implemented, will ensure that they are managed appropriately, that they understand their role, and that the home is therefore run in the best interests of the residents. Residents and staff will be better protected by adequate precautions being taken against the risk of fire, by fire drills and practices being held more frequently, and more regular fire awareness training being provided for staff. 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. The summary of this inspection report can be made available in other formats on request. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 & 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information available to prospective residents, and the way in which the admission procedure is implemented, provides an appropriate introduction to the home, and also helps people to make an informed decision about their future care needs. The pre-admission assessment provides relevant information about the prospective resident, and ensures that the home is able to meet their identified personal and healthcare needs. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Statement of Purpose for the home, and the Service Users Guide for residents, provide people with information about the home and the care that can be provided, which should then help prospective residents and their family or representative to decide if the home is likely to be suitable for them. Satisfactory assessment and admission procedures are in place at the home. The Care Manager undertakes a pre admission assessment for all prospective residents, either at home or in hospital, following the initial referral. The assessment then forms the basis of the care plan on admission. A visit to the home is encouraged, and prospective residents are invited to spend time with the people already living at the home, and to have a meal with them. Arrangements may also be made for a short stay, if this is preferable, prior to a final decision being made about living at the home. The first four weeks are considered to be a deciding period, during which time the resident is able to make up their mind about living at the home, and also the staff can further assess if they are able to meet their needs. A Community Care Assessment is also obtained from the placing authority, prior to admission, for people who are not self-funding. A written statement of the Terms and Conditions of Residence, is issued on admission to the home, it contains information on occupancy and the rights and responsibilities of both parties, and is signed to confirm acceptance. The need for these and other documents to be reviewed regularly, and amended to reflect any changes that take place at the home, was discussed with the registered manager, to ensure that accurate information is available. Residents and their relatives spoken with at the home, and also responses in the surveys confirmed that, ‘they had enough information before deciding to live there’, that ‘they were able to visit the home and meet everyone first ’, and ‘had been made to feel welcome’. One person was able ‘to have a short stay for a while, before deciding to move in permanently’. The home does not have the facilities to provide intermediate care for service users. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents plan of care is based on the initial assessment, which identifies their needs, and provides evidence that their personal and healthcare needs are being met. Risk assessment procedures help to identify the specific needs of each person and encourages their independence, although further development of these should better protect residents. The policy and procedures covering the administration of medication ensure the protection of service users. Staff understand the needs of residents, and offer care in a way that encourages and promotes their independence. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 13 EVIDENCE: A plan of care is produced for each resident based on the initial assessment undertaken prior to admission. The individual plans of care for two residents were examined, and evidence of ongoing development in the process was seen. Relevant information was recorded in each care plan that covers all aspects of the life of the resident, and including health and personal care, emotional wellbeing, relationships, dietary needs and preferences, and faith and cultural issues. The daily log reflects how each persons day has been, and included the many activities of daily living for each individual. Risk assessments are completed in respect of moving and handling and nutrition, and the weight of residents is also monitored. There is a specific risk assessment in place for a resident who administers her own medication. The inspector would wish to acknowledge the progress that has been made in regard to the development of care planning and the procedures relating to the assessment of risk to residents at the home. The need for further development, and for consideration to be given to the introduction of a more person centred approach to the delivery of care was discussed with the care manager and her deputy. The involvement of residents in determining their care was evident, and several people confirmed when talking with the inspector, that their care needs are discussed with them and their family. They also said that staff respected their wishes and that they were treated respectfully at all times. One lady said, ‘I am quite independent, and like to stay in my own room most of the time, but I am very happy here’. Another person explained, ‘I am not in good health, but I feel well cared for by everyone’. In addition, the wife of a resident admitted for a short stay, ‘was delighted with the way her husband had been looked after, and she couldn’t speak too highly of the staff’. The health and personal care needs of residents are monitored and the home is well supported by the Primary Health Care Team. Appropriate treatment can be accessed, and the advice of specialist nurses is sought when necessary. Staff were observed administering medication to residents, and the correct procedures were being followed. The Medication Administration Records were checked, and had been completed to a satisfactory standard. The care manager has responsibility for the administration of medication at the home, and she informed the inspector that formal medication training is now provided for staff. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The social, emotional and spiritual needs of residents are identified, and various recreational opportunities provided to ensure their interests are fulfilled. Residents have freedom in regard to their contacts, both within and outside the home, which is beneficial to them. The practices at the home enable residents who are able, to exercise choice and control over their lives, although more frequent consultation will enable more involvement in the running of the home Residents are offered a choice of nutritious, wholesome and well-balanced meals that helps in maintaining their health and wellbeing. EVIDENCE: Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 15 Residents have freedom of choice in regard to their contacts, both within and outside the home, and they are enabled to make choices with regard to the activities of daily living, how to spend their day, and whether or not to join in the various pastimes. This was confirmed in conversation with people living at the home, the staff, and also in comments made by relatives. One relative who visits at least twice each week was very positive about the way her husband has improved since being at the home. A sample programme of activities is provided in the Statement of Purpose, and a weekly list can be found on the notice board in the lounge. The daily log also shows a range of activities undertaken over recent weeks. These include: movement to music, a film/video afternoon, bingo, sing-along to the old time favourites, review of the news/current affairs, skittles/quoits, board/card games, reminiscence, quiz-time, or a manicure session. Occasional shopping trips are also arranged. Residents said that they could stay quietly in their rooms, if they preferred not to be involved with the various activities that usually took place in the lounge or dining room. A mobile hairdresser also visits the home each week. The care manager explained that the spiritual needs of residents are also considered. The Catholic priest visits one resident regularly. A monthly service is held at the home, and residents are enabled to attend the local church, if this is their wish. Details are also posted on the notice board. Residents meetings are held, but rather infrequently, about every six months. Discussions with the care manager outlined the need for the more regular involvement of residents with the running of their home, to ensure that the wishes of each individual, and a consensus of the opinions of the resident group are taken into consideration at all times. This would also be of help in developing the more person centred approach to the delivery of care that the home is working towards. The involvement of family and friends is encouraged, and visitors said they are always made welcome. A tray of tea was offered to visitors during the inspection. People visiting the home, and also the written responses received, confirmed that everyone was happy with the services provided, and the kindness and support of staff. The catering arrangements at the home are satisfactory, and comments about the meals were all very good. Fresh vegetables and fruit are purchased daily. The menus seen confirmed that a choice is offered, and that alternatives are also available. Special diets can also be catered for, and are mainly for residents who are diabetic. The kitchen area was seen to be clean and tidy, and food hygiene training is provided for all staff who handle food. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A satisfactory complaints procedure is in place at the home and residents and their families are aware of how, and to whom they should complain, should the need arise. The policy and procedures in place at the home relating to abuse and the training for staff should, with some further development, enhance the protection of the people who live there. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 17 EVIDENCE: A satisfactory complaints procedure has been produced and is accessible to residents and their families, who confirmed that they were confident that any concerns raised with the management of the home, would be listened to and addressed in an appropriate way. People felt that their opinions were welcomed, and they confirmed that they knew the procedure to be followed if they wanted to air their views. There have been no complaints made to the Commission about the service, although three complaints addressed to the home were recorded during the past year, and were all investigated in line with the procedures, and resolved to the satisfaction of everyone concerned. There were no compliments included in the log. The acting care manager was encouraged to record all the comments made about the home and the care provided, to give a more balanced view of the service, and further responses should also be actively sought, to inform the management if a satisfactory service is being provided. A policy and procedure on adult protection at the home has been produced, although the need for further development was identified, to include the procedure to be followed in relation to staff who may be unsuitable to work with vulnerable people. In addition, a procedure for managing aggressive behaviour, that may include the need for the physical restraint of an individual, also needs to be developed, to ensure the protection of everyone at the home. Staff are given training on abuse awareness as part of their induction package, and this is also covered during NVQ training, to increase their understanding of the issues relating to the protection of vulnerable people. The care manager said that further training is also planned. Discussions with several members of staff confirmed their understanding of the many aspects of abuse. A copy of the Vulnerable Adults Procedures produced by Worcestershire County Council was available in the home, together with a copy of the Department of Health publication ‘No Secrets’, and the care manager said that these documents, together with their own procedures, informed the practices followed within the home. Residents who were interviewed said that they, ‘felt very safe and secure living at the home’. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are suitable for their purpose, and the facilities provided at the home, provide a pleasant environment for the people who live there. The location of the house is satisfactory, and local services and amenities can be accessed. The layout provides adequate communal space for the needs of the residents. Residents live in a pleasant home that is clean and comfortable and attractively decorated and furnished, although further work needs to be done to ensure that the environment is safe, and that the people who live there are protected. EVIDENCE: Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 19 Pals is an extended Victorian house situated in a pleasant residential area of Worcester, approximately 2 miles from the city centre. The property is well maintained and provides a pleasant and homely environment for fourteen older people. The communal areas of the home include a large dining area, which is nicely furnished to provide refectory style dining facilities, and a separate lounge, which is comfortable and well appointed, with domestic style lighting. There is also an established garden that is accessible to residents. There are 12 single bedrooms, 5 of which have en-suite facilities, and one shared room. Those seen had been decorated and furnished very nicely, and also personalised to a high standard by the people who live there. The accommodation is provided on two floors, which can be reached by a central passenger lift and two staircases. Several people said, ‘how happy they are to be living at the home’, and one resident commented, ‘how lovely it is to be here’, and another person said, ‘how much they like their room, and therefore spend most of their time there’. The need for window restrictors to be fitted to all opening windows on the first floor, through which people could fall, had been identified previously. The care manager confirmed that this work has now been completed. A further requirement had been for all exposed hot water pipes in bedrooms, to be boxed in, to prevent injury from contact burns, but this work had not yet been undertaken. The management of the home was reminded that the accommodation provided must meet the relevant health and safety requirements, and that residents have the right to live in a safe environment. This work must therefore be completed without further delay. In addition, the extractor fan was not working in the toilet/bathroom adjacent to room 7 on the first floor. The care manager confirmed that this would be given immediate attention. The home is clean and fresh throughout and staff confirmed that they are familiar with the procedures regarding the control of infection, and that they have also been given training in health and safety matters. A visit from the Environmental Health Officer, recommended that staff at the home follow the Food Standards Agency Safer Food Better Business guidance, to ensure compliance with the new regulations regarding Food Safety Management. The acting manager is working with the catering staff at present, to ensure that this is implemented in the home. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are sufficient to meet the needs of the people who live at the home. The commitment to NVQ training for staff, together with a relevant training programme, help to ensure that each member of staff is competent, has a clear understanding of their role and is able to deliver the appropriate care for residents. Recruitment procedures are now being implemented to a more satisfactory standard, and should ensure the safety and protection of residents. EVIDENCE: Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 21 The staff rotas were seen and the care manager considered that care staffing levels are adequate for the needs of the people who live at the home, and this was confirmed in conversation with residents, who were very complimentary in their comments about the staff and the care they receive. Staff were observed by the inspector to deal very kindly and professionally with all residents, and there was evidence seen of their commitment to maintaining a good standard of care. Visitors to the home were also made very welcome. There have been some staff changes during the last 12 months, and the manager explained that the home has had some difficulty in retaining staff at times, although there is a stable group who have worked at the home for several years. The care manager said that the management of the home is committed to providing the National Vocational Qualification (NVQ) training, and she stated that 75 of staff have completed the NVQ Level 2 in Care course, two staff have the NVQ Level 3 in Care, and the remaining four care staff are currently doing NVQ Level 2 in Care. An external Assessor supports staff throughout the course. A record is now being maintained of the training undertaken at the home, and includes both statutory and care related courses, and the records show that training has been provided for staff in basic first aid, fire safety, food hygiene, and moving and handling. Training on medication administration and abuse awareness have also been attended by some staff. The need for an individual training and development assessment and profile, to identify the training needs of each person was discussed with the care manager. The staff with whom the inspector spoke, confirmed that they enjoy their work, and all were very positive about being employed at the home. They said that induction training was provided, when they began their employment, and that other training opportunities have since been available. One member of staff confirmed that she had worked at the home for about 18 months, and had just completed her NVQ Level 2 training. In addition to the basic training courses, she had also attended sessions on medication, health and safety and the control of infection. Another carer who had commenced working at the home more recently said she was made to feel very welcome when she arrived, and had been well supported by senior staff. She is doing her induction training currently. A satisfactory recruitment and selection policy and procedure is in place at the home, although this had not always been followed previously. The deputy Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 22 manager explained that she is in the process of reviewing these procedures, producing individual files for staff records, and also developing a more organised and professional approach to staff management, to ensure that the recruitment procedures are implemented consistently and thoroughly, for the safety and protection of residents. The staff files seen during the inspection contained relevant information, including an application form, two references, Criminal Record Bureau (CRB) checks and proof of identity. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is focussed on the best interests of the people who live at the home, but several aspects of the management of the home including quality monitoring, the formal supervision of staff, and the general organisation need to be further developed and implemented, in order to be more effective. The health, safety and welfare of service users and staff is promoted in respect of all safe working practices, although fire awareness training, and fire drills and practices should be arranged more regularly, to ensure that the people who live and work at the home are fully protected. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Eileen Jeynes, the Registered Care Manager, has responsibility for the dayto-day running of the home. She has been employed by Mr Sharanjit Singh Purewal, the Registered Provider for the last ten years, and had worked in the care industry for many years prior to this. She therefore has extensive experience in working with older people, and has undertaken periodic training, but does not have the Registered Managers Award, a qualification that is now considered essential to the position of Registered Care Manager. Discussions have been held with Mrs Jeynes about undertaking this training, but she has expressed her intention of retiring in the near future, and therefore does not wish to pursue this course of action. Arrangements were made for a deputy manager to be appointed, who is now intending to do the RMA training. She is currently reviewing and updating all the documentation, and giving support and assistance to the care manager and the provider in the further development and organisation of the service. The care manager also acknowledges areas where further changes are needed, and that her skills do not extend to computer literacy, therefore proposals are in place for the deputy manager to also develop these areas. The need for a quality assurance system to be introduced at the home, has been identified at previous inspections, but still remains outstanding. A formal system must be implemented, without further delay, for measuring how well the home succeeds in achieving the stated aims and objectives, and the results should then be audited and published annually. The management of the home confirmed that staff do not have any involvement with the financial affairs of residents. Arrangements are in place for the family or a representative to take responsibility, where a service user lacks capacity or does not wish to be involved. A small petty cash float is held for incidental purchases, and the records, which were viewed briefly, are maintained to a satisfactory standard. A procedure for the formal supervision and appraisal of staff has been developed, and the care manager said that the process is being introduced to staff, although it has not yet been fully implemented. The importance of providing regular, ongoing supervision for all care staff was discussed further with the care manager, who was advised that the format should reflect the process recommended in the National Minimum Standards, and cover care practice, philosophy of care in the home and career development needs. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 25 The records seen during the inspection are being maintained to a satisfactory standard, and the policies and procedures are reviewed regularly, the care manager said, although this could not be confirmed, as the documents are not dated. Copies are available for reference and information in the staff room. The care manger was reminded that the best interests of residents are safeguarded by the record keeping procedures that are followed at the home, therefore further attention should be given to updating and amending them at least annually. A health and safety policy and procedure is in place, and training in safe working practices is provided. The records seen during the inspection, relating to health and safety are being completed to a satisfactory standard. Contracts are in place for the regular servicing and maintenance of equipment. The Fire Log indicated that weekly checks of the fire alarm system are undertaken, although the fire awareness training for staff is not provided every three months, and fire drills and practices have not been undertaken at regular intervals. The Fire Risk Assessment for the home has been completed. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 2 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 X 2 Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 OP38 Regulation 23(4)(a) Requirement Timescale for action 31/12/07 2 OP25 13(4)(a) The Regulatory Reform (Fire Safety) Order 2005 must be complied with in respect of fire drills and practices, and fire awareness training for all staff. The risk to residents from 31/12/07 exposed hot water pipes must be assessed and appropriate action taken, to prevent any injury from contact burns 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 OP7 OP7 OP14 OP16 Good Practice Recommendations The independence of the people living at the home would be promoted, by further development of the procedures relating to the assessment of risk Consideration should be given to the introduction of a more person centred approach to the delivery of care The opportunity for residents to have more involvement in the running of the home would be provided by holding more regular meetings with them All comments, concerns and compliments made about the DS0000018669.V341524.R01.S.doc Version 5.2 Page 28 Pals Residential Home 5 OP18 6 OP18 7 8 9 10 11 OP22 OP30 OP33 OP36 OP37 home should be recorded to provide a more balanced view of the service A procedure should be produced for the protection of residents in relation to staff who may be unsuitable to work with vulnerable people, and who may need to be considered for inclusion on the POVA register A procedure for managing aggressive behaviour, that may include the need for the physical restraint of an individual, should be developed, to ensure the protection of everyone at the home Repairs to the dysfunctional extractor on the first floor of the home should be undertaken without delay, in order to maintain a satisfactory environment for residents An individual training and development assessment and profile should be provided for each member of staff to identify training needs of each person A quality assurance system, should be introduced to ensure that the home is run in the best interests of the people who live there The supervision of care staff should be undertaken by the manager, and cover care practice, the philosophy of care in the home and career development needs All documentation within the home should be reviewed regularly and dated to confirm when it was last reviewed, to ensure that accurate information is available for people who live and work at the home. Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park Droitwich Road WORCESTER WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Pals Residential Home DS0000018669.V341524.R01.S.doc Version 5.2 Page 30 - 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. 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