Inspection on 29/11/05 for Passmonds House

This inspection was carried out on 29th November 2005.

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

Passmonds House 26/07/06

Passmonds House 31/05/05

Passmonds House 16/11/04

Passmonds House 26/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Passmonds House Edenfield Road Rochdale Lancashire OL11 5AG Lead Inspector Tracey Devine Unannounced Inspection 29th November 2005 10.45 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 Passmonds House DS0000025487.V268163.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 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. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Passmonds House Address Edenfield Road Rochdale Lancashire OL11 5AG 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) 01706 644483 01706 647701 Denehurst Care Limited Mrs Irene Ingram Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (1) of places Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users, to include: up to 35 service users in the category of Older People (OP); up to 1 service user in the category of Physical Disability (PD under 65 years of age). The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. One person in the category of Physical Disability (PD under 65 years of age) may be accommodated within the overal number of registered places. 31st May 2005 2. 3. Date of last inspection Brief Description of the Service: Passmonds House is a care home providing care for older people. The property has been extended over the years to offer accommodation for 35 service users over the age of 65 years, in 2 double and 31 single rooms. Twenty-two of the rooms have en-suite facilities. There are four lounges, one of which is used for residents who wish to smoke, and one dining room. Toilets and bathrooms have aids to assist residents who have a problem with mobility. The home is set in its own grounds and situated adjacent to Denehurst Park. It is approximately 1½ miles from Rochdale town centre and a regular bus service passes the home. Several shops are situated around the locality. Parking is provided to the front of the house. Ramped access is provided to all entrances. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 29th November 2005 by 1 Inspector. The inspection started at 10.45am and finished at 3.00pm – a period of 4.15 hours. The inspector arrived at the home without informing them of the visit – this is called an unannounced inspection. Time was spent time talking with the Provider, the Manager, the deputy manager, and 5 residents. Staff were spoken with on an informal basis as the Inspector looked around the home and watched how the staff worked. This is the second inspection the home has had this year. On this occasion, the inspector looked at the (key) standards which were not looked at on the first inspection, and she also looked to see if the things the provider and manager were asked to do at the last inspection had been done. What the service does well: What has improved since the last inspection? Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 6 Since the last inspection the Provider and the Manager have done most of the things they were asked to do at the last inspection. The Provider has attended to the environment and the corridors have started to be redecorated, the armchairs are on a cleaning programme, and other minor works have been attended to. Residents are invited to help in writing their care plan, and any identified risk resulting from this is written down so that the Manager and the resident and/or their representative can talk about what they are going to do to make sure that the resident remains as safe as possible without taking away their right to live their life as they choose. Staff test the temperature of the bath before they assist the resident to get in, they also write down this temperature. This ensures that no one enters the bath with water which is too hot, and which potentially may scald them. What they could do better: The Manager was asked at the last inspection to display the menu for residents to read. Whilst this had been done, the menu displayed was not in a good position and could not be easily seen by residents. The Manager must make sure that she displays the menu in a place which can be easily seen by residents and in a style which suits their capabilities. The Provider must keep going with redecorating the corridors. The Manager must make sure that when she is looking for new staff that she takes up references from a previous employer and that she undertakes her own CRB/POVA 1st check to make sure that staff employed are suitable to work with older people. The CRB check is commonly known as a “police” check, and the POVA 1st check is a check against a register of names of people found to be unsuitable to work with vulnerable adults. When these checks have been made and the Manager is satisfied with them, only then must the Manager employ the staff member. This will ensure that no one who is unsuitable starts work at the home. The Manager has good practice in working with care staff and offering them individual time to talk to her about how they care for residents, what training they may need to help them do it better, and if they are having any difficulties which the manager needs to know about. This good practice of time with the Manager needs to include the deputy manager, so that she too can talk about how she does her job, how she can do it better, and what help she may need to do this. The provider takes responsibility for receiving all monies into the home and recording them for each resident – the date and amount. However, for some residents, the Provider receives the money and on the same day he gives it to the resident (in total) for them to spend as they wish. As he does this on the Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 7 day he receives it, the Provider had not been recording it on his sheet. But he does record it if he keeps any amount of money for a resident. The provider must make sure that he records all money he handles for residents. 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. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 8 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 Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 3, 4 and 5 were assessed at the last inspection. report of 31st May 2005. Please refer to the Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Risk assessments in place identify the risk, and how this is to be reduced or eliminated, thereby ensuring that residents remain safe. The sharing of the content of the care plan allows the resident and/or their representative to contribute their ideas on how they would like their needs to be met. Medication systems in place allow for residents to receive their medication as prescribed ensuring that their physical and mental well being is maintained. EVIDENCE: Standards 7, 8 and 10 were assessed at the last inspection. the report of 31st May 2005. Please refer to At the last inspection, the manager was required to share the formulation of a care plan with residents and/or their representative, this has now commenced. It was also required that risk assessments are introduced for any identified risk, the manager has introduced risk assessments wherever there is an identified risk. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 11 The medication systems in place were satisfactory. The home uses the Monitored Dosage System which come pre-prepared from the Pharmacist. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 Residents felt fulfilled, and enabled to make choices as to how to spend their days and who with. This promotes their feeling of wellbeing and retaining autonomy in respect of their lives. EVIDENCE: Standards 12 and 15 were assessed at the last inspection. report of 31st May 2005. Please refer to the At the last inspection, it was required that the manager improves the provision of activities for residents and that a programme of activities is drawn up and displayed. This has now occurred, and residents spoken with said they had “plenty to do”, and enjoyed the various entertainers. TV and listening to music were said to be popular and residents spoken with said they enjoyed watching TV, and would often watch it in the privacy of their room. At the last inspection, it was required that the menu be displayed. The menu on display was small, and not particularly visible to residents. This was discussed with the deputy manager, and it was agreed that she would ensure that the lunchtime meal and tea time meal would be displayed on the large poster she currently has on the wall of the dining room. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 13 Residents spoken with said they felt they could live “pretty much as they pleased” at Passmonds, and felt the routine of the home was “easy going”. Observations on the day demonstrated that residents could have a lie-in until late morning if they wished, that they could sit in any of the lounges, or stay in their room if they wished. Those spoken with said they did make use of the various rooms – some preferring to spend most of their time in the smokers lounge, and some preferring to stay in their room for parts of the day. Residents said they felt to have control over their lives, and gave examples of this – choosing when to get up, and when to go to bed, where to sit and who with, what to wear, what to eat, whether to smoke and if so how often, what to watch on TV and where to see visitors. Where residents have no visitors or family who are able to assist them in private/financial matters, the manager contacts a local solicitor who is able to act as an advocate for them. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 16 and 18 were assessed at the last inspection. report of 31st May 2005. Please refer to the Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home is generally well maintained providing a homely and comfortable environment. Domestic staff are employed in such numbers as to keep the home clean and odour free, providing residents with a pleasant and clean environment. EVIDENCE: Standards 19, 20, 21 and 25 were assessed at the last inspection. refer to the report of 31st May 2005. Please At the last inspection it was required that some parts of the environment needed some attention. Of the matters listed in the report of 31st May 2005, the only one which has not been fully complied with relates to the redecoration of the corridor walls. This has commenced however, but some parts are still waiting redecoration. The Provider said that he was aware of this, and had plans in place for the redecoration to continue at the start of the new year. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 16 The home continues to be reasonably well maintained in other areas, and has a comfy, homely feel. Residents spoken with said they felt to be “at home” and liked the way the home looked. The home employs sufficient domestic staff to keep it clean and odour free. Residents said they felt the home was particularly clean, and they appreciated their bedrooms “being done daily”. Sufficient laundry facilities are provided in the basement. A sluice wash is provided on the washing machines which reduces the risk of cross infection. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 In the main, the recruitment practice at the home in ensuring that all new staff are suitably vetted is satisfactory and protects residents from possible harm. This practice must be more rigorously applied to ensure that residents continue to be protected from harm. EVIDENCE: Standards 27, 28, and 30 were assessed at the last inspection. the report of 31st May 2005. Please refer to Several staff files were looked at to ensure that staff had been subject to the necessary checks prior to commencing work. The deputy manager produced a list of staff names showing that they had in place a CRB check and 2 references and this was seen to be verified. However, this list was not up to date in respect of new staff, and of new staff files looked at, 2 were seen not to have had references taken up from the last employer, nor had new CRB/POVA checks been undertaken. The deputy manager said this was an oversight on her part, and she would ensure that she applied for references and CRB’s immediately. In the meantime, the staff would not work unsupervised. It was discussed with the Provider, Manager and deputy manager the importance of taking up new CRB’s (in order that the POVA register could be checked) and that the CRB’s are not portable between employers for this reason. Residents were asked for their opinion on staff, and those spoken with said they found them to be “smashing”, “kind”, “patient”, “lovely girls”. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 18 Observations of staff and residents talking together, and staff helping residents showed that there is mutual respect and affection. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 38 The systems in place for residents’ monies to be held safely and securely are largely satisfactory. Health and safety arrangements including staff training provide for the home to be a safe place for staff to work in and for residents to live in. EVIDENCE: Standards 31, 33, and 36 were assessed at the last inspection. the report of 31st May 2005. Please refer to At the last inspection, it was required that a supervision system which offers care staff time to discuss care practice and their development be set up not only with care staff but also with the deputy manager. Whilst supervision is ongoing with care staff, the deputy has still not been included in this programme. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 20 Residents monies are safeguarded by the policy and procedure in place at the home. Appropriate records were evidenced. It was established in discussion with the Provider that a small number of residents receive their monies into the home, and are paid directly the full sum by the provider weekly. As the provider saw this simply as money coming in for residents and going directly to them, he had not included it on the transactions sheets he uses for residents whose monies he safeguards. It is important that all monies coming into the home for residents, even if they go straight to the resident (via the provider) can be tracked as monies in and monies out. A number of residents spoken with confirmed they received their weekly money as they wished. Health and safety matters were inspected, and the Inspector evidenced service certificates in respect of gas, electricity (5 yearly), annual small appliance testing, legionnella, hoists, fire alarm, lift, and fire equipment. All were in order. The staff of the home were attending a fire lecture during the afternoon of the inspection, facilitated by an officer from Greater Manchester Fire Service. Hot water temperatures are recorded for each resident prior to bathing to ensure the water is at a suitable temperature. Staff receive training in fire safety, food hygiene, moving and handling, infection control and a sufficient number are trained in first aid. Training records support this information. Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 21 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 X X X 3 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 2 X 3 Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 22 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 OP15 Regulation 12(2)(3) Requirement A menu offering an accurate choice of meals must be displayed (previous timescale of 31/07/05 not met). The remaining corridors must be decorated (previous timescale of 30/09/05 not met). The supervision system must include the deputy manager (previous timescale of 31/07/05 not met). All staff employed at the home must be suitably vetted (references and CRB/POVA 1st) prior to employment. The provider must ensure that he records all monies received on behalf of a resident, and details the amount and the date when they are returned to the resident. Timescale for action 30/12/05 2 3 OP19 OP36 23(2)(d) 18 31/03/06 31/01/06 4 OP29 19 29/11/05 5 OP35 17(2) 20/12/05 Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Passmonds House DS0000025487.V268163.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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