Inspection on 01/11/05 for Paulmay Dementia Care

This inspection was carried out on 1st 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

Paulmay Dementia Care 25/07/07

Paulmay Dementia Care 04/04/06

Paulmay Dementia Care 13/04/05

Paulmay Dementia Care 28/09/04

Paulmay Dementia Care 08/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Paulmay Residential Home 17 Dukes Avenue Finchley London N3 2DE Lead Inspector Tola Akinde-Hummel Unannounced Inspection 09:00 1 November 2005 st 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 Paulmay Residential Home DS0000010508.V251248.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. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Paulmay Residential Home Address 17 Dukes Avenue Finchley London N3 2DE 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) 020 8346 3642 020 8349 3424 Mr Kevin Gurry Mrs Marjorie L Gurry Mrs Marjorie L Gurry Care Home 8 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th April 2005 Brief Description of the Service: Paulmay is a large, converted house situated in a quiet residential area of Finchley in North London. The home is registered to provide care for eight older people who have some form of dementia. The home has one single and one double room on the ground floor. There are three single rooms and one double room on the first floor. The home has a stair lift to the first floor. There is a large lounge/dining area on the ground floor leading to the well-maintained garden. The stated aim of the home is to provide professional and skilled care to residents. This is within a friendly, family atmosphere where freedom, choice and dignity are maintained. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took five hours to complete. The inspector was able to speak to three service users, the two members of staff on duty and Mr Gurry, the homes owner. The manager Mrs Gurry was not at the home during the inspection, but the inspector was able to talk to her during the day. The home currently has one vacancy, one service user is in hospital and six service users were in the home at the time of inspection. The inspector did a tour of the building, looked at the care plans, examined the medication records and storage, and examined policies and procedures and addressed the requirements made at the previous inspection. The inspector would like to thank the service users and the two members of staff who were helpful and available throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Paulmay is failing to meet their health and safety responsibilities. The home has not completed a gas safety check or a Legionella check as required in the Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 6 previous inspection. The home does not have a fire risk assessment in place and are not completing night fire drills. The lack of the above is a cause of serious concern. These issues clearly compromise service users health and safety and results in the home not meeting the Care Homes Regulations as set out in the Care Homes for Older People, National Minimum Standards. The home must prioritise these issues and ensure that unnecessary risks are not taken with regards to health and safety. 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. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 7 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 Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 8 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): 3, 5 Paulmay ensures that prospective service users have the opportunity to visit the home prior to making a decision about living there. Detailed assessments are undertaken to ascertain that any placement is appropriate and able to meet service users needs. EVIDENCE: The care plans of five service users were examined. One new service user entered the home in June 2005. Records show that the needs of the service users are properly assessed prior to admission to the home. The assessment undertaken once the service user has entered the home is detailed and informative. This includes a personal profile, past medical history and a medical care plan. All care plans examined contained relevant information. Staff advised the inspector that prospective service users visit the home and they and their relatives make a decision about its suitability. The manager also assesses if the home is likely to meet the needs of prospective service users. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 9 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): 7, 9 Paulmay actively promote service users health and personal care. This ensures that service users get the appropriate assistance when required. EVIDENCE: Care plans record the health needs of service users in detail. Due to the nature of dementia, different service users require different levels of support within the home. Where service users behaviour changes, there is great detail in care plans about how staff should handle this. These directions given in care plans are sensitive to individual needs and highlight how well staff knows service users. Evidence shows that GP’s and other health professionals are involved in the health care of service users where appropriate. Reviews are also conducted on a monthly basis and changes to care plans are made as necessary. Two service users explained that they are well cared for in the home and the staff are very supportive of them. Where possible service users stated that they have privacy in the home and are treated with respect by the staff team. Observations of interactions between staff and service users are respectful, understanding and positive. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 10 Records and storage of medication examined, confirm that care is taken in this area and procedures are followed. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 11 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): 12, 13 14, There has been positive improvement in the programme of activities for service users. This ensures that service users are adequately stimulated during the day and helps maintain a level of cognitive and physical ability. EVIDENCE: A requirement from the previous inspection highlighted the need for a more detailed activities programme based on the interests of service users. Care plans tracked demonstrate that work has been completed to draw out service users past interests. Care plan notes also show that where a service user has shown an interest in new activities these are explored and service users are encouraged to participate. Paulmay has allocated the organisation of activities to one care worker. This has proved successful. The activities programme covers individual and group sessions. These are detailed and include times of rest for service users to ensure they are neither bored nor over stimulated during the day. Purchased games seen help staff assess and maintain basic cognitive abilities, other equipment available for service users to play with encourage physical movement. The home also has visitors from local churches and one priest gives communion. Service users are also accompanied by staff to go out in the local area as part of their activities programme. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 12 On the day of inspection, most service users had been unwell with flu so the activities programme was not being followed as usual. Service users spoken to stated that they did not feel like taking part in activities but confirmed that these took place. Service users relatives and friends are actively involved in the life of their family members that live there. With the exception of one service user all others have relatives or friends that visit regularly. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 13 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): 16,17,18 The system for complaints to be made and acted upon remains the same as at the previous inspection. EVIDENCE: There have been no complaints since the previous inspection. These standards were assessed as met at the previous inspection. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 14 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): 19,23,26 Paulmay is currently being made more comfortable through a programme of redecoration. Service users will benefit from a brighter, fresher and more homely environment. EVIDENCE: The previous inspection highlighted the need for repairs to be made to the ground floor double bedroom following a leaked toilet on the first floor. The tour of the building confirmed that the room has been completely redecorated and new carpet has been laid. The home is currently undergoing external and internal redecoration. Two service users rooms on the first floor have also been redecorated and the owner of the home confirmed that work would be undertaken in the next four weeks to decorate the remaining areas in the home including the kitchen and the lounge. The home has had most of the carpets replaced and those outstanding will be completed. . The air vent in the upstairs toilet is clean and there are adequate toileting facilities for service users. On the day of inspection, the home was clean in all areas and free from any offensive odours. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 15 Service users rooms continue to be comfortably decorated and personalised to suit individual tastes. Those rooms that are shared have large screens to ensure privacy. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 16 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): 27, 28, The home has adequate numbers of staff on duty during the day and night. The home must ensure that staff complete their NVQ qualification as required. EVIDENCE: The management at Paulmay remains the same since the previous inspection. Staff confirmed that they have key responsibilities in the home. These include health and safety responsibilities, activities planning, and medication documentation. Staff stated that this system works well and brings clarity to staff members pertaining to their other roles in the home. Staff confirmed that they receive regular supervision although the supervision records were not inspected on this occasion, as the manager was unavailable. The senior carer stated that a number of staff are currently studying for their NVQ qualification. Presently no staff have completed their NVQ qualification. It is hoped that staff will complete by August 2006. Whilst there have been difficulties, staff continue to persevere. The home has a stable staff team, which, benefits service users immensely in terms of familiarity and continuity. The rota was examined. It was clear that there is flexibility around when staff work. All staff work days and nights. This allows all staff the opportunity to care for service users at all times of the day and to work with all staff. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 17 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 homes financial procedures for service users monies is satisfactory. Paulmay is failing to adequately protect the health and safety of service users in the home. This means that without proper procedures and checks, service users are more vulnerable. EVIDENCE: Service users in Paulmay have their finances managed largely by their relatives. One service users finances are managed by the courts. The home is required to submit detailed records and receipts of all monies spent on the service user prior to any reimbursement being made. Records show that fire tests and fire drills are taking place and a total evacuation was carried out during the day recently. However, there are no records of night fire drills. There is also no fire risk assessment in the home. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 18 This was discussed with the owner and the manager and agreed that the manager would prepare a fire risk assessment for the home. The previous requirement relating to the testing of the water system for Legionella has not been completed. The gas safety check is also outstanding. This situation is unsatisfactory and continues to compromise the health and safety of service users and staff. The floor covering in the office, which is frequented by staff and one service user in particular, is a trip hazard. Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 19 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 3 X 3 X 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 X X X 3 X X X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 1 Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 20 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 13, (4)(c) Requirement The registered person must ensure that Gas safety checks are carried out as a priority and the certificate is sent to the commission. (This requirement is restated. Previous timescale 30/05/05 not met). The registered person must ensure that the Legionella testing is completed as a priority and the certificate is sent to the commission. (This requirement is restated. Previous timescale 30/05/05 not met). The registered person must ensure that night fire drills are undertaken and recorded. The registered person must complete a fire risk assessment of the home to be reviewed at least annually to ensure the safety of service users and staff in the home. On completion, a copy of the assessment must be forwarded to the commission. The registered person must ensure that the rug in the office is secured or removed to prevent accidents. DS0000010508.V251248.R01.S.doc Timescale for action 13/01/06 2 OP38 13, (4)(c) 13/01/06 3 4 OP38 OP38 23, (4), (e) 23, (4), (a), (c) 12/12/05 12/12/06 5 OP38 13, (4), (a) 12/12/05 Paulmay Residential Home Version 5.0 Page 21 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 Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Paulmay Residential Home DS0000010508.V251248.R01.S.doc Version 5.0 Page 23 - 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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