CARE HOMES FOR OLDER PEOPLE
Pavillion Care Centre North View Terrace Chilton Moor Houghton-le-spring Tyne And Wear DH4 5NW Lead Inspector
Mr Clifford Renwick Unannounced Inspection 09:30 4 & 5 October 2007
th th 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 Pavillion Care Centre DS0000063779.V351019.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. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Pavillion Care Centre Address North View Terrace Chilton Moor Houghton-le-spring Tyne And Wear DH4 5NW 0191 3853555 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) www.europeancare.co.uk European Care (England) Ltd Mrs Ann Marie Shillaw Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (40), Physical disability (2), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (6) Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service may from time-to-time admit persons under the age of 65 within the OP category. 14th July 2006 Date of last inspection Brief Description of the Service: The Pavilion is a large detached building set in its own grounds in a small village near Houghton-le-Spring, near the boundaries of Durham. It was originally built in the 1960’s and is currently owned by European Care Ltd, an independent provider. The home provides personal care for up to 40 older people. The home is divided into 2 distinct units with 20 bedrooms on the ground floor, and 20 bedrooms on the first floor for older people with dementia care and mental health needs. The home is not registered to provide nursing care. Each floor provides a range of lounge and dining rooms, bathrooms and small kitchens. All necessary facilities are provided and are suitable for the people who live there. A staff call system, which is accessible to the service users, is provided in all parts of the home. Set back from the main road the home is close to local amenities and bus routes. There are well kept gardens around all sides of the home and the large front lawn has a wishing well and other garden features of visual interest for the people who live there. The laundry and staffroom are located on the second floor of the home. A place at this home costs £372 - £416 per week. Additional charges are made for toiletries, newspapers/magazines, private chiropody and manicurist (if required) and hairdressing. Items, which are included in the cost, are listed in the homes terms and conditions. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit in October 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. Information was submitted by the provider in the annual quality assurance assessment. (AQAA) • The views of people who use the service & their relatives, staff & other professionals. This information was collected using surveys sent out to families and residents. The Visit: An unannounced visit was made on the 4th October. An announced visit was made on 5th October 2007. During the visit we: • Talked with people who use the service, their relatives, staff, visiting health professionals and the deputy manager. • Observed life in the home. • Looked at information about the people who use the service & how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe & comfortable. • Checked what improvements had been made since the last visit. • Looked at reports compiled by the owner of his monthly visits to the home. We told the deputy manager what we had found. The people who reside in this home prefer to be known as “residents”; therefore this term of reference is used throughout the report. The registered manager was on holiday at the time of the inspection so the inspection was carried out with the deputy manager. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 6 What the service does well:
This is a popular home in the area and almost all of the residents are from the surrounding areas. Similarly staff employed in the home are from the same areas and share the same cultural background as most of the residents who live in the home. The people who live here and also their relatives had many positive comments to make about the service they receive. “I am always informed about any health issues relating to my mother, medication changes, Doctors visits, Hospital appointments, any falls or accidents which may happen to my mother.” “I am happy with the care that is given to my mother”. “I think that the staff do a really good job of caring for my mother”. “Ive never had any cause for complaint” “Never had any concerns to date”. “The staff have a warm and friendly greeting whenever I visit the home”. Residents and their relatives are actively involved at this home. Resident’s staff and visitors get on well, which adds to the ‘homely’ atmosphere of the service. The home offers residents a homely, clean and comfortable place in which to live. The accommodation is clean bright and cheerful. The home has a number of different lounges for people to use and following some changes to the premises additional craft facilities have been provided. There are also large gardens to the front and back of the house, which have comfortable bench seating, raised flowerbeds and level access. Residents receive the support that they need from staff to ensure that their personal, physical and emotional needs are met. And written plans are in place for each resident so that the care they receive is individual to them. The staff works well as a team and are supported and supervised by an experienced and qualified manager. This ensures that staff receives the necessary support to do the job. When new people do commence work in the home good recruitment procedures are in place to ensure that only people who are seen as suitable to work in the home are employed. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 7 Staff training is good and this ensures that staff has up to date knowledge and practices to support the needs of people living at the home. As noted in previous inspection reports there are few staff who leave this home, so they know each other and the resident’s well. The manager and staff have good working practices with community healthcare staff such as community nurses, which helps to ensure that the resident’s receive prompt medical attention or monitoring should these be required. Activities both in and outside of the home are available so that people have the opportunity to lead stimulating and interesting lives and relatives and friends are encouraged to take part if they wish. Residents and their relatives are encouraged to offer their views on the service and the manager listens to these. This has ensured that there are hardly any formal complaints made about the service. What has improved since the last inspection?
The home has made a number of changes with the premises as part of their plans to vary the homes registration so that they can provide nursing care. These changes have included the installation of a sluicing facility, fitting specialised assisted baths on each floor, new medicine storage facilities on both floors and the change of use of some rooms to create additional storage space. Since the inspection was completed on 5th October the application for variation to the homes registration has changed and the home is now registered to provide nursing care. The registration took effect from 10th October 2007. As part of the premises changes a room on the ground floor has been converted from a kitchen store room to an area that can be used by the residents for craft sessions. This room is also used for staff training and provides a good area for staff to meet with NVQ assessors and other training personnel. A small dining room has been converted from a bathroom that was rarely used by residents. This dining room can be used for those residents who require staff support during the meal and offers a good facility for the residents. Bigger nameplates have been placed on bedroom doors so that they are more visible and help residents to easily find their bedroom. Handrails have been painted a bright colour so that they are more visible and these too assist those residents who might have problems with finding their way around the building.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 8 Changes have also been made to the rear garden, which now has a gazebo, bench seating, wheelchair height raised flowerbeds and a new level path that offers good disabled access to all residents. The seating area is screened with willow fencing and provides a nice private area to sit in during the good weather. Hygiene practices in dealing with laundry are much improved and new laundry skips are in place to assist with eliminating the risk of any infections. A website is in place and this includes information about this home and other homes operated by the company. This means that anyone who wishes to obtain information about the services provided in the home can do so by using the Internet. The website also includes a copy of the most recent Commission for Social Care Inspection, inspection report which can be printed off. A new format of written plans of care for residents has been introduced and this is to include more detailed information to demonstrate how staff are to help residents. What they could do better:
The new written plans of care that have been introduced must be developed further to demonstrate how staff are helping residents. When completing the monthly evaluations more detail is needed to demonstrate any change in residents assessed needs. Records that are used when administering medicines to residents must be improved. Whenever medicine is issued staff must sign the appropriate record sheet. If medication is not issued for any reason then there must be a record of why and what actions have been taken. A record of staff who are authorised to administer medicines must be kept in each medicine administration file. This record must show the staff name and the initial they use when signing, as this will help the manager with auditing the records system. For those residents who have been assessed as being unable to manage their own medicines then a risk assessment should be completed to confirm this. Once this has been completed a written consent form must be completed that confirms that each resident/or their representative have given consent for staff to administer their prescribed medicines. Mealtime practice should be reviewed as discussed both in this report and during the inspection. And this should take into consideration better use/display of menus in the dining rooms. How tables are laid out with crockery, cutlery and the timing of meals, so that people are not having to sit at the table for a long period of time while waiting for the food to be served. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 9 The bathrooms must not be used for storing inappropriate items such as blinds, incontinence aids, talcum powders and bubble baths. Any personal items used by residents must be stored in their own bedrooms. Hot water in bathrooms must be provided at the recommended safe temperature of 44 degrees centigrade and in order for staff to check hot water temperatures a thermometer must be available in each bathroom. This will ensure that residents are kept safe while bathing. The records that are in use to confirm that fire instruction training and fire drills have been carried out with staff require updating. The records should include the staff that take part, their designated role, what the instruction covered and what the outcome was and staff signature of attendance. Once this has been carried out a reference (the date) to any drill or instruction should be made in the fire logbook to confirm that they have taken place. The reference should then indicate that the full details are kept in a separate book known as the fire precaution book. The accident records in use should also include a record of the outcome of any accident. And staff should only record in this record what they see/witness, they should not record someone as falling if they have not witnessed a fall. 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. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 10 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 Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 11 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, 3 & 6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service’. A range of information about what life is like at the home is available to help people to decide if they want to move there. Each service user’s needs are assessed before they move to the home. This helps to make sure that their needs can be met at the home and inappropriate admissions are avoided. The home does not provide intermediate care. EVIDENCE: The home has written information called the service users guide, which gives all of the important information that people need to know about the home. This
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 12 includes information about how to make a complaint and the most recent Inspection report. The company that own this home also have a website and information about their homes including the Pavilion Care Centre can be accessed from the website. The website allows you to download and print off a copy of the statement of purpose and service user guide. In addition to this you can also request a visit to the home and download a sample menu, copy of the complaints procedure, a specimen contract and also the latest inspection report. Discussion with the deputy manager confirmed that the statement of purpose is currently being updated to reflect the current changes being made to the homes registration as they are going to provide nursing care. The deputy manager stated that they prefer people to visit the home before they decide to move in as this gives them an opportunity to look around and see what is being provided. Staff also uses these visits to complete an assessment in order to make sure that any prospective residents needs can be met. Each resident’s needs are assessed before they move to the home either by a local authority social worker, the manager, or by both. This is so that the manager can be sure that the home is suitable for meeting the needs of people who are going to live there. Documentation used by the home as part of the assessment process includes finding out about residents cultural and lifestyle needs. This is to make sure that staff have enough information to help them with getting to know residents. And also the best way to support residents with maintaining a valued lifestyle in the home. Care files that we looked at contained a range of assessment information to confirm that a full assessment of need had been completed prior to admission. The home does not provide care for those people who have been admitted on a short-term basis to get special therapy while they recover from injury or hospital treatment. . Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 13 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 adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service’. Each resident has a written plan of care (care plan), which sets out their preferences and how their assessed needs will be met by staff at the home. However a new system of recording is being implemented that means not all care plans are up to date. All residents have access to a range of health professionals, which ensures that their health needs can be met. Staff take responsibility for administering medicines that have been prescribed for residents health needs. However the records of medication administration are not managed appropriately to promote the health and well being of residents Staff have a friendly and respectful approach towards resident’s, which empowers them and helps to keep in control of their lives. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 14 EVIDENCE: Four care plans were looked at in order to see how staff are meeting residents needs. The company has recently introduced a new care plan format and the deputy manager stated that the staff team are in the process of transferring personal information form the old care plan system onto this new system. The new care plans have a 12-step process of demonstrating how individual assessed needs are to be met. For the two most recent admissions into the home the system is in use now. There is a lot of information in the care files, which includes an assessment of risk, nutritional, needs and how people prefer and need to be supported by staff. Care plans identify how people prefer to be addressed, what routines they have and how any individual interests and hobbies can be followed while living in the home. As a result of introducing the new care planning system not all records have yet been updated. The care plans are evaluated each month by staff but these do not include sufficient detail to demonstrate how individual needs are being met. Similarly the care plans do not always clearly demonstrate the actions that are being carried out by staff to support residents. Some of the written terminology that is used by staff would be better if replaced with “plain English” in order to ensure clarity for staff. This was discussed with the deputy manager who was receptive to the advice that was offered. Individual care plans identified choice of gender and whether a resident preferred to be supported with personal and intimate tasks by a male or female worker. The care plans also take into consideration how residents can be supported to maintain their independence, which includes going out of the home unaccompanied. Some further work is required in this area for one person who goes out using a motorised scooter with a need to develop and update the risk assessment. Records are available that confirm residents are seen by the appropriate health professional when required. Observations made during the inspection confirmed that good support is available from community health services. During the inspection staff had to arrange for emergency medical care for one resident and this was dealt with speedily and appropriately with good cooperation between the staff and heath services.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 15 The medicines storage and records of administration are now split between the 2 floors with records available for staff to use. Medication is being stored appropriately on both floors however the records of administration on the ground floor are not being managed appropriately. There are a number of gaps on the administration records for 8 residents where medicines had not been given but no explanation as to why. Therefore it could not be determined from the records whether the residents had or had not received their prescribed medication. As a result of this an audit of the medicines was carried out with the deputy manager who stated that residents would have received these medicines but staff had not recorded this. The audit provided assurances that prescribed medicines had been given but the absence of a signed sheet in the administration file, of staff who are authorised to give out medicines. Made it difficult to raise these matters directly with the staff member responsible for the omission on the records. Discussion with the deputy manager confirmed that an audit is carried out weekly of 6 residents medicines to ensure that they are being stored and managed correctly. As a result of these omissions in the administration records the deputy manager stated they would be included in the weekly audit with a view to improving the records. None of the residents administer all of their own medicines but 2 people are supported by staff to manage their own creams and inhalers. Where this occurs the residents have signed to accept responsibility for these medicines. Staff administers other medicines but there are no consent forms signed by residents or their representative authorising staff to do this. Neither is there a risk assessment in place to demonstrate that a resident is not capable of managing his or her own medication. Staff ensures residents are treated with respect and support is given sensitively and discreetly. Assistance with personal care is carried out in the privacy of a person’s room or bathroom. Observations confirmed that staff knocks on their bedroom door before entering and that they speak to residents in an appropriate manner. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 16 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 judgment using a range of evidence, including a visit to this service’. Residents are able to follow their own daily routines, which satisfy their social, cultural and religious needs. There are no restrictions on visiting the home and friendships with people outside and inside the home are encouraged, this helps to maintain contact with friends and family. Staff encourages residents to take control and make choice in their lives, which helps to promote independence. Residents are offered a variety of wholesome and nutritious meals in comfortable surroundings, which can promote health and well being. EVIDENCE: An activities co-ordinator works at the home and supports service users to take part in opportunities. At the time of the inspection staff were supporting
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 17 residents to take part in a pampering and beauty session, which also involved the use of a foot spa. The residents said that they enjoyed this activity as well as other activities that were organised in the home. The residents spoke of the things that they do both inside and out of the home, in the local and wider community. They said there are games sessions, using colouring books, making things, shopping visits, social events and entertainers. On the day of the inspection Bingo was arranged for the afternoon and the residents said that they were looking forward to this. In addition to this craft sessions were being carried out in the room designated for activities. There are numerous photographs of celebrations, annual events and visits to places of interest on display throughout the home. As noted in previous inspection reports the home has strong links with the local community, this ensures that residents can take part in activities that are organised in the area. The manager and some staff have undertaken training so that they can improve the support they give to promote the lifestyle opportunities of people at the home who have dementia type illness. And this has been noted in previous inspection reports. This training has equipped staff with the knowledge and skills to ensure that best practice guidelines are always followed. Observations made during the inspection noted staff respond in a positive and professional manner especially when dealing with behaviours that challenge. Staff are also positive in how they support residents to maintain their independence with one resident being actively encouraged to go out unaccompanied. The relationships between staff and relatives are good and visitors are made to feel welcome and supported. Information received in surveys we sent out to relatives prior to the inspection was positive about the home. Some of these comments are reflected below, • “I am happy with the care that is given to my mother. The manager, deputy manager and every one of the staff at the home are very caring and show it in many ways. I think my mother is well looked after”. “I think that the staff do a really good job of caring for my mother, sometimes I know they have a difficult job with her changing moods. They all show her kindness and affection”.
DS0000063779.V351019.R01.S.doc Version 5.2 Page 18 • Pavillion Care Centre • “Whenever my mother has ever been in difficulties, the carer’s and the home have acted responsively at all times”. A number of relatives were visiting the home during the inspection and took time to inform us that they felt they could talk to staff easily and would approach them first if they had any concerns. All of the relatives said, “They can visit at anytime and the manager and staff are always welcoming to them.” They went on to say that are always offered refreshments when they visit and the atmosphere in the home is always nice. Staff were observed asking residents about their choice of meal, size of portion to ensure that the element of choice for residents is always followed. Where needed staff offered support and assistance to residents to eat their meal and this made the meal time a relaxed and unhurried experience. Lunch was taken on both days with the residents and in each dining room. The meals provided were well presented, hot and tasty and sufficient in quantity. Discussion with the residents confirmed that they like the meals that are offered in the home. They went on to say that there is always a good choice of food as well as drinks and refreshments in between meals. In the residents surveys that were issued before the inspection a number of residents indicated their satisfaction with the meals in the home. In the relatives survey only one comment was made about the food and this is below. “Mother is quite happy, but the meals need spicing up. I know its hard with old people but mother liked a good range of different dishes.” Discussion was held with the cook and the menus, which were available, were discussed. This confirmed that a range of meals is provided on a rotating basis and which offers residents a balanced diet. A range of fresh fruit and vegetables are used in the preparation of food at the home, which increases the nutritional benefit for residents. Service users and their families are involved in choosing the meals, which are included in the menu. As noted in previous inspection reports the home has received an award from the local authority because the meals are good and provide a healthy diet for people living at the home.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 19 Some practice issues were discussed with the deputy manager during the inspection about the meal services and staff practices. For example menus are displayed on a wipe clean board and are placed in an area of the dining room that are not easy to see once you are sitting at the table. This did cause some confusion for those residents with dementia and short-term memory loss, as they could not remember what they had ordered earlier in the day. Menus on the table would have assisted with this process. At the last inspection it was identified that a pictorial menus showing pictures of the meal were to be developed so that they could be displayed on the tables. Another matter related to tablecloths which were available in the ground floor dining room but not in the first floor dining room that is used by people who have dementia. Observations we made confirmed that on the first floor the residents sat for a long period of time (15 minutes) until the hot lock food trolley arrived from downstairs. As most people on this floor have a short concentration span the timing of the meal and when people come into the dining room could be changed to avoid unnecessary waiting. Staff served hot drinks from a large catering size teapot, which in turn limited the choice of those residents who are able to manage having a smaller teapot on their own table. In addition to this when having a second cup of tea from the large teapot the quality had noticeably deteriorated. The use of plastic aprons to protect residents clothes where needed while eating are not appropriate and discussion was held with the deputy manager about alternatives such as large cloth napkins or cloth tabards. Not only would these look better but would offer more protection especially with spillages of drinks. Where necessary and as identified in the individual assessment, special diets and food supplements are made available and, as part of an ongoing process of monitoring health, records of weight loss/gain are recorded in service users’ files. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 20 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 good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service’. The home has a rigorous and robust complaints system that residents can use if they are unhappy, have a grievance or dispute. They also give feedback when they are happy with the service. The home has measures in place which protect residents from being harmed which helps to promote their safety and security. EVIDENCE: The home have an open approach to how they deal with concerns or complaints expressed by the residents or their representatives. All comments that are made are dealt with quickly with appropriate actions being taken. This was observed during the inspection when a relative raised concerns about some missing laundry items. This openness and quick response of the staff has resulted in no formal complaints being made to the home or anyone else since August 2006. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 21 Discussions with residents and their relatives confirmed that they would have no hesitation in discussing any concerns with any member of staff, knowing that it would be dealt with positively. From the surveys received from relatives and residents all indicated that they knew who to complain to and how any complaint would be addressed by the home. Some of the comments made in the survey are as follows, • • • “Ive never had any cause for complaint” “Never had any concerns to date” “Good all round and have no problems with home or care” All staff in the home has had training in the protection of vulnerable adults this is known as “safeguarding adults”. There have been no instances where abuse has been suspected or reported, the home has a safeguarding adults procedure, which is robust and complies with the Public Disclosure Act and the Department of Health Guidance. Information on the role of the local authority is available and included in the homes procedures. There is a staff guide, which gives clear instructions about the actions, which they must take if abuse is disclosed or witnessed. All staff spoken to is knowledgeable of these practices and could demonstrate that they know the actions they must take. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 22 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 & 26 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service’. The home is clean, warm and comfortable offering residents a homely and safe environment in which to live. Disabled access is available to external garden and seating areas, which offer a safe and comfortable area to sit in. A number of specialised bathing facilities are in place to ensure that residents needs can be met. EVIDENCE: During the inspection visit we looked at all communal areas used by residents and some bedrooms.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 23 A good standard of housekeeping is in place and all areas are clean and tidy and free of any unpleasant odours. As previously noted in this report (What has Improved since the Last Inspection) a number of changes have been made to some rooms and bathing areas. In order to ensure that residents get the best use out of the building. These changes have also taken place in preparation for the homes change towards offering nursing care as well as personal care. Appropriate storage facilities are in place on the ground and first floor for medicines. And each floor has its own specialised bathing facilities. Some items are being stored in bathrooms that should not be and could compromise health and safety. This was discussed with the deputy manage who took immediate action to remove these. Hot water temperatures were tested at bathing points and this is discussed more fully in standards 31-38 (management) of this report. The rear garden area has comfortable bench seating, level paths, wheelchair height flowerbeds, and disabled access and is surrounded by willow fencing which offers privacy and security. All areas offer disabled access and all residents in the home are able to access these external areas. There are several lounges around the home where people can spend their time and also an activity room that is used for craftwork. Laundry facilities are well maintained and run to ensure that all laundry is properly cleaned. Appropriate equipment is in place to ensure there are no issues with infection. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 24 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 judgment using a range of evidence, including a visit to this service’. The residents are supported by staff that know them well and are committed to their wellbeing, this makes sure that their needs are consistently met. Robust recruitment procedures ensure that resident’s are protected from people who are unsuitable to work with vulnerable people. There are sufficient staff working at the home to meet the needs of people who live there. Training on an ongoing basis is provided to staff and organised by the manager to make sure that their care practice is good and residents receive the correct support to meet their needs. EVIDENCE: Since the last inspection 8 staff have commenced work in the home in a variety of roles. Files for these 8 people were examined to ensure that the home had obtained the necessary information as required as part of recruitment.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 25 Staff files are in good order and contain a range of information that confirms all necessary checks, references and previous employment history is covered in detail prior to being offered employment in the home. This recruitment process helps to make sure that all staff employed is seen as being suitable to work with vulnerable people. Most people who work in the home are from the surrounding areas and come from the same cultural background as the people who live in the home. This helps staff with their understanding of resident’s lifestyle and the cultural needs that are associated with their background. In some cases staff have known residents when they previously lived in the community and this has also assisted in them building a good relationship with residents. In addition to this the home have also appointed people from other cultural backgrounds as part of their equality and diversity policy. Induction training and support ensures that staff settles into the home and become a valued member of the staff team. Observations made and looking at staff rotas confirmed there is sufficient staff available to meet the needs of residents at the home. Staffing rotas are well structured and arrangements are in place to cover any staff absences such as holidays or sickness. Discussions with staff confirmed that they are flexible in their working practices and pick up extra shifts when needed to ensure that there is always a safe staffing level in the home. Discussions with staff confirmed that they have a good knowledge of individual residents including information about their previous lifestyles before moving into the home. This level of knowledge assists them in the care process and has also assisted them in maintaining good relationships with resident’s relatives. It was observed that staff are good humoured, have a good rapport with the residents and spend a lot of quality time engaging in conversations. This contributed to the positive atmosphere that was present throughout the inspection. The manager has sourced training opportunities for herself and senior staff from a national organisation that supports people with dementia and their families. This has given staff additional knowledge and a better understanding about dementia type illnesses, which in turn ensures that best practice guidelines are followed. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 26 Evidence is available to confirm that the manager identifies staff training needs through supervision and this is used to plan future training for staff. This ensures that at all times staff have opportunities to develop their knowledge and skills and offer a good service to the residents. Staffing records confirmed that induction training is given when first commencing work in the home. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 27 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, 32, 33, 35, 36, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service’. The manager offers clear leadership and direction to the staff to maintain the quality of care in the home. The manager is motivated and committed to change and supports and supervises staff to make sure that they carry out their role effectively. This helps to make sure that staff meets the needs of residents. Arrangements are in place to ensure the health safety and welfare of service users and staff. Effective and accurate records are in place to makes sure that resident’s financial interests are safeguarded. This supports resident’s to remain independent and helps if they or their families have a query.
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 28 EVIDENCE: The manager was on holiday at the time of the inspection and in her absence the deputy manager was available. It was confirmed in discussion with the deputy manager that the manager is supportive to her and all off the staff. This assists staff in their work and helps them to work as a team, which was evident throughout the inspection. The manager has worked in the home for more than 7 years and similarly a large number of the staff have worked in the home for a similar period of time or longer. This has established continuity with the staff team, which in turn has positive benefits for the residents. The Registered Manager has attained NVQ level 4 in Care, a Diploma in Business Studies and has also completed the Registered Managers’ Award. An external manager from the company visits the home regularly and carries out visits on behalf of the owner. This person offers support to the manager and is available to the staff team should they wish to discuss any matters about the home. There are clear lines of accountability within the home and within the organisation. The manager has overall day-to-day control of the home and is able to make changes or decisions that will have positive results for the residents. This information was collected using surveys set out to families and residents. Staff receive formal one to one supervision at least six times per year this ensures that staff have the opportunity to discuss their work, identify any training needs and also receive feedback form the manager on their work performance. As noted in the last inspection report the manager runs the home in a way that is clear, open and objective. She has an open management style and is approachable so residents and relatives as well as staff are consulted about issues affecting the home. She routinely works alongside staff to monitor their performance and always makes herself available to residents and families. Staff made positive comments about the manager and stated that they enjoy working in this home. Appropriate records are maintained to show how any repairs or matters relating to health and safety are addressed immediately. Staff receive regular
Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 29 fire drills and fire instruction and records are kept to confirm when this has taken place. The manager has identified 6 staff as being designated fire wardens and this means they have extra responsibilities for dealing with fire safety in the home. However the fire training records do not show the designated role of staff, the level of instruction given or who attended. The records are kept in a book called the “Fire Precaution book” as opposed to being entered in the fire logbook. Neither do they say who carried out the training/drills, the duration and what the outcome was. This was discussed with the deputy manager who was offered advice as to how the records should be maintained in order to provide greater clarity of who attended fire training. The manager has devised a fire safety questionnaire for staff and this is used as part of fire instruction training. This is good and ensures that fire training is solely related to this building and sets out what staff have to do in the event of an emergency. Records are kept of any accidents in the home for both residents and staff but these records do not always show what the outcome was. Some staff are also recording in the accident book “resident falls” without witnessing the incident. In discussion with the deputy manager we advised that staff should only record the facts e.g. what they see and witness. This will ensure that records are accurate. Records of accidents are also linked to other records in residents care files and this assists staff to monitor individual residents health needs. As a result of this monitoring process staff sought specialist input from the GP due to one resident experiencing a number of falls in one week. The home have an administrator who offers support to the manager and this ensures that good records are in place for dealing with resident’s personal allowances. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 30 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 3 2 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 31 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 OP7 Regulation 15 (1) Requirement The new care plan format must be updated for all residents. And they must clearly demonstrate how residents assessed needs are to be met by staff. The manager must take steps to ensure that accurate administration of medication takes place at the home. Immediate. (Previous timescale 01/10/06) A record of staff who are authorised to administer prescribed medicines must be kept in the medicine administration files. Immediate. Each resident or their representative must sign a consent form that authorises staff to administer their prescribed medicines. The manager must make sure that Bathrooms are not used for storing items. Immediate. Timescale for action 30/04/08 2. OP9 13 (2) 05/10/07 3. OP9 13 (2) 05/10/07 4. OP9 13 (2) 31/12/07 5. OP21 23 05/10/07 Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 32 6. OP38 13 (4) (a) & (c) 7. OP38 17 (2) & Schedule 4 Hot water at all bathing points must not exceed the safe recommended temperature of 44 degrees centigrade. A thermometer must be available in each bathroom so that staff can test hot water before bathing residents. Immediate. Records of all fire drills and fire instruction training must be kept as advised within this report. An as outlined in the guidance notes of the Fire Logbook. Immediate. 05/10/07 05/10/07 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. Refer to Standard OP15 OP38 Good Practice Recommendations The mealtime practices should be reviewed as discussed and advised in this report. Accident records should be maintained as advised in this report. Pavillion Care Centre DS0000063779.V351019.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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
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