Inspection on 16/05/08 for Pavilion Court

This inspection was carried out on 16th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pavilion Court 28/01/10

Pavilion Court 23/11/09

Pavilion Court 11/02/09

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pavilion Court Brieryside Cowgate Newcastle Upon Tyne NE5 3AB Lead Inspector Glynis Gaffney Key Unannounced Inspection 14:30 16, 20, 21 & 28 May 2008 , 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 Pavilion Court DS0000071026.V364242.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. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pavilion Court Address Brieryside Cowgate Newcastle Upon Tyne NE5 3AB 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) 0191 2867653 0191 2865794 pavilioncourt@cshealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Manager post vacant Care Home 75 Category(ies) of Dementia (75), Old age, not falling within any registration, with number other category (75) of places Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 75 Dementia - Code DE, maximum number of places 75 2. The maximum number of service users who can be accommodated is: 75 03 July 2007 Date of last inspection Brief Description of the Service: Pavilion Court is a 75-bedded care home situated in the Cowgate residential area of Newcastle. The home opened in August 2005 and provides residential and nursing care to older people over two floors, including those with dementia care needs. All bedrooms are single and have en-suite facilities. There is a range of communal space including seven dining rooms and lounge areas. The home is attractively decorated and furnished. A range of aids and equipment has been provided. People who use wheelchairs can access all areas of the home. Off road parking is available and the home is close to local bus routes. There is a £10 top up fee for people funded by social services. The top up fee for people receiving nursing care is £15. Fee rates for people who are selffunding range from £447 to £613 per week. Further information about fees can be found in the home’s statement of purpose and service user guide. A copy of the last inspection report has been appended to the service user guide a copy of which is available in the main reception area. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. How the inspection was carried out: Before the visit: We looked at: • • • • • Information we have received since the provider registered the home in November 2007; How the service dealt with any complaints and concerns since the provider registered the home; Any changes to how the home is run; The temporary manager’s view of how well they care for people; The views of people who use the service and their relatives and staff. A small number of relatives have expressed concerns about some aspects of the care and support received by their family members. Some of the concerns mentioned relate to staffing shortages, missing clothing and inadequate meals. The temporary manager, who has been in post for approximately two weeks, convened a meeting with relatives to try to address their concerns. Minutes from the first relative’s meeting have been displayed in the building. Further meetings are planned to provide relatives with feedback on the measures put in place to address the concerns they have raised. The Commission will monitor how effective the service is in addressing the concerns raised by people’s relatives. The Visit: An unannounced visit was made on the 16 May 2008. Further visits took place on the 20 and 21 May 2008. During the inspection we: • • • • Talked with some staff and members of the provider’s operational and project management team; Spoke to people living at home and spent time observing the care and support they receive; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; DS0000071026.V364242.R01.S.doc Version 5.2 Page 6 Pavilion Court • • • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the provider registered the home. A thematic probe was carried out as part of the inspection. A thematic probe is how we gather additional information on a particular theme during a key inspection. In this inspection, we looked at the arrangements for safeguarding vulnerable adults. We told the provider’s operational manager and the home’s temporary manager what we found. What the service does well: This is a sample of what the home does well: There is a comprehensive service user guide, a copy of which is available in the main reception area. It includes comments made by people living at the home. The home assesses people’s needs before they move into Pavilion Court. A record of the assessment carried out is placed in people’s care records. At the time of the inspection, a person considering whether to move into the home had been given the opportunity to visit and take their lunch with other people living at Pavilion Court. The new provider has devised a comprehensive assessment and care-planning format. Detailed care plans and preventative health care risk assessments have been carried out for each person. The new provider has: • • An equal opportunities policy and obtains equal opportunities information as part of the staff recruitment process; Devised care plans that consider such issues as people’s preferences for the gender of their carers. The home’s manager has access to good administrative support. The home has its own maintenance person who carries out general repairs and maintenance tasks. The home is purpose built and has been designed to take account of the needs of people with physical disabilities. There is a lift to the first and second floors. There are wide corridors making it easy for people using wheelchairs to move Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 7 around the home. Assisted baths, adapted shower rooms, hoists and other moving and handling equipment have been provided. All equipment is in good working order. Staff are kind, polite and courteous. They conduct themselves in a considerate and respectful manner. Staff have developed warm and caring relationships with the people in their care. People have been supported to personalise their bedrooms in accordance with their personal preferences. The cook has completed in-house training on promoting better nutrition and how to implement the new provider’s nutritional policies and procedures and catering systems. The kitchen is well organised, clean and hygienic. The home has recently been awarded the local authority’s highest score for operating a kitchen that is well equipped, tidy and hygienic. The home has updated the fire safety evacuation information regarding each person resident. Laundry equipment is in good working order. The laundry is tidy, clean and hygienic. What has improved since the last inspection? The ‘Welcome’ packs given to new people and the home’s service user guide have been revised and updated. Information about fire safety has been included in the revised service user guide. Arrangements have been made for an artist to visit the home and provide people with support to develop their skills in this area. Some staff have attended training workshops in palliative care and completed accredited medication training. The provider has devised a booklet that can be used to record staffs’ professional developmental in relation to safe manual handling. A senior member of staff has been designated as the link person between the home and the speech and language therapy service. Some staff have received training in this area. Arrangements have been made for staff to receive more specialised training in caring for people with dementia. Relatives have also been invited to attend this training. The senior management team have sourced training Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 8 opportunities that will provide staff with accredited training in safeguarding vulnerable adults. At the point at which the inspection took place, the new provider was in the process of updating staffs’ statutory training. Action was also being taken to ensure that documentary evidence of the training completed by staff is in place. Further staff have obtained a recognised qualification in care. What they could do better: Replace the kitchen bench tops located in the unit dining rooms and repair the damage to the wallpaper in the dementia unit dining room. This will help to ensure that the premises continue to be well-maintained. Ensure that at least 50 of the non-nursing care team have obtained a National Vocational Qualification in Care at Level 2. This will help to ensure that staff have the skills and knowledge required to provide people with a good standard of care that meets their assessed needs. Ensure that all staff have completed the required statutory training and that there is documentary evidence to support this. This will help to ensure that staff have the skills and knowledge required to provide safe care. Ensure that senior staff receive their medication This will help to ensure that they remain healthy update their medication training. People must also in accordance with the GPs prescribing instructions. that people receive their prescribed medication and and safe. Ensure that all senior staff update their safeguarding training. Staff must also be clear about what action they need to take to keep people safe. This will mean that people can be confident that staff know how to keep them safe. Undertake a further review of the home’s staffing levels to ensure that they allow for people’s assessed needs to be fully met. 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. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements for making sure that the needs of people admitted into the home are assessed. This helps make sure the home’s staff will be able to meet their needs. EVIDENCE: The home’s service user guide states that admissions will not take place until after people have undergone a full needs assessment. A sample of three people’s care records was examined. A Southern Cross Healthcare preadmission needs assessment had been completed and a copy placed in each person’s file. The previous provider had obtained social services assessment and care plan information for each person where relevant. This information had been made available to the new provider. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are generally well met. However, the occurrence of a serious medication incident could have led to people suffering harm because they did not receive the medication they needed to stay healthy. EVIDENCE: The provider has developed an assessment and care planning format that is comprehensive, covers the required areas and is easy to use. A sample of three people’s care records was checked. Those examined contained: • Useful assessment information covering such areas as people’s physical and social care needs; Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 12 • • Detailed care plans with clearly defined needs, plans of intervention and desired outcomes. Care plans are well written and provide staff with clear guidance on how to meet people’s needs; Evidence that people’s care plans are evaluated monthly. Some of those checked were detailed and clearly related to the plan of intervention. Other evaluations were not as comprehensive and contained limited information. The temporary manager had already identified this as an issue and was looking at ways of addressing this. A range of preventative health care risk assessments have been completed for each person. In the sample of care records checked risk assessments covering people’s susceptibility to falling, developing pressure areas and under-nutrition had been carried out. Call bells have been fitted in individual bedrooms and in all communal areas. Following a concern disclosed by a person living at the home that they had had to wait 45 minutes for someone to help them use the toilet, staff response times were tested. In two of the three tests carried out, the response time was almost immediate. However, a call bell test was carried out in a bathroom on the nursing unit. None of the carers present responded to the call bell alarm. Eventually, the home’s maintenance man answered the call following a request by the temporary manager to check what was happening. A discussion about this concern took place during the feedback session. The Operations Manager and temporary manager agreed to carry out a review of staff response times to requests for help using the nurse call system. The provider has agreed to provide the Commission with feedback on the outcome of their review. One person’s relatives said that on two recent occasions, the domestic worker cleaning the en-suite had left the nurse call chord tied up around the top of the shower unit. They also said that they had informed a senior nurse on duty about this matter who agreed to ensure that this did not happen again. People are supported to access community health facilities such as GPs and practice nurses when they need to. In one person’s care record there was evidence that they had been seen by both an optician and a dentist in the previous 12 months. However, in the records of two other people, there was no reference to when they had last seen a dentist, chiropodist or an optician. Records indicate that people’s weights had not always been checked every month. People interviewed said that they felt their health care needs were satisfactorily met. Of the three people using the service who returned surveys: • One person said that they ‘always’ receive the care and support they require. Two others said that this is only ‘sometimes’ the case; Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 13 • • • One person said that staff ‘always’ listen to and act upon what they say. Two others said that this only happens ‘sometimes’; One person said that staff are ‘always’ available when you need them. Two others said that this is ‘usually’ the case’; One person said that they ‘always’ receive medical support when they require it. Two others said that this is ‘usually’ the case. The medication arrangements for people living in the nursing unit were checked. All medication is stored in a lockable room and in locked trolleys. All were found to be clean and hygienic. Drawers and cupboards used to store dressings, creams, stock medication and other nursing related equipment were tidy and organised. The suction machine had been charged ready for use in an emergency. Staff have access to sharps bins, which are appropriately stored. The records relating to the ordering, receipt and administration of medication were accurate, up to date and well completed. Photographs to identify each person have been placed with their medication records. Staff with responsibilities for administering medication have received accredited training. However, not all staff have received level 1 medication training as recommended by the Commission for Social Care Inspection. The temporary manager said that arrangements have been made for each member of staff to complete or update their medication training. The Commission has recently been notified of one serious concern where the home failed to ensure that some people received their prescribed medication over a period of approximately two days. This matter has been referred to the local authority safeguarding team and is currently under investigation by the provider. The provider has already established that a senior member of staff failed to take appropriate action to protect some of the people in their care from potential harm. On being notified of the safeguarding concern, the provider took immediate action to rectify the situation and keep people safe. They also worked in partnership with the local safeguarding team to achieve this. The Commission is satisfied with the action taken by the new provider. Generally, people are treated with respect and receive care that is provided in a kind and dignified manner. For example, when people on the dementia care unit became agitated or upset, staff spoke gently and tried to calm them down by diverting their attention. During meal times, staff tried to engage people in everyday conversation in a respectful manner. Staff were observed knocking on people’s bedroom doors before entering. Two issues about how staff ensure people’s privacy were discussed as part of the feedback session. The provider gave an undertaking to review the home’s practices in these areas and provide the Commission with feedback about any improvements made. People’s personal information is stored in a confidential manner. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 12, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people living at the home experience a lifestyle that matches their expectations and preferences about how they want to live their lives. However, the arrangements for providing people with access to varied programme of organised and individual based social activities are not fully satisfactory. This may mean that people living at the home are not always able to lead fulfilling and stimulating lives. EVIDENCE: Before people move into the home staff obtain information about their social care needs, interests, and hobbies, following which a social care plan is devised. In the sample of care records checked, a social needs care plan had been devised for each person. Those examined had been reviewed monthly. Each person’s care record contains a log that provides an overview of what activities people have engaged in during the previous month. This had not always been completed for some people. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 15 An activities planner has been placed in each person’s bedroom. This sets out the organised activities that will be provided each day. The home’s management team was keen to emphasise that the provision of social care at Pavilion Court is not just about providing organised events or group based activities, but also about giving individual access to activities such as visiting the hairdresser, receiving personal visitors and attending religious services. The temporary manager said that the provision of activities within the home will not just be the responsibility of the activities organiser, but that all care staff will be expected to play a part in this area. The home has access to a mini-bus and the temporary manager intends to offer people with opportunities to participate in twice monthly trips outs. The temporary manager has arranged for an artist to visit the home and provide people with opportunities to develop or enhance their skills in this area. Although the home employs a paid activities organiser, the post was vacant at the time of the inspection. Arrangements have been made to fill the post. Apart from a social event led by an outside entertainer, there was no evidence of any other organised activities taking place in the units visited during the inspection. People using the service, and their families, had mixed opinions about the provision of activities within the home. For example, one person said that they preferred to occupy themselves and were allowed to do so by staff. Another person said that staff had agreed to provide them with access to painting materials so that they could take up their hobby again. Concerns were also raised. One person said that since moving to the home last year, there had been no organised daily activities. However, they did mention that they enjoyed the special Christmas events that were arranged by the home. A person living at the home also said that ‘…there are no longer any activities for me during the day due to staff shortages.’ The relatives of one person said that there had been no activities provided over the last six to eight months. Another person’s family said ‘…there are not enough activities and patients get bored.’ People are provided with opportunities to develop and maintain important personal and family relationships. Visitors are made to feel welcome on arrival. People are able to see their visitors in private if they wish. The home has a varied menu that offers choice. The provider is reviewing the home’s menus to ensure that nutritional balance and appealing choices are offered. The Commission has requested a copy of the revised menus on completion of the review. People are consulted about what they would like to eat at each mealtime. People have access to snacks and drinks in-between meal times. People said that there is always enough to eat and drink. The inspector joined people living on the nursing unit for their lunchtime meal. The food served was tasty, nutritious, and appetising. Staff responded to people’s needs in a caring and sensitive manner and provided them with the assistance they needed to eat their meals. For example, staff sat beside people whilst helping and encouraging them to eat. The atmosphere was relaxed and Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 16 unhurried. The dining room is a pleasant and attractive area. It has been nicely decorated and has suitable furniture. Appropriate diets are provided for people who experience difficulties eating and drinking. There are no people with a different ethnic or cultural background using the service. Plans have been made to provide the cook with training in the provision of diets for people from different cultural backgrounds. A person living at the home raised one concern. This person said that previously they had been allowed to eat their meal in a separate dining area with a small group of ‘…other alert people’. They told the inspector that recently this had been stopped because staffing levels were insufficient to support this arrangement. They said that they felt ‘sad’ that this had happened. Of the three people using the service who returned surveys, one person said that they enjoy the food served at the home. Two others said that they only enjoy the food served ‘sometimes.’ Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of complaints and safeguarding concerns is generally well managed by the home. However, a recent failure to follow the provider’s safeguarding policy and procedures could have placed some of the people living at the home at risk of harm. EVIDENCE: The home has a complaints procedure that covers the recommended areas. Details of the Commission’s local office address had not been updated. Of the three staff that returned surveys, all said that they would know what to do if they received a complaint. People using the service who were interviewed said that they had been told whom they could complain to. They also said that they felt listened to. Of the three people who returned surveys, the majority said that they knew how to make a complaint and to whom. Seven complaints have been received since the last inspection. A sample of complaint outcomes was examined. Satisfactory records were in place. In the Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 18 home’s Annual Quality Assurance Assessment, the temporary manager had advised that two of the seven complaints were still under investigation. The evidence in this section is taken from the findings of a thematic probe that was carried out as part of the inspection. A thematic probe is how we gather additional information on a particular theme from a key inspection. In this inspection we looked at the arrangements for safeguarding vulnerable adults. The provider has devised safeguarding policies and procedures that provide guidance on how to deal with safeguarding concerns and what measures must be followed to ensure that only suitable staff are employed within the home. People using the service, and their families, said that they feel safe and have been told what to do if they feel frightened or are being abused. They said that they had been told whom they should report their concerns to. The provider carries out a range of pre-employment checks before staff commence working at the home. In the sample of staff files examined, the following checks had been carried out: • • • • • Application forms had been completed and staff said that they had been interviewed; A full employment history and Criminal Records Bureau disclosure checks had been obtained; Written references had been obtained, including testimonials; Staff had made statements as to whether they had any criminal convictions. They had also confirmed they were physically and mentally fit to do the job for which they were being employed; Staffs’ identities had been verified. The Commission has been notified of three safeguarding concerns since the last inspection. Although the most recent safeguarding concern is still under investigation by Southern Cross Healthcare, the provider has already established that a senior member of staff failed to take appropriate action to protect some of the people in their care from potential harm. The safeguarding concern arose following a ‘whistle-blowing’ disclosure that over a period of approximately 48 hours, the medication administration records for people living on the dementia care unit could not be found. As a result, people did not receive their prescribed medication. On being notified of the safeguarding concern, the provider took immediate action to rectify the situation and keep people safe. They also worked in partnership with the local safeguarding team to achieve this. The two other safeguarding concerns were found to be unsubstantiated. The temporary manager was able to demonstrate how learning from the recent safeguarding referral has improved staffs’ day-to-day practice. For example, procedures for booking-in medication have been tightened. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 19 All staff have received training in safeguarding vulnerable adults. This training also covers ‘whistle blowing.’ Staff spoken to had a good understanding of what the term ‘safeguarding’ meant and what constituted abuse. However, a senior member of staff told the inspector that they had not yet read the home’s protection of vulnerable adults policy and procedures. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 20 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, 21, 22, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment generally meets the needs of the people living at the home. This means that people have access to a well-maintained environment that provides a good standard of furnishings, fittings and décor. EVIDENCE: The physical environment of the home provides for the individual requirements of the people who live there. The environment is homely, clean, safe, comfortable and well maintained. There is disabled access which enables people using wheelchairs to enter the building safely. The lay out and design of the home allows people to live together in small units. Each person has their own bedroom and en-suite facility. The fixtures and fittings are generally Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 21 of a good quality. Bedroom and corridor carpets are clean and in a good condition. However, it was identified that: • • • The work surfaces in the kitchenette areas are in a poor condition; In places, the wallpaper was not adhering to the walls in the ground floor dementia care unit dining room; The carpet in the bedroom of one of the people interviewed was stained in places. Time was spent observing the social care provided to people with dementia living on the ground floor unit. Although the level of contact and interaction between staff and people living on the unit was good, the environment has not been developed to meet the specialist needs of people with dementia. For example, there is a lack of contrast and colour changes between walls and doors. There are no orientation boards displaying calendar information or details of the day’s menu. However, since taking over the home in November 2007, positive and proactive steps are being taken to improve the environment in which dementia care is delivered. For example, during the inspection, small groups of staff attended a workshop focussing on people’s journey through dementia. Rummage boxes are to be introduced as part of the home’s move towards creative therapies for people with dementia. More individualised activities for people with dementia are to be introduced. The temporary manager hopes that this will help build relationships and enhance people’s living experience at Pavilion Court. People are able to personalise their rooms and some have brought their own furniture in with them. There is a selection of communal areas and this means that people have a choice of places to sit quietly, meet with family or be actively engaged with other people living at Pavilion Court. People living in each unit have access to their own dining area and small kitchenette, a lounge and separate bathing and toilet facilities. All bathrooms and toilets were clean, hygienic and free of obstacles. All were in good working order. A range of specialist equipment has been provided. For example: • • All people requiring nursing care have a specialist nursing bed; The provision of bathing and mobile hoists helps staff to carry out safe transfers. The laundry was clean, tidy and hygienic. There is a range of laundry equipment including washers and dryers. All equipment was in good working order. After laundering, clothing is placed in labelled baskets ready for staff to deliver to people’s bedrooms. The temporary manager said that there have been some problems ensuring that clothing is returned to the right person. In the two weeks since she started, the temporary manager has met with people’s relatives to try to address the concerns they have about how their family member’s laundry is handled. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 22 A tour of the kitchen was carried out. It is well equipped and satisfactorily maintained. Fridges, freezers and store cupboards were well stocked. The kitchen was clean and hygienic throughout. The home has recently been awarded the local authority’s ‘Five Scores’ award for operating a well-managed kitchen with good levels of hygiene and cleanliness. A more detailed inspection of the kitchen was not considered necessary. No infection control issues were identified during the inspection. Of the three people using the service who returned surveys, the majority said that the home was clean and fresh. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 23 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for ensuring that only suitable staff are employed within the home are good as are the opportunities provided for staff to complete a recognised qualification in care. This will help to ensure that only safe staff are employed and that they have the skills and knowledge they require to provide people with good quality care. EVIDENCE: There are rotas showing which staff are on duty and at what times. It is Southern Cross Healthcare policy to provide their homes with an extra 10 over and above the overall establishment hours to take account of sickness and holidays. However, on reviewing staffing levels at the home, the temporary manager found that staff sickness had led to shortfalls in the rotas. Ms Douglas had been able to confirm that whilst every effort had been made to cover these shifts this had not always been possible for a variety of reasons. The Commission takes the view that reduced staffing levels due to uncovered shifts has the potential to have a detrimental effect on the welfare of people living at the home. Also, given that six of the seven staff that returned surveys said that there are only ‘enough’ staff on duty ‘sometimes’, and Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 24 response times to requests for assistance using the nurse call system are slow, this would suggest that staffing levels need to be reviewed further. Some people’s families have also identified staffing levels as an issue during a recent relatives’ meeting, and it was identified as a concern in two surveys returned to the Commission. However, it is evident that Ms Douglas has taken this matter seriously and has already put arrangements in place to recruit to vacant posts. Ms Douglas said that during the recent relatives meeting she had explained how staff were deployed within the home as well as the overall numbers of staff that should be on duty at any one time. She also said that she had reassured families that any shortfalls in staffing would be immediately covered. The Commission has judged that the temporary manager has made an appropriate response to the staffing concerns that have been raised and is clear about how she intends to address them. Changes have been made to how staff are deployed within the home. This has occurred because the numbers of people cared for on some units has changed. Ms Douglas said that current staff levels are sufficient to meet the needs of the people living at the home as long as the rota is fully covered. The home’s staffing levels are as follows: Ground floor residential unit: 1 senior carer and 1 carer throughout the day. (At the time of the inspection this had been reduced to one carer to take account of empty beds on the unit) 1 carer during the night. Dementia care unit ground floor: 1 senior carer and 2 carers throughout the day. 1 senior carer and 1 carer throughout the night. Dementia care unit first floor: 1 senior and 2 carers throughout the day. One senior and one carer throughout the night. Nursing unit: 1 qualified nurse throughout each 24-hour period. 3 or 4 carers throughout the day. (The size of this unit has been reduced since the last inspection and consequently staffing levels have been adjusted to reflect this) 2 carers throughout the night. Staff have opportunities to obtain a professional qualification in care. To date, nine of the 37 carers employed at the home have obtained a National Vocational Qualification in Care at Level 2. A further ten staff are working Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 25 towards obtaining such a qualification and another nine have enrolled. There are also opportunities for staff to receive extra training. For example, during the inspection staff were observed participating in dementia care awareness training. A member of the qualified nursing staff had completed training in artificial feeding, palliative care and good pressure care management. There are opportunities for staff to complete and update their training in key areas. For example, in the sample of three staff files examined, there was documentary evidence that all staff had completed moving and handling, food hygiene and fire safety training. Two staff had completed first aid training. However, there was no documentary evidence in any of the files examined that staff had received health and safety or infection control training. Arrangements had been made for one member of staff to complete first aid training. The temporary manager said that arrangements had been made to ensure that all staffs’ training is up to date. Of the seven staff who returned surveys: • • • • • • Six said that their employer carries out pre-employment checks. One said that this is not the case; Three said that their induction covered what they needed to know to do their job. Four said that this was ‘mostly’ the case; All said that the training they receive is relevant to their job, helps them to understand people’s needs and keeps them up to date with new ways of working; Two said that they met ‘regularly’ with their manager. Five said that this ‘sometimes’ happens; One said that the ways in which information is shared within the home ‘always’ works well. Five said that this is ‘usually’ the case and one said it was only the case ‘sometimes’; One said they have the skills and experience to meet people’s needs. Six said that this is ‘usually’ the case. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good and there is an awareness of the need to make further improvements ensuring that people’s health and safety is taken seriously and promoted. EVIDENCE: The home does not have a registered manager. However, a new manager has been appointed and the provider intends to submit an application to register this person as soon as possible. At the time of the inspection, a Southern Cross Healthcare Project Manager was overseeing the day-to-day management Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 27 of the home on a temporary basis. This person is appropriately qualified and experienced. Some people’s money is managed and held for safekeeping by the home. All money is pooled and securely held. The provider said that changes to the way in which people’s money is handled are due to be introduced shortly. This will mean that each person living in a Southern Cross Health Care home will have an individual bank account in which their money will be held. A financial profile and supportive care plan have not been completed for each person for whom the home manages their money. Staff do not act as a financial ‘appointee’ for any of the people accommodated at the home. The new provider has introduced systems to assess and monitor the quality of care and services provided at the home. For example: • • • The provider carries out regular unannounced visits to monitor conduct of the home and its staff; The area manager carries out a monthly audit which focuses on home’s performance in such areas as care documentation and maintenance of the environment; The new provider intends to survey people living at Pavilion Court their opinions about how well the home is meeting their needs. the the the for An examination of a sample of staff records showed that two members of staff had received regular formal supervision. Records of the outcomes had been kept. However, one member of staff had not received any formal supervision since the new provider took over in November 2007. All staff had received a recent appraisal and records of these were available. The provider has devised a comprehensive health and safety policy. inspection of the premises revealed no health and safety concerns. example: • • • • • • An For The lift had been serviced on two occasions in 2007 and all hoisting equipment had recently been checked; This includes checks of the temperature of hot water supplied to people’s bedrooms, the condition of window restrictors and people’s wheelchairs; A range of fire safety checks is carried out and there is an up to date fire risk assessment. A tour of the premises revealed no potential fire hazards; The home has current gas safety and periodic electrical installations and wiring certificates; A record of all accidents occurring within the home has been kept. The records checked had been completed satisfactorily; The home has a current waste disposal contract. DS0000071026.V364242.R01.S.doc Version 5.2 Page 28 Pavilion Court 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 3 3 X 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 X 2 Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement Ensure that: • • All senior staff update their medication training; People receive their medication in accordance with the GPs prescribing instructions. Timescale for action 01/10/08 This will help to ensure that people receive their prescribed medication and that they remain healthy and safe. 2. OP18 13(6) Ensure that: • • All senior staff update their safeguarding training; All staff are clear about what action to take to keep people using the service safe. 01/10/08 This will mean that people can be confident that staff know how to keep them safe. 3. OP19 23(2) Replace the kitchen bench tops 01/10/08 located in the unit dining rooms. DS0000071026.V364242.R01.S.doc Version 5.2 Page 30 Pavilion Court Repair the damage to the wallpaper in the dementia unit dining room. This will help to ensure that the premises continue to be maintained in a good condition. 4. OP27 18 Carry out a review of the staffing 01/08/08 levels provided on each unit. Provide written evidence that shows how the levels of staffing provided on each unit: • • Relate to peoples dependency levels; Have taken into consideration that care staff are also expected to provide individual and group social activities. 5. OP28 18 Ensure that at least 50 of the 01/01/09 non-nursing care team have obtained a National Vocational Qualification in Care at Level 2. This will help to ensure that staff have the skills and knowledge required to provide people with a good standard of care that meets their assessed needs. 6. OP38 13 & 18 Ensure that all staff complete 01/12/08 training in the following areas: • • Health and safety; Infection control. Ensure that staff files contain documentary evidence of any training completed whilst working at the home. This will help to ensure that staff have the skills and knowledge required to provide safe care. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 31 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. Refer to Standard OP7 Good Practice Recommendations Ensure that the evaluations of people’s care plans contain a robust description of: • • How effective they have been in meeting their needs; The key events that have occurred in the person’s life during the previous month. Carry out a review of how promptly staff respond to requests for assistance from people who use the nurse call system. Address any issues identified. 2. OP8 Ensure that: • • People’s weight is checked each month and a written record kept of the outcome; Care records contain, wherever possible, the date on which a person last received treatment from their dentist or optician. 3. OP9 Ensure that all staff receive Level 1 medication training as recommended by the Commission for Social Care Inspection. Following the appointment of the activities co-ordinator, undertake a review of the provision of activities within the home. Develop person centred activity plans for people with dementia. Ensure that: • • All staff have read the provider’s safeguarding policy and procedures. Staff should sign the policy to confirm that they have done so; All senior staff update their safeguarding training as DS0000071026.V364242.R01.S.doc Version 5.2 Page 32 4. OP12 5. OP18 Pavilion Court soon as possible. 6. OP19 Carry out a review to determine how the dementia care unit environment can be made more ‘dementia care friendly.’ Ensure that money held on behalf of people is not pooled. Develop a financial profile for each person that covers the following areas: • • • • • • 7. OP36 What the person needs to pay for; A risk assessment of the person’s money management skills; How their money and valuables will be made secure; Documentation of the informal and formal financial support arrangements; Arrangements for contacting relevant people with regards to the management of their money; A money management action plan. 7. OP35 Ensure that care staff receive formal structured supervision at least six times a year. The areas covered should include those referred to in the National Minimum Standards. This will help ensure that staff are well supported, appropriately supervised and aware of their responsibilities in promoting and protecting the welfare of people living at the home. Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pavilion Court DS0000071026.V364242.R01.S.doc Version 5.2 Page 34 - 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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