Inspection on 24/05/07 for Pavilion Residential Home (The)

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pavilion Residential Home (The) 25/05/06

Pavilion Residential Home (The) 19/05/05

Pavilion Residential Home (The) 28/09/04

Pavilion Residential Home (The) 19/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Pavilion Residential Home (The) 36 St John`s Road Buxton Derbyshire SK17 6XJ Lead Inspector Rose Veale Key Unannounced Inspection 24th May 2007 10:00 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 Residential Home (The) DS0000020069.V337650.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 Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pavilion Residential Home (The) Address 36 St John`s Road Buxton Derbyshire SK17 6XJ 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) (01298) 71422 01298 73839 Guardian Care Homes Ltd Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered for 1 place in the category of (MD) for (1) named individual for as long as they are accommodated at the home. 25th May 2006 Date of last inspection Brief Description of the Service: The Pavilion Care Home is a large Victorian building close to the centre of Buxton, local gardens and leisure facilities. The home provides accommodation and personal care for up to 32 older people. The home has 20 en-suite bedrooms and 6 bedrooms without en-suite facilities. Accommodation is on 3 floors accessed by a passenger lift. There are 2 lounge / dining areas, one on the ground floor and one on the first floor. The home is served by a central kitchen and laundry. Garden areas are provided although access is limited to the rear garden. Car parking space is provided. Information about the home, including CSCI inspection reports, is available in the main entrance area of the home and on request from the acting manager or provider. Fees at the home range from £427.21 to £482.22 per week. This information was provided in the pre-inspection questionnaire completed by the acting manager and received on 15th May 2007. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 6 hours. The inspection visit focused on assessing compliance to requirements made at the previous key inspection and on assessing all the key standards. There were 23 residents accommodated in the home on the day of the inspection visit. 5 residents, 1 visitor and 4 staff were spoken with during the visit. The acting manager was available for part of the inspection visit due to a pre-arranged meeting. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. A questionnaire and surveys had been completed and returned prior to the inspection and information from this has been included in the body of this report. A random, unannounced inspection of the home took place on 5th October 2006. The purpose of the random inspection was to assess compliance with requirements made at the key inspection on 25th May 2006. The findings of the random inspection are referred to in the body of this report. What the service does well: Residents / their representatives spoken with and those responding to the surveys were generally pleased with the care and support provided and the attitudes of staff. Residents commented that staff were “kind”, and “they come straightaway when I need them”. Relatives commented that staff showed “great tact and understanding” and “they comfort my mother if they feel she is upset”. It was observed that staff generally interacted with residents in a friendly, patient and respectful way. There was a good quality assurance system in place at the home. Regular surveys were sent to residents / their representatives, the results analysed and a report produced to inform residents / their representatives of action taken to address the issues raised. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a good needs assessment process so that residents were confident the home was able to meet their needs. EVIDENCE: The records of 4 residents were examined. All the records included assessment information obtained prior to the admission of the resident. There was assessment information from Social Services and / or from hospitals, plus an assessment carried out by the home. Each record had an individual care plan produced from the assessment information. The survey responses received indicated that most residents had received sufficient information before moving to the home and that their needs for care and support were met at the home. Standard 6 did not apply to this service. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 9 Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a consistent, structured approach to care planning so that residents received care and support to meet their individual needs and preferences. EVIDENCE: The care plans seen included a range of relevant risk assessments, such as tissue viability and nutritional state. Assessments had all been reviewed and updated monthly. The care plans included details of the personal preferences of residents regarding their daily routines and care needs. The care plans mostly covered all the assessed needs of residents. One plan did not include instructions for staff about when and why a particular ‘as required’ medication should be given. All the care plans seen had been reviewed monthly. It was a requirement at the key inspection in May 2006 and the random inspection in October 2006 that care plans should be more consistent in assessing and planning the social care needs of residents. At this inspection, it Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 11 was seen that the records included more information about residents’ social history and preferences. There was some evidence that residents and their representatives were involved in some aspects of care planning, particularly regarding life history and personal preferences. It was not clear that residents and / or their representatives were involved in devising care plans. All the care records seen included a photograph of the resident – it was noted at the random inspection in October 2006 that there were no photographs on the records. There was evidence that residents’ healthcare needs were met with records kept of the input of other healthcare professionals, such as the GP, District Nurse, and optician. The survey responses indicated that most residents felt that they received the medical support they needed. Medication was stored in a small room off the hairdressing room on the second floor. The lock on the store room door did not provide sufficient security. The Medication Administration Records (MARs) were seen and were generally in good order. There were examples of a code letter used on MARs with no explanation in the key. All staff administering medication had received appropriate training. Residents spoken with and those responding to the surveys were positive about staff attitudes and the care provided. Residents commented that staff were “kind”, and “they come straightaway when I need them”. Relatives commented that staff showed “great tact and understanding” and “they comfort my mother if they feel she is upset”. It was observed that staff generally interacted with residents in a friendly, patient and respectful way. Staff spoken with were aware of how to ensure privacy and dignity for residents. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a lack of organised activities for residents so that their social and recreational needs and preferences were not met. EVIDENCE: There was no activities coordinator at the home and the acting manager said this post was being advertised. Care staff were responsible for organising activities for residents. There were comments received on the surveys and on the day of the inspection visit about the lack of activities for residents. Visitors said they were always made welcome and could visit at any reasonable time. Residents spoken with said they could usually follow their preferred daily routines. Residents were encouraged to bring in items from home to personalise their bedrooms. The survey responses indicated that residents were usually pleased with the meals at the home. Residents spoken with said they enjoyed the meals and Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 13 that they were able to have a choice. The menus seen appeared varied and balanced. Residents were encouraged to complete regular food satisfaction surveys and to comment to the cooks on the meals provided. The meal served on the day of the inspection visit appeared appetising. It was observed that one resident requiring assistance with eating was helped in an unobtrusive and sensitive way. Most residents ate in the main dining room which was spacious and pleasant. The atmosphere at lunchtime was quite noisy and busy with care assistants calling out across the room to residents to ask what they would like to eat. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were satisfactory policies in place and good staff awareness so that residents were protected and their concerns effectively dealt with. EVIDENCE: Residents and relatives spoken with and those responding to the surveys nearly all knew how to make a complaint, or who to speak to if they were unhappy. The complaints procedure was included in the Service Users Guide and was displayed in the home. Complaints were recorded with details of the action taken and the outcome. No complaints had been made directly to CSCI. Staff training records showed that most staff had received training about safeguarding adults issues and procedures. Staff spoken with were aware of the correct procedures to follow if abuse was suspected. There was evidence that allegations of abuse were dealt with correctly and promptly. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some progress had been made, there remained areas of the home requiring attention to ensure a safe and pleasant environment for residents. EVIDENCE: Most parts of the building were seen, including some of the bedrooms. Some improvements had been made since the inspection in May 2006. At the random inspection in October 2006 it was noted that new kitchen tiles had been fitted, sash windows had been repaired, lighting had been improved, and some bedrooms had been redecorated. Since October 2006, several bedrooms had been redecorated, new chairs had been provided in the first floor lounge, and devices had been fitted to enable doors to be held open and to close automatically in the event of fire. The acting manager said that it was planned to replace the tables and chairs in the ground floor dining room. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 16 The ground floor bathroom was out of action as the bath was awaiting repair. There were several areas in need of redecoration, including the ground floor bathroom, the ground floor lounge / dining room, and a ground floor toilet. There remained areas of cracked and flaking plaster in the ground floor corridor as noted at the inspection in May 2006. There was a ‘baby gate’ in situ at the kitchen door. The advice of the fire service had not been sought as to the safety of this arrangement. The medication store room had been relocated to a small room off the hairdressing room on the second floor. The door lock was not secure. The advice of the fire service had not been sought to check whether the room should be fitted with a fire resisting door and a smoke or heat detector. The home was suitably equipped to meet the needs of residents, for example, handrails, raised toilet seats, and a bath hoist. As noted at previous inspections, there was no loop system in place to assist residents with limited hearing. The laundry was situated on the second floor and was suitably equipped. It was noted at the random inspection in October 2006 that locks had been fitted to the doors to the sluice rooms, as required at the inspection in May 2006. The home was clean throughout on the day of the inspection visit and the responses to surveys indicated that the home was usually clean. There were comments received that there was sometimes an odour of urine in certain areas of the home. It was found at this inspection that although the home was generally fresh, there was one area where there was an odour problem. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Satisfactory staffing levels, and good systems for recruitment, induction and training ensured that residents were supported by competent staff in sufficient numbers to meet their needs. EVIDENCE: The current staff rotas showed that there were usually 3 care staff on duty for the morning and afternoon shifts, and 2 care staff on duty at night. Care staff were supported by kitchen and domestic staff, plus an administrator. Residents spoken with and the survey responses indicated that residents felt there were usually staff available when needed. Staff spoken with said that staffing levels were sufficient to meet the needs of residents in the home. 2 staff files were examined and both were in good order with all the required information. A recently recruited member of staff confirmed that they had ‘shadowed’ an experienced member of staff as part of their induction. Individual staff training records were kept, plus an overall record of all staff training. Records indicated that most staff had completed all the required training, such as fire safety and manual handling. Some staff had received training about supporting people with dementia. The acting manager said that 35 of care staff had already achieved a National Vocational Qualification Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 18 (NVQ) at level 2 or 3, and that a further 35 were working towards NVQ. The acting manager said that the kitchen staff were also working towards a relevant NVQ. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and there were good systems in place so that the health, safety and welfare of residents was promoted and protected. EVIDENCE: The acting manager had worked at the home prior to taking the manager post towards the end of 2005. The acting manager had not applied for registration with CSCI. The acting manager was working towards NVQ Level 4 in care. Residents and staff spoken with said the manager was “approachable”, and “well organised”. There was a quality assurance system in place that included surveys sent out to residents and / or their representatives every six months. The results of the Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 20 surveys were analysed and a report written noting how issues had been addressed. The report was made available to residents / their representatives. There were monthly visits from the area manager on behalf of the providers. Records were seen of residents personal money held at the home. There were satisfactory systems in place to ensure the money was securely kept and properly accounted for. Records relating to health and safety were sampled and all were up to date. The acting manager carried out a monthly audit of all accidents in the home. As required at the inspection in May 2006, a hazard assessment of the home had been carried out. Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement When residents are prescribed medication to be taken ‘as required’, there must be detailed instructions for care staff as to when and why the medication is to be given. This will ensure that residents receive medication as intended by the prescribing doctor. Medication must be stored securely to ensure the safety of residents. The premises must be kept in a good state of repair as detailed in the Environment section of this report. This will ensure a safe and pleasant home for residents. Original timescale 28/02/06 The advice of the local Fire and Rescue Service must be sought regarding the use of the ‘baby gate’ and the change of use of the small room off the hairdressing room. This will ensure the safety of residents and staff. The acting manager must apply for registration if she intends to DS0000020069.V337650.R01.S.doc Timescale for action 30/06/07 2. 3. OP9 OP19 13(2) 23(2)(b) 30/06/07 31/08/07 4. OP19 23(4)(a) 30/06/07 5. OP31 Care Standards 30/06/07 Pavilion Residential Home (The) Version 5.2 Page 23 Act Part II carry on as the manager of the Section 11 home. The registration process protects residents by ensuring the fitness of the manager to run the home. 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 There should be evidence of the involvement of residents and / or their representatives in devising care plans. This will ensure that care plans accurately reflect residents’ needs and preferences. A loop system should be considered to assist communication for people with limited hearing. Any code letters used on Medication Administration Records should be explained in the key. This will provide clarity and consistency of record keeping and ensure that residents receive medication as prescribed. Arrangements should be made to ensure the identified area is free of offensive odours. This will provide a more pleasant environment for residents, visitors and staff. 2. 3. OP8 OP9 4. OP26 Pavilion Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Residential Home (The) DS0000020069.V337650.R01.S.doc Version 5.2 Page 25 - 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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