Inspection on 25/05/06 for Pavilion Residential Home (The)

This inspection was carried out on 25th May 2006.

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) 24/05/07

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 Ray Coonan Unannounced Inspection 25th May 2006 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.V289101.R01.S.doc Version 5.1 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.V289101.R01.S.doc Version 5.1 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.V289101.R01.S.doc Version 5.1 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 s they are accommodated at the home. 3rd November 2005 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 comprises of 20 en-suite bedrooms and 6 bedrooms without en-suite facilities. These are 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. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place over a period of just over six hours on the 25th May. The acting manager, Lynn Richards, was present throughout the visit and there was the opportunity to talk with several staff on duty at the time. There was also the chance to meet with many of the Home’s residents during the day, though no relatives or visitors were spoken to on this occasion. Most parts of the premises were viewed, including several of the residents’ bedrooms. A variety of documentation was also examined such as individual care plans, staff files, training records, staffing rotas and relevant policies and procedures. What the service does well: What has improved since the last inspection? The Home has benefited from a more consistent management approach in the past six months with training and monitoring of staff managed in a purposeful manner. Recent developments in care planning systems are now firmly established with assessments and care plans more clearly set out. Recreational and activity programmes are also more varied and planned. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 6 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. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 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.V289101.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a suitable range of information about the Home and satisfactory assessments are made in order to develop relevant plans of care. EVIDENCE: The Home’s statement of purpose was seen and this has been updated to reflect current staffing and training arrangements, and this together with information on the Home is given to prospective residents and their relatives. New contracts/terms and conditions have been established for all residents. Appropriate pre-admission information is obtained by the Home and resident files demonstrated that this informs initial assessments made by the Home and the development of care plans. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff contributed to a warm and friendly atmosphere at the Home and residents commented positively on their care practice. Residents benefited from an overall purposeful approach to assessing their health and personal needs, and care plans were suitably kept under review and promoted. EVIDENCE: Residents were generally very positive in their comments about the care and attitudes of staff, and were observed interacting in a friendly, patient and respectful manner. Discussions with staff showed that they were clear about the values and principles of their role and committed to the best interests of residents. A sample of three individual care plans was examined and these were in good general order with a wide range of relevant risk assessments made and kept under review on a regular basis. There was good detail in the actual plan of care and clear instructions for staff. There was some inconsistency in the Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 10 assessment of social care and emotional needs of residents and a shortfall in detailing any actions in this area, plans focussing on the physical aspects of care. However, records of each resident’s participation in leisure activities were kept. Care plans demonstrated that the health of residents was suitably monitored at the Home. There were clear ongoing assessments in place regarding such areas as nutrition, skin integrity and residents weight was regularly checked. Records of contacts were kept of visits from local Doctors, community nurses, chiropodist, optician and other community health services. Any notes from district nurses were maintained on specific files. There was evidence of appropriate reviews of medication for each resident and regular audits of the arrangements for administration and storage of medicines were made by the local pharmacist. The Home has a separate locked medication room and stock levels were at appropriate levels. Records for the administration of medicines were satisfactory and disposal records were also maintained. Only senior staff are involved in administering medication and most have completed distance learning courses in this area. A further refresher course in the safe handling of medication has been arranged for next month. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an active approach to providing recreational opportunities at the Home and family contacts are suitably encouraged. Menus have been reviewed and residents’ views are now beginning to be obtained in a more systematic manner. EVIDENCE: At the time of the last inspection the activity coordinator had only been in post for one month. A more developed and varied programme of recreational activities are now in place with the coordinator coming in every week day afternoon. Various games are played in order to encourage a degree of physical exercise, there was occasional bingo, some reminiscence work and various music and entertainer sessions arranged. Two residents access local shops and facilities independently, though otherwise there is not a great deal of contact with the local community. However, the Home is organising an open day in July and is hoping to organise more trips out. None of the residents use local churches on a regular basis, though clergy visit the Home, usually on a monthly basis. There were no residents with any specific cultural needs. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 12 Individual care plans were supplemented by a resident diary, developed by key workers, which was based on routines of daily living and detailed residents preferred routines and wishes in such areas as food likes/dislikes and preferred times for going to bed and waking. There was evidence of resident and family involvement in this process. Care Plans also kept records of visits by family or friends and residents confirmed that this contact is encouraged at the Home. Since the last inspection a three weekly menu has been established and the manager has begun a system of ongoing questionnaires for residents in order to gauge their views on meals at the Home. Residents spoken to were generally satisfied with the standard of meals without being effusive. Alternatives are made available and special dietary needs/preferences are catered for. However, alternatives to the main meal were not always recorded. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are made aware of residents rights and entitlement to protection and relevant training is provided. EVIDENCE: The Home has an up to date and accessible complaints policy and procedure. The Home has had no formal complaints since the last inspection and records showed that several minor complaints raised by residents had been responded to appropriately. No complaints have been made directly to the Commission. The Home continues to arrange training opportunities for staff in the area of protection and abuse. Staff interviewed, including two staff taken on in the past few months, had received input in this area. All showed a satisfactory awareness of the issues and were very clear in their understanding of responsibilities to report any concerns or complaints on behalf of residents. The acting manager had a good sense of relevant policies and procedures including local interagency protocols for referral of incidents. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were many areas of the Home that still required redecoration and renewal. Whilst many areas were comfortably furnished there remained aspects of maintenance and practice around the Home that did not enhance the safety of residents. Bathroom facilities were particularly inadequate. EVIDENCE: Most parts of the Home were seen including a sample of residents’ bedrooms. These were comfortably furbished and very much personalised by individual residents. There were many parts of the Home requiring improved decoration though there was no clear works or maintenance plan. Many parts of the Home had cracked plasterwork and paintwork and the ground floor corridor was particularly neglected with large chunks of plasterwork missing on walls. Tiles were missing in the kitchen area. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 15 Bathroom facilities were also in need of improved decoration and several bathrooms were not functioning or being used. For example the bath hoist on the second floor was out of order. In fact all residents, no matter what floor they were on, were only able to use the one bathroom on the ground floor. Lounge areas were satisfactorily furnished and on the day of the inspection a new carpet was being fitted in the first floor lounge. However it was noted that a window in this room was being kept closed by a settee pushed against it. It was also noted that several doors were being propped open rather than have automatic self - closing devices fitted. There were satisfactory aids and adaptations around the Home, such as handrails, raised toilet seats and grab rails, but there had been no progress on the fitting of a loop system, though the manager stated that there were several residents with a degree of hearing impairment who would benefit. The ground floor lounge was also in need of redecoration. The Home had an accessible garden and sitting area at the rear though this was not tidily maintained. The Home’s laundry is on the top floor and was suitably equipped and organised. The Home has separate sluice areas, however, there were no locks on the doors. Cleaning materials and substances were kept securely on the top floor. There were no offensive odours around the Home. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the Home’s purposeful approach to staff development and a systematic recruitment and selection process. Satisfactory staffing levels are maintained. EVIDENCE: Staffing rotas were clear and usually drawn up in a month in advance. They showed that adequate staffing levels were being maintained and though there has been several new staff appointed since the last inspection, no one had left. A sample of staff files were examined and these were in good order with written references and CRB checks taken out. Contracts were also on file. Staff training records were available and a systematic approach has been developed in this area. The provider company have their own training manager and an annual training plan has been produced, with the Home’s manager providing a monthly training report. The acting manager of the Home has also being developing links with the local social services in order to improve the range of courses on offer. Mandatory courses are kept under review and staff confirmed that they are provided with regular training opportunities. Two recently appointed staff were interviewed and are already involved in NVQ training. They also confirmed that they have received a thorough induction process with individual information folders provided. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There is an overall purposeful approach to the management of the Home and Health and safety matters are monitored in a generally systematic manner. EVIDENCE: The current acting manager has been in post for over six months now though a registration application has not been received by the Commission. She has substantial practice experience and is due to start NVQ 4 training in care and management in the near future. The manager is developing consultation systems with residents and a supervision process with staff is also up and running. Staff are also given twice yearly appraisals. The Regional manager visits the Home regularly and provides monthly reports on the quality of services. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 18 An annual health and safety audit is made though there is no formal hazard assessment of the premises. Health and safety records were examined and were in good order with all servicing records up to date. Fire safety testing records were suitably maintained and staff confirmed that they received regular training in this area. Appropriate accident records were kept and were monitored by the manager who provided regular reports to head office. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 1 2 1 2 3 3 2 2 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 2 X 3 X 3 3 X 2 Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP19 Regulation 15 (1) 23 (2) (b) Requirement There must be more consistency in assessing and planning the social care needs of residents. The registered person must ensure that the premises are kept in a good state of repair externally and internally as detailed in the main body of the report (Previous timescale of 28/02/06 not met). The registered person must provide the CSCI with an action plan including timescales for completion regarding the programme of works required (Previous timescale of 28/02/06 not met). The cause of the areas of cracked plaster must be established and the areas must be repaired and made good (Previous timescale of 28/02/06 not met). All bathroom facilities must be upgraded ensuring that the ratio of baths available to the number DS0000020069.V289101.R01.S.doc Timescale for action 31/07/06 30/09/06 3. OP19 23 (1) (a) 31/07/06 4. OP20 23 (2) (b) 31/08/06 5. OP21 23 (2) (b) (j) 30/09/06 Pavilion Residential Home (The) Version 5.1 Page 21 6. 7. OP26 OP25 23 (2) (b) 23 (2) (p) of residents at the Home meets National Minimum Standards Locks must be fitted to the doors of sluicing facilities. The cords to sash windows must be repaired / replaced. From inspection report 28.09.04. and 28/02/06 Safe ways of holding open fire doors must to be put in place, i.e. devices which would allow the doors to close when the fire alarm sounds (Previous timescale of 30/12/05 not met). A hazard assessment of the premises must be completed 31/07/06 31/07/06 8. OP38 13(4) (b)(c) 31/08/06 9. OP38 13 (4) 30/09/06 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. 3. Refer to Standard OP8 OP15 OP19 Good Practice Recommendations A loop system should be considered. Accurate menus should be displayed and records kept of any alternatives provided to the menu of the day. The garden areas should be tidied up. Pavilion Residential Home (The) DS0000020069.V289101.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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