CARE HOMES FOR OLDER PEOPLE
Pelham Grove Lark Lane Aigburth Liverpool L17 8XD Lead Inspector
Leila Mavropoulou Unannounced 08 August 2005 - 11:00 am 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 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. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Pelham Grove Address Lark Lane Aigburth Liverpool L17 8XD 0151 727 0758 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Home Properties Ltd Irene Hughes CRH PC only 35 Category(ies) of OP registration, with number of places Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 35 Personal Care Beds. Two named persons under 65 years old may be accommodated, within the overall total of 35. The Manager will obtain an NVQ Level 4 qualification in management and care, or the equivalent. Date of last inspection 7th January 2005 Brief Description of the Service: Pelham Grove is a purpose built care home in the Sefton Park area of Liverpool. It is situated off Lark Lane and is very close to various local amenities and public transport. The home provides personsal care for 35 Older People over the age of 65 years. The home is staffed twenty-four hours a day and many of the staff have completed their NVQ level 2 Care Award. All acccommodation is provided in single bedrooms on two floors. The accommodation on the upper floors can be accesed easily by the passenger lift. Some of the bedroom are large and can be shared on request of the resident e.g. for couples. In addition the home has many aids to promote the safety of the residents such as: grab rails, assisted baths, hoists, call system etc. The home has a dining room and lounge on the ground floor and additional sitting room on the first floor,which is also used as an activity room. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which lasted for five hours. During this time information was obtained through talking to residents, visitor and staff and various records were inspected such as: residents’ records, fire records, risk assessments of the building and the residents, staff records etc. to assess if the home was complying with various regulations and to evaluate the quality of care provided at the home. What the service does well: What has improved since the last inspection?
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 6 The registered manager appears to be more confident in her role, which was confirmed in discussion with staff. The staff members spoken to feel that the staff are working as a team. Also, the increase frequency of staff meetings where staff feels they are able to express their opinions freely has led to improvements in staff morale. Since the last inspection the manager has been able to fill the staff vacancies. Thus, reducing the use of agency staff to promote continuity of care to the residents. In addition staff sickness has also reduced. Many of staff have attended various training courses since the last inspection such as: Protection of Vulnerable Adult, Infection Control, Managing Challenging Behaviour and Health and Safety which the manager feels has had a direct impact on the improvement of quality of care provided to the residents. The residents’ medication records have improved significantly since the last inspection to promote the health and safety of the residents. Part of the lounge on the first floor has been organised to accommodate various activities such as: a keyboard, a pool table, dart board etc., which the residents are able to use on their own or with the staff. What they could do better:
The home could improve the heath and safety of the residents by undertaking risk assessments for each of the resident’s bedrooms, at the same time of the monthly environmental audit. The lock on the resident’s bedroom door could be open by staff using a master key, which is kept by the person in charge of the shift. The manager should review this as in an emergency the time it would take to obtain the master key, significant harm to the resident may be prevented if staff had immediate entry to residents bedrooms in an emergency. Assessment of residents needs should be ongoing to ensure that they have the necessary aid to promote their dignity or re-assessment to find out if the placement at Pelham Grove continues to meet their needs. Currently, two residents behaviour indicate that an assessment is required to promote their wellbeing and others in the home. Discussion with the manager indicated that some residents do not wish to participate in any of the activities organised. The manager must be able to demonstrate instances when staff have attempted on a regular basis to engage those residents in any social activity to meet their emotional and psychological needs. Formal staff supervision should be implemented to ensure that all staff have the necessary understanding and skills to carry out their roles effectively. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 7 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. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 9 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 standard(s) 1,2,3,5,6 The staff from the care home assesses the service user prior to admission to ensure that the home has the necessary resources and skills to meet the assessed needs of the resident. EVIDENCE: Southern Cross recently purchased the home and the home’s Statement of Purpose has not been changed to reflect the change in ownership. The staff at the care home assesses the prospective residents needs prior to offering the person a place at the care home. The residents’ files showed that this assessment could take place at the home during a visit or where the person is living at the time e.g. in their own home or in hospital. Wherever possible the prospective resident is encouraged by the management in the care home to visit the home before making a decision to accept a place at Pelham Grove. This also makes settling easier, as the resident is familiar with some of the residents and staff. All residents are issued with a terms and conditions of their stay and are informed when the weekly fee is increased as evidenced in the residents financial file. However, the weekly fee must be written in the service user contract in the space provided.
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 10 The home does not provide intermediate care. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, Overall the residents’ health needs are being met. However, significant improvements could be made through early assessment and improve record keeping. EVIDENCE: Each of the residents have a service user plan showing how their assessed needs are to be met by the staff at the care home. Many of the residents’ care plans are signed either by the resident or their family. The care plan is review monthly by the resident key worker. The residents’ files show that the residents visit the optician, dentist and chiropodist regularly and a record of visit are kept in the resident file. The residents in the care home are able to administer their own medication if the staff assesses the resident as being competent to do so safely. The record keeping and stock of residents medication kept in the care home has improved significantly since the last inspection. The number of omission of signatures when medication was administered was greatly reduced since the last inspection. Observation of the manner in which staff assisted residents with various aspects of daily living such as: accompanying residents to the toilet, the manner in which the staff spoke to residents, some of the residents right to
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 12 privacy by having a key to their bedroom etc. demonstrated that the residents are treated with respect and dignity. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12,13,14,15 The staff supports the residents to use local community facilities and maintain contact with family and friends to promote their independence and emotional wellbeing. EVIDENCE: The location of the home enables many of the resident of Pelham Grove to access the community facilities independently as it is within a short walking distance to the shops, pub, betting shop etc. The residents can receive visitors throughout the day. One visitor spoken to said “that she had no complaints about the services offered at Pelham Grove as her mother health had improved greatly since she moved into the home”. Overall, the entire family is happy, as they are able to visit their mother when they wish, as there is no restriction of visiting times and are able to spend quality time with her. Observation and discussion with some residents show that they are able to exercise control over all aspect of their daily lives. This was evidenced by some residents choosing to buy microwave meals, which they could have when they wish, as they had a microwave in their bedroom. Other residents were seen spending time in their bedroom watching television programme of their choice, videos or listening to music, whilst, others were sitting out in the garden and the communal areas. The home employs an activities person twenty hours per week to organise various activities for the residents, which
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 14 they enjoy as evidenced by the photographs displayed around the home and discussion with the residents. The activities include: snooker, tea dancing, outing in the mini bus and handicrafts. All residents are provided with three meals a day and drinks at regular intervals. A cooked breakfast is provided daily with a light meal at lunchtime and the main meal in the evening. The home would provide special diets for residents as required. Some of the residents indicated that more choice could be offered at lunchtime. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16,18 Some staff have recently attended a training course on the protection of vulnerable adults to ensure the safety of the residents. EVIDENCE: The home has various policies and procedures in place to protect the residents from all forms of abuse. This is achieved through staff attending training courses and increase staff awareness of the various ways they could raise concerns of abuse such as through the home’s complaints procedure, the Whistle Blowing policy. Discussion with staff indicated that they felt able to approach the manager with any concerns they have regarding abuse. The home has not received any complaints since the last inspection. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,20,21, 26 The home has a planned maintenance and renewal programme and complies with fire and environmental regulations to promote the health and safety of the residents. EVIDENCE: The tour of the building and discussion with the manager showed that the management of the home ensure that the building is maintained both internally and externally. All parts of the home are easily accessible to the residents. A number of bedrooms are awaiting new flooring to be fitted to meet the changing needs of the resident, as some bedrooms and areas of the corridor there was a malodour even though the staff were cleaning the areas concerned regularly. The fire officer and environmental officer visited the home recently and all recommendations have been met. The home has a dining room on the ground floor, which is bright and furnished with good quality furnishings. However, it is not large enough to for all residents to have their meal in one sitting. The size of the dining room/arrangement makes it difficult for residents using wheelchairs and other
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 17 aids to move easily around the room. The furnishings in the two lounges are homely and the areas could be used for different activities. Various aids are provided in the home to support the residents’ independence such as: grab rails, passenger lift, handrails etc. Where residents require assistance with moving, lifting aids is provided for the safety of both the resident and staff. Staff are provided training in the use of lifting equipment, which is regularly updated. The home has a number of assisted of baths to promote the safety of the residents. The baths and toilets are situated close to the residents’ bedrooms and the communal areas to promote their independence and dignity. The home’s laundry facility is located away from the food preparation area and policies and procedures are in place to minimise the spread of infection. Recently, some of the staff attended a training course on Infection Control. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The staffing level in the care home should be reviewed to reflect the dependency level of the residents in the care home to ensure that their assessed needs are met. EVIDENCE: The home has appointed permanent staff to all of its care vacancies and sickness level has reduced resulting in continuity of care provided to the residents. An accurate record is maintained of hours worked by staff and in what capacity. The competence of the staff group is demonstrated by over 50 of the staff have the NVQ level 2 in Care Award and others are working towards achieving this qualification to improve the quality of care provided to the residents. Discussion with the staff indicate that they are aware of the limited knowledge and skills in caring for the residents and would seek advice from specialist health professionals when necessary such as: the District Nurse, GP, Community Psychiatric Nurse, Continence Adviser etc. as evidenced in some of the residents’ files examined. The staff files inspected showed that the home a stringent recruitment procedure to ensure that the every effort is made by the home to protect the residents through obtaining Criminal Records Bureau checks for staff before commencing employment and two written references. All staff are issued with a job description and are given a written terms and conditions of employment. The staff files show that new staff is inducted into their role. However, the manager must ensure that the staff induction is accompanied by supervision at
Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 19 regular interval to make sure the staff is confident and competent in carrying the tasks expected of them. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36,37 38, The home is managed effectively to promote the health and safety of the residents. EVIDENCE: The manager since her appointment is developing the skills required to carry out the roles and responsibilities effectively through attending various training courses e.g. Protection of Vulnerable Adult, Infection Control etc to improve her knowledge base, together with regular supervision by the regional operational manager. In addition her computer skills has improved enabling her easier access to information and communication with senior management in the organisation. Discussion with the staff and visitor commented positively on the style of management adopted by the manager, as they feel able to approach her with any concerns. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 21 Currently, the manager does not provide formal supervision to staff as required by the National Minimum Standards. This must be implemented to meet the requirements of one of the standards, which the home should meet. The home maintains detailed record of expenditure of residents monies left for safekeeping with the management of the home. All of the residents’ monies and records are kept in a secured place. Inspection of the various records such as residents and staff files showed that the files are well maintained. To promote the health and safety of the residents all staff receive training in food hygiene, fire awareness, moving and handling and first aid and the manager maintains a record which shows at glance when it is necessary for these training to be updated. In addition weekly fire and monthly hot water checks are carried out and all equipment is service at regular intervals as required by the manufacturer or the Health and Safety Executive as evidenced by service agreements and certificates provided. Detailed monthly risk assessments are carried out of the building, however this should also include the residents bedroom to promote their safety. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 2 3 3 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 2 3 2 Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 23 no Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The registered person must ensure that the details in the Homes Statement of Purpose is reviewed regularly to show any changes. The registered person must ensure that the service user terms and conditions state the weekly fee,which must be paid by the service user. The registered person must ensure that the health needs of the service user is reviewed and make proper provision for the health of the service user by reassessment of the service user health needs, as changes are observed. The registered person must ensure that accurate records are maintained of all service user medication administered in the care home. The registered person must ensure that all staff are appropriately supervised. The registered person must ensure that a risk assessment is carried out in the service users bedroom as well as the communal areas of the building
F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Timescale for action 15th October 2005 15th October 2005 15th October 2005 2. 2 5 3. 8 12 4. 9 13 15th October 2005 30th October 2005 15th October 2005 5. 6. 36 38 18 12 Pelham Grove Version 1.30 Page 24 to promote their safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 15 20 Good Practice Recommendations The registered person should discuss with the residents changes they would like to the lunchtime menu. The registered person should review the dining arrangment in the care home to ensure that all service users could be seated in the dining room at the same time if they so wish. Pelham Grove F52 F02 S25190 Pelham V243922 080805 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, Campbell Square 10 Duke Street Liverpool, L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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