Inspection on 12/12/07 for Pelham House

This inspection was carried out on 12th December 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 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

Pelham House 26/06/06

Pelham House 25/10/05

Pelham House 19/04/05

Pelham House 12/01/05

Pelham House 20/08/04

Pelham House 04/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Pelham House 32-34 Pelham Road Wimbledon London SW19 1SX Lead Inspector Jean Stuart Unannounced Inspection 12 & 13 December 2007 14:20 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 Pelham House DS0000027227.V344788.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. Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham House Address 32-34 Pelham Road Wimbledon London SW19 1SX 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) 020 8543 8434 pelhamhouseSW19@AOL.com www.pelhamhouse.org.uk Abbeyfield Peabody (sth London) soc. Limited None Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 June 06 Brief Description of the Service: Pelham House is a registered care home for up to twenty-five older people. The home is owned and managed by a voluntary committee of the Abbeyfield Peabody South London Society Limited. Pelham House is a purpose built three storey building in a residential area of Wimbledon. Accommodation comprises of twenty-five single bedrooms, a large lounge, dining room, four bathrooms and eleven toilets. There is a small garden to the rear of the home and a lift to all floors. The home is situated close to the main shopping centre of Wimbledon and the good public transport links served by the area. On the date of inspection the fees charged by the home per week were: £446.25 for a single room £547.05 for enhanced care or respite Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Expert by Experience joined us on 13 December 07 to help get a picture of what it is like to use the service. We spent ten hours speaking with twenty people who were able to tell us about their experiences at the home. The manager and two staff members, and two relatives also contributed. We looked at records and documents that included care plans, risk assessments, medication and food records, also the record of complaints. The home has a new acting manager, Mr Patrick Edwards. Twenty-five survey forms were sent to people using the service, fifteen to relatives and ten to staff. One relative and five staff returned completed surveys. A relative reported that “overall the service was satisfactory”. Another relative said “the quality of care given by staff is excellent”, people living at the home were very complimentary about the care provided. The Expert by Experience reported that “there was generally a happy and warm atmosphere and staff were welcoming”. What the service does well: What has improved since the last inspection? Staff received training in record keeping. The quality of daily recording has improved but this standard must be consistently maintained. Weekly checks are carried out of hot water temperatures. Appropriate stocks of medication are maintained. All people are able to register with a G.P. of their choosing. Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pelham House DS0000027227.V344788.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 Pelham House DS0000027227.V344788.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): 1,3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose would benefit from being produced in different formats and reflect the limitations of the lift. Not all people admitted to Pelham House have their needs appropriately assessed, thus people may receive poor quality care based on the lack of information. EVIDENCE: To improve people understanding of the Statement of Purpose this should be produced in different formats. This should meet the needs of people with dementia. The Statement of Purpose should also detail the limitations of the lift Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 9 with regard to wheelchairs. This will provide a better understanding of the facilities in the home. Six files were seen. Only one had the appropriate assessment completed. The lack of information was confirmed by the acting manager, who stated that he will ensure assessments are completed for the persons living in the home. Pelham House DS0000027227.V344788.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are available but are not always adequate due to poor assessment. Risk assessments must reflect all activities that could place people at risk. Health care needs are met. Responsibility for their own medication can rest with the individual if desired. People are treated with respect. EVIDENCE: The service does not have a clear assessment and care planning process. However people reported that they receive good care and support. A relative reported that “I am quiet satisfied with the care”. Care plans do not always reflect the person’s ability to carry out tasks, the person is placed in a dependent role. Overall statements are based on what Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 11 people cannot achieved rather than what the person can do and the support that is required to achieve. People’s independent living skills are not being developed. People are not regularly involved in the care planning process, they or their representative should be consulted. Care plans for each person are reviewed monthly, and amended by staff as required. Risk assessments must cover all activities including social outings that could place people at risk. Time was spent with a visiting Doctor, the doctor reported that the home enables people who have moved to the home to retain their own G.P. as long as the home is in the catchment area. We found that an optician visits as do the community nurses. It was observed that residents have nicely kept nails and hair. The Expert by Experience confirmed these points. Health care needs are documented and that staff support people as required. The expressed needs of a person are respected. Individuals walk to the Doctors independently. A person chooses to sit away from the group of people at lunchtime. Staff responded sensitively to peoples needs. The medication charts are well maintained, and signed appropriately. Fresh medication was delivered by the pharmacist during this visit. All people had adequate stock to meet their needs. There was training in February in accurate record keeping and there is some noticeable improvement to the quality of the record. However this is not consistently maintained. An issue in July showed a failure to record a person being turned in bed. The failure to record does not safeguard people’s best interests. Pelham House DS0000027227.V344788.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to enjoy a full and stimulating lifestyle with a variety of options to chose from either at home or in the community. The right of individuals to make choices is actively promoted. Families and friends are encouraged to visit and relationships are maintained. Mealtimes are relaxed, food is appreciated and people are helped when required. EVIDENCE: People are encouraged to be involved in a daytime activity of their own choice, according to their individual interests and capability. The Expert by Experience found that found that the home has “a volunteer who attends twice weekly”, and “offers activities in a friendly and relaxed manner”. On the day people were busy making Christmas cards “with obvious enjoyment and a member of staff was also helping”. Other people spend the day in their bedroom, one person attends a local synagogue for social activities. It is planned that an activity organiser will be employed. Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 13 Families were seen leaving the building after visiting their relatives. One person was spoken was very complimentary about the service provided and the kind help from staff. The food in the home is to a satisfactory quality and meets the dietary needs of people. One person spoke of their dislike of bacon or pork. When this is on the menu they have chicken. This was confirmed by the kitchen. The record of food served must reflect this. The Expert by Experience confirmed that “Fresh table napkins were provided” “Meals were nicely presented”. Some people are helped to eat. The Expert reported “most people seem to enjoy the meal” but questioned “the wisdom of serving spaghetti to people who may have problems manipulating a fork to eat it”. Meal times were observed to be unhurried. For one person the cutlery and crockery used for the meal did not meet their needs. The Expert by Experience confirmed this. The manager stated that an appointment has been set up for this person with the occupational therapist for the person’s daily living activities to be assessed. Observations on the day suggest that a second person should also have their needs assessed. We saw that some people take their meals in their own room, other people sit in the dining area some of tables for four people other people on smaller tables. Pelham House DS0000027227.V344788.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals know how to make a complaint. People feel safe and supported. The complaint procedure is supplied to everyone living at the home. Staff are trained in safeguarding adults. EVIDENCE: One person who had only just moved to Pelham House said a good thing about being here is that they feel “secure”. They will not be harmed. The complaint procedure is in the Statement of Purpose/service users guide, but is not available in any alternative formats. Different formats would help people with different levels of understanding to comprehend the procedure. One person informed the Expert by Experience that it is easy to raise issues of concern but “nothing will change though” another person said that staff are “always ready to listen and respond”. A relative reported that they know how to complain. The service has received one complaint since the last inspection, which was examined under the Protection Of Vulnerable Adults guidance. Staff records indicate they have received training in abuse ands neglect, to minimise the risk to people. Pelham House DS0000027227.V344788.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment is clean, safe and comfortable. However the needs of people who use a wheelchair are compromised by an inadequate size lift. An additional person cannot travel with the wheelchair user and as such cannot ensure people’s safety. EVIDENCE: People are positive about the environment. One person said they are “very comfortable”. The Expert by Experience found that “the communal area was pleasant with furniture arranged in a homely way”. As far as possible the environment provides for the individual requirements of people. Bedrooms are Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 16 personalised by some people, with pieces of their own furniture and pictures on the walls. Bathrooms have been adapted to meet the needs of people with disability. There are showers and baths in the assisted bathing areas. These areas are not functional and not homely. The Expert by Experience found the bathrooms and toilets to be “bleak and very institutionalised”. The home should think about how they can improve the environment in these areas. One relative stated that her parent would like to have separate sitting and dining “facilities for the more able bodied and alert residents”. The lift is of limited size. For a person who uses a wheelchair a member of staff will remove the footplates, and the person will then to use the lift alone. There is no room for a member of staff and the wheelchair. A person of an independent nature reported that they feel able to use the lift alone, and it causes them no concern. Three wheelchair users were seen on the day. People are adaptable and made the situation work for them. A relative stated “The lift is not big enough for wheelchairs”. The limitations on the use of the lift should be clearly stated in the Statement of purpose so that people clearly know whet they are to use. The home was well lit, clean and tidy and smelt fresh adequate. A relative confirmed this. Pelham House DS0000027227.V344788.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service follows good recruitment procedure. Training is prioritised and staff have the necessary skills for the job. People feel that they know the staff team well. EVIDENCE: A relative reported that the “staff are so kind and helpful”. Another person said, “staff are always around when needed”. A relative reported “the staff are wonderful” A comprehensive recruitment procedure is now followed. We saw four staff on duty plus the acting manager who is a registered nurse. The senior person on a shift is a nurse with other people holding or working towards the National Vocational Qualification level two. A person was on duty in the kitchen. There are enough people to meet the health needs and welfare of people. The record of training shows that staff have completed training in all the mandatory areas. The format of this record lacks clarity and could be improved. Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 18 We saw that staff were kind to people. The Expert by Experience found staff to be “friendly but a little institutionalised, forgetting that each person is an individual”, believing that staff should have more interaction with people rather than “a focus on tasks”. Pelham House DS0000027227.V344788.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new acting manger has the necessary skills and qualifications to discharge their duties. The acting manager has a clear vision and is searching for continues improvement to the service in the best interests of the people. The management of people finances for people who cannot handle money is improved. Pelham House follows safe working practices. EVIDENCE: There is a new manger who must commence the registration process. The acting manager has suitable skills to provide care for older people. The new manager is very person focused and to have settled in well and people Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 20 responded very positively to him. The acting manager is already casting a fresh eye on working practices to ensure they are in the best interests of people. He plans to improve record keeping including care planning , daily recording, and risk assessment, also to consider how meals are provided and how a more flexible pattern of eating can be offered. The Expert by Experience was impressed by “ his commitment and determination to improve existing services”. A revision of how people’s money is handled has recently taken place. For people who cannot handle their own finances the individual, or their representative will be invoiced concerning the outstanding monies. Staff training is also given on essential areas such as moving and handling, infection control and fire safety. This provides staff with the knowledge and expertise to provide a feeling of safety for both people at the home and other staff on duty. Water temperatures are recorded regularly, different taps are used and a satisfactory temperature was noted on all tests. This is the responsibility of the maintenance person. “Evac” chairs for use with people who have a disability in the event of fire were noted at the on stairwells, staff training has been given for their use. Pelham House DS0000027227.V344788.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 2 x 1 x x x 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 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 22 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 2 3 Standard OP3 OP7 OP7 Regulation 14 (1) 15 13(4)(b) Requirement To receive appropriate care the home must ensure peoples needs are appropriately assessed The home must ensure quality care through good assessments and care planning. The home must ensure that risk assessments are completed and any activity is free from avoidable risks. The home must keep a record of food served reflecting a balanced diet and any special needs. The provider must ensure that a suitable person is appointed to run the home and the registration process commenced. Timescale for action 30/06/08 30/06/08 28/02/08 4 5 OP15 OP31 Schedule 4 (13) 8 28/02/08 28/02/08 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 YA1 Good Practice Recommendations To improve people understanding of the Statement of DS0000027227.V344788.R01.S.doc Version 5.2 Page 23 Pelham House 2 YA1 Purpose this should be produced in different formats. The Statement of Purpose should detail the limitations of the lift. This will provide a better understanding of the facilities in the home. Pelham House DS0000027227.V344788.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Pelham House DS0000027227.V344788.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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