Inspection on 19/04/05 for Pelham House

This inspection was carried out on 19th April 2005.

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

Pelham House 12/12/07

Pelham House 26/06/06

Pelham House 25/10/05

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 Louise Phillips Unannounced 19 April 2005 10:10am 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 House Version 1.10 Page 3 SERVICE INFORMATION Name of service Pelham House Address 32/34 Pelham Road, Wimbledon, London SW19 1SX 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) 020 8543 8434 020 85439688 Abbeyfield Peabody Mrs Mavis Louise Stewart Care Home (CRH) 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Pelham House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th January 2005 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 for service users 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 the floors. The home is situated close to the main shopping centre of Wimbledon and the good public transport links served by the area. Pelham House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and took approximately 5.5 hours. The inspection was carried out because the home has not been inspected since the January 2005, and a new manager has been running the home since that time. A tour of the premises took place and staff and care records were inspected. Seven of the staff on duty on the day were spoken to. Five of the twenty-five service users were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The home needs to work on the service users files with regard to ensuring that the care given to individuals is reviewed monthly. In the files the home also needs to ensure that correct practice is implemented when recording in the Pelham House Version 1.10 Page 6 daily notes of service users. Environmentally the service is warm and inviting, apart from the toilets where there are no lampshades and the hallways where the carpets are stained with bleach. Requirements have been made to address these areas. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pelham House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Pelham House Version 1.10 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 standard(s) 1, 3 and 4. Standard 6 is not applicable to this service. There has been progress made to update the Statement of Purpose. There is good evidence that service users are assessed appropriately prior to their moving into the home. EVIDENCE: Since the last inspection the Statement of Purpose has been updated to include details regarding the skills and qualifications of the staff team and the correct contact details for the CSCI. There is a well-presented Service Users Guide available at the service that provides detailed information about the services offered by Pelham House, including the clear criteria for admission to the home. Five service user files were examined and found to include an adequate needs assessment carried out by a social worker. Each file contained an application form from the service user and there was evidence to indicate that an assessment by the home manager has been carried out to ensure that the needs of the service user can be met. Pelham House Version 1.10 Page 9 Pelham House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 The health needs of the service users are well met, though the care provision and plans need to be reviewed more frequently. The record-keeping in service users daily records is poor. EVIDENCE: The inspector met with a senior carer to examine the service user care files. On this occasion five files were examined. Each file was found to be in good order with a copy of the application form and needs assessment by the social worker that introduces the reader to the service users’ needs. Following this there are individual plans of care for each service user which were seen to be drawn from the original care needs assessment and the care planned in accordance with the activities of daily living. Each care plan was dated as being reviewed every three months. Some work needs to be done in this area as care plans should be reviewed monthly and a record maintained of who has been involved in the review and the date for subsequent reviews. It was discussed with the senior carer that the care plans could benefit from being separated onto a different sheet for each care to enable space and accurate recording of reviews, the outcomes and for any amendments made. Pelham House Version 1.10 Page 11 Adequate records are maintained of GP, dentist or chiropody appointments and any referrals made to other professionals such as physiotherapists or occupational therapy services. The daily records for each service user were found to contain areas of bad practice where the entries had been amended through the use of Tip-ex or areas of writing covered over with a white sticky label and a new entry made over the top. It is recommended that any changes to entries should be made clear by a simple line put through the original wording, a reason given for the change and this is dated and signed by the person carrying this out. On the day of the inspection a new service user was being admitted to the home. The manager and administrator were observed giving a warm welcome to the service user and outlining the admission processes to be followed to ensure that she settles in comfortably. Pelham House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The staff and volunteers have a good understanding of the service users’ support needs. Support with activities is offered in such a way as to promote service users individual needs and interests. EVIDENCE: The administrator for the service showed the inspector around the home. Outside the lounge area on the ground floor there were a number of photographs displayed of activities that have occurred in the home since the start of the year; including cooking, visits by an accordion player and the recent party of a service user celebrating their 100th birthday. The administrator discussed that the home benefits from a voluntary activities coordinator and members of the trustee committee who visit the home and conduct group activities with the service users. Feedback sheets from service users are collated and given to the activities coordinator to enable the planning of future events and groups based on the likes and dislikes of those living in the home. A detailed report from the activities co-ordinator to the home management committee was observed. Examination of this provided her feedback on the success of recent activities, plans for future outings and visiting performers to Pelham House Version 1.10 Page 13 the home. The report also included some positive suggestions that are stimulating for the service users, which are for the staff team to implement in the absence of the co-ordinator. It would seem that staff are proactive in this as they were observed conducting a keep-fit group with the service users on the morning of the inspection. It was observed that the visiting and involvement of relatives is actively encouraged by the home. This was evident where in the process of a new service user being admitted to the home there was good telephone contact with the relatives prior to the service users’ arrival at the home. Once the service user had arrived she was able to arrange with the manager that her relatives take lunch with her in the privacy of her room. The home has dedicated kitchen staff. The resident chef at Pelham House has been at the home for a number of years and demonstrated a sound understanding of the nutritional needs of the service users. The chef showed the four-week rolling menu that included a choice of breakfasts, lunches and evening meal/ snack. The chef discussed his responsibilities in relation to ensuring that appropriate checks are carried out on the fridge and freezer temperatures. The record-keeping for these checks was observed and found to be well maintained and up-to-date. The inspector observed lunch being served in an unhurried manner, with staff offering assistance where necessary. The inspector was pleased to observe that there is a recently installed tap and sink in the dining area which enables the service users access to freshly filtered and chilled water throughout the day. Pelham House Version 1.10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints procedure and format for the recording of complaints. EVIDENCE: There is a satisfactory complaints procedure in place at the home, which is included in the Service Users Guide. A record is maintained for any complaints received at the home and the outcomes of these. The home maintains a comprehensive record of all staff that have received training in the Protection of Vulnerable Adults. The manager informed the inspector that all new staff at the home receive training in abuse awareness during their induction period. Pelham House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of décor in the service users bedrooms is tasteful in appearance. The hallway carpet is stained and needs replacing. EVIDENCE: A tour of the building was carried out and the home was found to be tastefully decorated, with individually decorated bedrooms and a comfortable lounge and dining area. One service user spoken to said that she liked the home, stating that “… it’s alright here, there’s lots of space to move about…”. The previous inspection required that the hall carpet be replaced due to noticeable bleach stains. It was observed that the carpet had not been replaced and the Responsible Person discussed that there is a plan to re-carpet all the hallway areas of the home over the next year. The previous inspection also required that the lampshade in the first floor toilet be replaced. On this inspection it was noted that there are no lampshades in Pelham House Version 1.10 Page 16 any of the toilets. It is required that these are installed to ensure that the areas are more homely for the service users. The home has domestic staff who maintain the cleanliness of the home to a good standard. Pelham House Version 1.10 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 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 and 30 The information contained in the staff files is good and demonstrates that the recruitment procedures protect service users. The home is proactive in the training of staff. EVIDENCE: The manager stated that the home currently has a full complement of staff, consisting of a senior care officer, three senior carers, carers, an apprentice carer, and dedicated kitchen, maintenance, domestic and laundry staff. The home has also recently recruited more bank staff to cover staff absences. The staff and volunteer files were found to be well maintained and contain all the relevant information required by the Care Homes Regulations 2001. The three staff files examined also contained a statement of the terms and conditions for each staff member and all correspondence relating to their interview and offer of employment. At the time of inspection the home had an apprentice carer employed who works part-time at the home whilst undertaking the NVQ level 2 in Care at college. Appropriate documentation in relation to their induction, role and responsibility was seen included in their file. During the inspection the apprentice discussed at length his work and career ambitions to become a nurse, he further discussed that he enjoys working at the home and feels well supported by the staff team. Pelham House Version 1.10 Page 18 The home has been working well to meet the standard of ensuring that all staff have an NVQ in Care, with five staff having obtained an NVQ level 3 and four with a level 2 in care. The staff files further demonstrate that staff undertake training in fire safety, moving and handling and abuse awareness. Pelham House Version 1.10 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 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 and 38 The manager has a clear understanding of the service user needs and areas for improvement in the home. EVIDENCE: The manager discussed that she has worked at the home since 2002, when she joined as a senior care officer and took up the current post in January 2005. An application to be the Registered Manager has been received by the CSCI and is currently being processed. The manager is suitably qualified for the position and demonstrated that she is knowledgeable about her role, with a good awareness of the areas of improvement that are required for the home in regard to the environment. Two members of staff spoken to stated that the approach of the manager is good, describing that she communicates that the needs of the service users Pelham House Version 1.10 Page 20 are paramount, also that she delegates work to encourage staff to take on more responsibility. Documentary evidence was seen to demonstrate that fire drills are carried out every 2-3 months. The fire alarm call-points are tested weekly on a rollingrota of a different call-point each week. The last fire inspection certificate was dated 6th March 2003. The inspector has arranged that the local fire authority visit the home to provide advice for the safe running of the fire system in the home. Gas safety records demonstrate that a check has been carried out in the past year. The Responsible Person discussed that portable appliance testing is carried out though no records are currently maintained for this. The storing of documentation relating to service users and staff was found to be secure, however please refer to Recommendation 2 regarding the daily records maintained for service users. Pelham House Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 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 x x 2 2 Pelham House Version 1.10 Page 22 YES 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 OP19 Regulation 23(2)(d) Requirement The Registered Persons must esure that the hall carpet is replaced (previous timescale of 28/02/05 not met) The Registered Persons must ensure that all areas are reasonably decorated, with specific reference to the installation of lampshades in the toilets The Registered Persons must ensure that the portable appliances are checked annually, and a record maintained of this (previous timescale of 28/02/05 not met) Timescale for action 30/11/05 31/05/05 2. OP38 13(4) 31/05/05 17(2), Schedule 4 (14) The Registered Persons must 31/05/05 ensure that the fire system is serviced and a record maintained RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pelham House Version 1.10 Page 23 1. 2. OP7 OP7 The Registered Persons should ensure that care plans are reviewed monthly. It is recommended any changes to entries in daily records of service users are made clear by a simple line put through the original wording, a reason given for the change and that this is dated and signed by the person carrying this out. Pelham House Version 1.10 Page 24 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. Extracts may not be used or reproduced without the express permission of CSCI Pelham House Version 1.10 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!