Inspection on 25/10/05 for Pelham House

This inspection was carried out on 25th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/12/07

Pelham House 26/06/06

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 Louise Phillips Unannounced Inspection 25th October 2005 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 Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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.V260404.R01.S.doc Version 5.0 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 Abbeyfield Peabody (sth London) soc. Limited Mrs Shirley Hyacinth Elaine Wallace Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 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 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. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day for approximately 4 hours. Time was spent talking to residents, staff and the registered manager of the service. A tour of the premises took place and staff and care records were inspected, along with other relevant documentation. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could be doing better were discussed with the registered manager. These include improvements to the contractual arrangements between the home and each resident. A further area that the home needs to focus on is the record-keeping in the daily records for residents, where a number of discrepancies and areas of poor practice were noted. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 6 In addition, some areas of health and safety were observed to require attention, and requirements have been made for the home to address these. 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 House DS0000027227.V260404.R01.S.doc Version 5.0 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.V260404.R01.S.doc Version 5.0 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): 2, 3, 4 and 5 The assessment process ensures that the home is the right place for new residents to move to. Currently there is no contract in place between the organisation and any of the residents living at the home. EVIDENCE: The manager spoke about the process of new people moving to the home, describing how this is planned upon the needs of the potential resident. The manager described that either they or a senior carer carry out the assessment of the resident in the hospital or home setting. The resident and their family are also encouraged to visit Pelham House prior to the resident moving in, when they would have an initial month trial living at the home to see if they would like to move in on a more permanent basis. Most residents have been living at the home for some time, however the newest residents’ file maintains a good record of their admission/ assessment process. From this a plan of care setting out how this resident’s needs and wishes are to be met had been put in place. An initial risk assessment had also been completed to ensure that any risks identified could be managed by the home. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 9 A contract between the local authority and the organisation is in place for each resident whose accommodation is funded in this way. This document is titled ‘individual service contract - contract for the payment of care provider fees’ and details the agreement regarding the payment of fees only. The inspector was informed that there is no contract in place for privately funded residents. At present there is no contract/ statement of terms and conditions between the organisation and the resident. However, the Statement of Purpose for the home contains a document titled ‘your guide to Pelham House’, which details the terms and conditions of living at the home, what fees cover, plus facilities and services offered by the home. It is required that this document is developed to provide a more formal contract that details what services the charges cover and any additional charges. A copy of each contract must be agreed and signed by the resident or their representative, plus a representative of the organisation. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 the following standard(s): 7 and 8 The care plans are in a format that enables care to be planned towards meeting individual needs. This ensures that the residents get the right care and support. Record-keeping in the daily records for residents is poor and does not demonstrate that staff are observing and recording changes in the residents from day-to-day. EVIDENCE: The records for three residents were looked at and indicate that for each person there is a current plan of care that sets out the needs of the residents and how these are being met by the home. The care plans cover a number of relevant areas such as personal care needs and assistance required with eating and drinking. Since the last inspection good improvements have been made to the care plan documentation, with a different page for each care need. The formatting of the care plan starts from a summary of the ‘strength/ need’, followed by the ‘aim’ of the care plan and the actions that are to be taken by the staff/ resident, followed by a monthly review of the plan. These developments make it easy to identify the individual needs of the resident and the care that is being provided by the home. The manager spoke enthusiastically about this Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 11 new care plan format, commenting that “…it’s a lot easier to see the progress of residents…it reads like a story…”. In addition each file contained an assessment of any areas where there was considered to be any risk to the resident, along with how these risks were to be dealt with and reduced as far as possible. These included ensuring that health and safety risks relating to moving and handling and continence are managed appropriately at the service. The last inspection recommended that the record-keeping in the residents daily records be improved to ensure good practice in this area. A slight improvement was noted in this area, however this still needs to be developed further to ensure that good record-keeping practices are being carried out by all staff. This is because it was observed that gaps were left between entries, and where entries had been crossed out, they had not been dated and initialled by the person doing this. In addition, more work is needed on the quality of the content of the records in the daily notes. An entry is made at the end of each shift throughout the 24 hour period at Pelham House, and in almost all records seen comments stated ‘…medication given…’, …‘medication given as charted…’, ‘…comfortable morning…’ ‘…pleasant morning…’ ‘…meals and medication taken…’. In each file there were very few records detailing what the resident had actually done throughout the day, or what it was that made their morning ‘…comfortable…’ or ‘…pleasant…’, and there were no summaries of conversations with resident or activities they had been involved in. Following these findings it is required that all staff receive training in accurate record-keeping techniques. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 15 The home offers appropriate activities for the residents to become involved in, and support is available to pursue individual interests. Residents have good food served in a respectful manner. EVIDENCE: Along the hallway leading to the lounge on the ground floor there are a number of photographs that reflect the activities that residents have been involved in throughout the summer. It was noted that these had been changed since the last inspection to show an up-to-date pictorial record of recent events that had taken place. These included residents being involved in flower arranging, trips to Battersea Park and also a recent theatre outing to an ‘Old Time Music Hall’. A poster on the wall in the lounge was also seen, informing residents of a flute recital at the home in November. The manager stated that some residents are also involved in individual prayer sessions with visiting ministers and priests to the home. She further discussed that volunteers also spend time reading newspapers to residents, and often taking them out when the weather is nice. The inspector observed lunch being served in an unhurried manner, with staff offering support where requested. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 13 Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The home has a satisfactory complaints procedure and format for the recording of complaints. Staff training ensures that the risk of abuse to residents is minimised. EVIDENCE: There is a satisfactory complaints procedure, ‘whistle-blowing’ policy and ‘protecting people from abuse’ guidance available at the home. Records indicate that all staff have received recent training in the Protection of Vulnerable Adults. The records indicate that the training is carried out annually. The manager informed the inspector that all new staff at the home receive training in abuse awareness during their induction period, which is in line with Sector Skills (previously TOPPS) training. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 the following standard(s): 19, 21 and 26 Residents at Pelham House enjoy a homely and comfortable living environment that, along with the good standard of cleanliness and hygiene, adds to their quality of life. EVIDENCE: The previous inspection identified a number of areas in the environment that needed attention, eg. hallway carpets being replaced, installation of lampshades in the toilets. It was noted that all the toilets were observed to have a lampshade to make them look more homely. In addition, on the day on inspection the top floor hallway carpet was being replaced with a much brighter carpet. The inspector was informed that, starting with the top floor, all the hallways are being re-carpeted throughout the home. This creates a much more comfortable and homely environment for the residents. Furthermore, on the day of inspection, new beds for the ground floor bedrooms were seen being put together to replace those currently in use. The standard of cleanliness is good, with dedicated housekeepers employed at the home to maintain this. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 16 One area of concern was that the new fire door on the ground floor was found to need some attention, as when opening it catches on the ground and is stiff to open. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Residents benefit from a committed and experienced team of staff at the home who have the right approach and skills to meet their needs. Recruitment checks need some improvements to reduce the risk to residents. EVIDENCE: The manager stated that the home currently has a full complement of staff, with the recent addition of a new senior carer to the team. The manager stated that the home continues to recruit to the staff bank, to ensure that when there are staff absences the residents receive a consistent level of care. The staff 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. New staff files also contained details of their induction to the service, which covers introduction to the policies and procedures, medication practices and what to do in the event of an emergency. The file for one staff member contained a Criminal Records Bureau (CRB) check from a previous employer, and this was dated 2003. It is required that all staff employed have a current CRB check through their current employer. Information has also been provided to the home to ensure that prior to any new staff commencing work a POVA First check is received to ensure that they are suitable for working with vulnerable people. The staff files maintain a Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 18 record to demonstrate that staff receive training in fire safety, abuse awareness and basic food hygiene. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 and 38 The manager demonstrates a commitment to her role and the development of the service. Improvements are needed to ensure that staff receive appropriate supervision in their work. Further checks are required to ensure the health and safety of all residents living at the home. EVIDENCE: The registered manager at the service works well to aim for a high level of service offered by the home. Having been in post for ten months the manager discussed that she enjoys her role and feels well supported by their line manager and senior staff at the home. The manager discussed that she had recently been absent from the home for approximately six weeks. The CSCI was not notified of this. The Registered Persons must notify the CSCI if and when a manager is absent from the home for 28 days or more. This Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 20 must be put in writing to the CSCI, along with details of the management arrangements for the home during this absence. The manager stated that she has individual supervision sessions with senior carers, who in turn have supervision sessions with the carers at the home. The record of these sessions demonstrate that they are erratic in frequency, with a number of staff having only received one session since the start of the year, others four times. It is required that staff receive a minimum of six supervision sessions a year, at regular intervals The inspector observed records indicating that a fire system inspection had occurred in September 2005, and was satisfactory. The Portable Appliance Testing was seen to have taken place in July on all relevant appliances throughout home, and it is recommended that this is carried out on all equipment brought in by new resident when they arrived at the home to ensure the safety of all who reside at Pelham House. It was noted that the hot water in ground floor bathroom, in the toilet on the top floor and in a resident’s bedroom on the top floor was very hot to touch. The manager stated that water temperature testing is not carried out, and it is required that a monthly check of the water temperature for all outlets is commenced, along with installing thermostatic controls on all basins to ensure the water is dispersed at temperature of 44 degrees centigrade. Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X 2 Pelham House DS0000027227.V260404.R01.S.doc Version 5.0 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 Standard OP2 Regulation Sch 4(8) 5(1)(b) (c) Requirement The Registered Persons must provided each resident with a contract stating the terms and conditions of their living at the home, and this must be agreed and signed by both parties. The Registered Persons must ensure that all staff receive training in accurate recordkeeping techniques. The Registered Persons must ensure that the new fire exit on the ground floor opens easily. The Registered Persons must ensure that all staff have a Criminal Records Bureau (CRB) check carried out for all staff with them as the current employer. A POVA First check must be received for all staff prior to their commencing work at the home. The Registered Persons must notify the Commission of the absence of the registered manager, if over 28 days, and of the interim arrangements for managing the home The Registered Persons must DS0000027227.V260404.R01.S.doc Timescale for action 31/03/06 2 OP7 18 (1)(c)(i) 13(4)(c) 23(4)(b) 19, Sch 2 31/03/06 3 4 OP19 OP29 30/11/05 30/11/05 5 OP31 38 30/11/05 6 OP36 18(2) 30/11/05 Page 23 Pelham House Version 5.0 7 OP38 13(4) ensure that all staff receive supervision a minimum of six times a year, at regular intervals. The Registered Persons must ensure that a monthly check of the water temperature for all outlets is commenced, along with the installation of thermostatic controls on all basins to ensure the water is dispersed at temperature of 43 degrees centigrade. 30/11/05 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 DS0000027227.V260404.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SW London Area Office 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 DS0000027227.V260404.R01.S.doc Version 5.0 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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