Inspection on 26/06/06 for Pelham House

This inspection was carried out on 26th June 2006.

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 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 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 Louise Phillips Unannounced Inspection 26th June 2006 11:20 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.V305286.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.V305286.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 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.V305286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2006 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: £429.10 for a single room £526.05 for enhanced care or respite Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day with time spent talking to three staff, four residents, the manager and two volunteers. A tour of the premises was carried out and care records were inspected along with other relevant paperwork. Information has also been gained from the inspection record for the home. The questionnaires were sent to 25 residents, 17 health and social care professionals and relatives. They were received back from 8 residents, 4 health and social care professionals and 3 relatives. What the service does well: What has improved since the last inspection? 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. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 6 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.V305286.R01.S.doc Version 5.2 Page 7 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 and 6 Quality in this outcome area is good. This judgement has been made as residents are assessed prior to moving to the home and can be fully involved in this process. EVIDENCE: Standard 6 is not applicable to this service. Since the last inspection good progress has been made to ensure that each resident has a contract stating the terms and conditions of their accommodation at the home. These were seen in residents files, signed by the manager and the resident or their representative. The home continues to have a good process for assessing and admitting new residents, with appropriate referral information being sought from social workers or other health care professionals as necessary. Potential residents can be fully involved in the admission process through completing an application form where they are able to inform the home of their individual preferences, needs, likes and dislikes. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 8 Records indicate that the home maintains good phone contact with new residents before they move to the, which helps develop good relationships and ensure a smooth transition. One resident commented about their coming to the home, saying that they had an: “…excellent interview and details before moving to the home…”. Feedback from residents surveyed indicate that the majority felt they had enough information to enable them to decide that Pelham House was the right place for them to move to. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made as the feedback received from health and social care professionals, relatives and residents indicates that their needs are met. However the service needs to improve practices regarding medicine administration, resident’s choice and record-keeping. EVIDENCE: Feedback from health and social care professionals associated with Pelham House is positive, with all indicating that they feel the needs of the residents are well met, that the home works in partnership with them and that there is good communication from the home. Where asked where they feel the home provides an excellent service, the professionals commented that: “…the home is very client focused…” “…they are very patient and understanding of my clients health difficulties…” “…they respect my clients independence in all respects…” Relatives also felt that the residents receive good care and support, one describing how they were kept well informed of an injury to their relative and the actions taken to address this. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 10 A majority of the residents at Pelham House said that they feel they get the care and support that they need, one saying that “…the staff look after me well…”. Residents also feedback that staff support with medical needs is good and that they are able to access a general practitioner (GP) when they wish. However, one resident did state that: “…I wish to have personal doctor of my choice…”. A requirement has been made to ensure that each resident is able to register with a GP of their own choice. The care plans for each resident continue to in a good format, covering significant areas such as mobility, personal care, eating and drinking, continence, communication, socialising. A ‘dependency analysis risk assessment’ is also regularly carried out for each resident, assessing areas of risk that they may have in carrying out daily activities, for example walking or eating and drinking. The care plans and dependency analysis are reviewed monthly, and amendments to the care plan made as necessary. At the front of each resident file there is a summary of the needs of each resident along with details of their interests and former occupations, enabling staff to gain a ‘snapshot’ of the resident when planning their daily work with them. There are sufficient medication policies at the home, covering areas such as correct storage of medicines, safe checking of medication prior to administration and managing drug errors. The medicine administration charts are maintained well, signed appropriately and the prescribed medication corresponding with that in the NOMAD box. It was identified that one resident was prescribed Lactulose to be given in the morning and at night. This medication was not in stock for the resident and when asked the staff admitted that they use another residents Lactulose medication for this resident. This is not good practice and a requirement has been made to ensure that only medication is only given to the resident for who it is prescribed, and appropriate stocks are maintained of each residents medication. The previous inspection required that staff receive training in accurate recordkeeping techniques. There has been some improvement to the quality of recording in the daily occurrence notes for each resident, however further work is still needed in this area. The findings from these records show that staff are still using comments such as “…remains the same…” or “…had a good day…” without elaborating on this. An entry for one resident was that they “…complained of pain and weakness…” with no further details as to where or why, or of the actions taken to address this other than their being taken to the lounge and given a cup of coffee. This requirement has been restated as staff do require training in record-keeping techniques. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made as the residents can be involved in various activities provided by the home. Residents are generally positive about the food and are able to eat meals with other residents or on their own if they prefer. EVIDENCE: On the day the activities co-ordinator had spent the morning reading newspapers with the residents and a ‘sing-a-long’ was planned for later in the day. Information of forthcoming events were displayed in the lounge area, along with photographs of recent activities and visiting entertainers to the home. One relative commented that: “…the entertainments, communion services, etc are very good…”. This was similarly expressed by a professional who said that the activities “… cater to the needs of the residents…”. The feedback from all the professionals surveyed is that specific cultural, ethnic or disability issues are addressed, one giving the example of extra equipment being supplied for a resident with mobility needs. Two professionals commented where the home could improve for the benefit of the residents, one stating that there should be more support for arranging Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 12 activities for residents with high support needs; the other commenting that they would like to see staff “…helping my client to get more involved and take part in activities…”. Residents feedback that there are usually activities that they can take part in, one commenting that “…it depends on what kind of activity…”, where another said the activities “…cannot be faulted. Varied and educational and fun…”. Residents were positive about the food provided, with a majority saying that they always like the food, some saying that they usually like it. One resident said: “…if there is something I don’t like, an alternative is always available…”, another saying that they “…find main course dishes at times a little hard to take, desserts usually good…”. On the day lunch was observed being served in the dining area, with staff offering support where necessary and gentle reminders such as leaving the food to cool because it is hot. Residents are also able to eat meals in their room if they prefer. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made as residents feel confident to raise areas of concern they have and systems are in place to reduce the risk to residents. EVIDENCE: The service has the Pelham House complaints procedure that is provided in the Service Users Guide and Statement of Purpose for the home. All the residents said that they knew who to speak to if there was something they were not happy about and that they know how to make a complaint. The manager stated that there had been no complaints received since the last inspection. Staff records indicate that they have received recent training in ‘abuse and neglect’ awareness, so to minimise the risk to residents. There are also policies and procedures in place regarding abuse awareness and what to do in the event of this. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made as the staff and residents make the environment welcoming. The home is going through a period of redecoration to make the home more comfortable for the residents. EVIDENCE: At the time of inspection the top floor of the home had recently undergone a period of redecoration and this was in the process of happening throughout the home, with all the hallways due to be re-painted, and some doorways being widened. Residents are positive about hygiene at the home, saying that the environment is always fresh and clean and that personal laundry is done regularly, along with the bedding. Health and social care professionals who visit Pelham House say that: “…all the staff are very friendly and caring…the atmosphere is always good. I think the residents are happy and well cared for…”. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 15 A relative also stated that: “…there always seems to be a happy atmosphere…”, further commenting that “…when I have been there the standard of cleanliness is very apparent…”. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made because the service ensures that staff are trained and supported in their role so that residents receive the right level of care. EVIDENCE: The home holds recruitment information on each member of staff. Two staff files were examined and found to contain relevant information such as proof of identification, correspondence relating to offer of job, statement of terms and conditions of employment, two references and record of the interview of staff. Since the last inspection the service has ensured that all staff have a Criminal Records Bureau check with them as the current employer. Staff files also contain records of annual staff appraisals having been carried out last October, and the manager stated that these are due to occur starting in September 2006. A record is maintained of all training done by staff, and this was seen to include recent courses in moving and handling, ‘abuse and neglect’ and fire safety. Since the last inspection developments have been made to the night staffing at the service, with one senior and one care staff on ‘waking’ duty throughout the night, with back-up from an on-call manager. There is also a new deputy manager in post. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 17 Residents comment that there are usually/ always staff available when they need them, one stating that “…they are very helpful…”. One professional commented that the “…staff work well and cheerfully with residents to create a home atmosphere rather than an institution…”. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made as there is a competent manager at the home who has helped to progress the service for the benefit of the residents. EVIDENCE: One resident commented that: “…Pelham House is a very well run, caring home. A cut above the normal…”. In addition, feedback from health and social care professionals is that they feel that the home operates in the best interests of the person One staff member also spoke about the manager, saying “..she is super, very good with the residents…”. Observations and discussions with the residents during the inspection were positive, indicating that the manager is respected and well-liked by the those living at the home. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 19 The improvements since the last inspection demonstrate that the home has a committed manager who promotes the choices and interests of the residents. Staff receive regular supervision from the manger or deputy manager. The manager stated that the senior staff are due to commence a ‘coaching and supervision’ course to enable them to supervise care staff. The home holds a balance of ‘pocket money’ for all residents. The service informed the inspector that it holds the balance of all the pocket money in one account in a bank and that this does not accrue interest. The Care Homes Regulations 2001 states that resident’s monies must not be paid into a bank account other than that of the resident. The home should demonstrate that they have the resident or their representatives’ agreement for their money being managed in this way. It is good practice for the home to open an individual bank account for each resident and it is recommended that this occur. There are records to demonstrate that health and safety checks are carried out on the fire system and equipment, fridge and freezer temperatures and Portable Appliance Testing, etc. The service also carries out health and safety risk assessments for such areas as overloading plug sockets in offices, kitchens, staff room, lounge; all which have been done in the past three months. Each residents’ file contains a risk assessment for their individual bedroom and any potential areas of risk, such as cluttered furniture. The previous inspection required that the temperature of the water be tested from all outlets. This has not commenced. The Health and Safety Executive require that weekly monitoring of the outlet temperature of water be carried out. Therefore, the requirement has been made for Pelham House to carry out weekly checks of the water temperature from all outlets around the home and a record maintained of these, to ensure the water is dispersed at temperature of no more than 44 degrees centigrade. Guidance suggests that the tap should run for approximately one minute prior to taking the temperature to ensure an accurate temperature reading. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 20 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 X X 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 3 X 3 X 3 3 X 2 Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 18 (1)(c)(i) Requirement The Registered Persons must ensure that all staff receive training in accurate recordkeeping techniques. (Previous timescale not met) Timescale for action 31/08/06 2. OP9 13(2) The Registered Persons must 31/07/06 ensure that medication is only given to the resident for who it is prescribed, and appropriate stocks are maintained of each residents medication. The Registered Persons must ensure that residents are registered with a general practitioner of their own choice. The Registered Persons must ensure that a weekly check of the water temperature from all outlets around the home is carried out, and a record maintained of these to ensure the water is dispersed at temperature of no more than 44 degrees centigrade. 31/08/06 3. OP10 13(1)(a) 4. OP38 13(4) 31/07/06 Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 22 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 OP35 Good Practice Recommendations The Registered Persons should ensure that an individual bank account is opened for each resident. Pelham House DS0000027227.V305286.R01.S.doc Version 5.2 Page 23 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.V305286.R01.S.doc Version 5.2 Page 24 - 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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