Inspection on 01/09/05 for Pelham House Residential Home

This inspection was carried out on 1st September 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 Residential Home 31/07/08

Pelham House Residential Home 20/09/07

Pelham House Residential Home 17/07/06

Pelham House Residential Home 19/04/05

Pelham House Residential Home 01/11/04

Pelham House Residential Home 10/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Pelham House 5/6 Pelham Gardens Folkestone Kent CT20 2LF Lead Inspector Penny McMullan Announced 01/09/05 at 10:00am 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 H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pelham House Address 5/6 Pelham Gardens , Folkestone Kent CT20 2LF 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) 01303 252145 Mr and Mrs Thomas Registered Care Home 22 Category(ies) of Old Age registration, with number of places Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/4/05 Brief Description of the Service: Pelham House is a large detached sprawling house, located within a quiet and select residential area of Folkestone. The home is sited at the end of a cul-desac, so there is very little traffic and the street is quiet. The home is well decorated, comfortable and homely and most service users are self-funding. There is a stable staff group who have a broad range of health and social care experience. The home has a number of small lounge facilities enabling users the opportunity for quiet and private time either alone or with other users or relatives. There is a very well kept paved and lawn area to the front of the property, which has off street parking. There is a large accessible garden to the rear of the home, with raised flowerbeds, a greenhouse and paved pathways to allow maximum access to the garden. The home also has a conservatory with houseplants, where service users can access the garden facilities. The home does not have a lift or stair lift to the first floor. It must be acknowledged that due to the lack of access via lift or stair lift all service users accommodated on the first floor must be mobile to enable use of the recreational facilities available. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Announced inspection took place over two days a total of 9.75 hours. The first day was spent talking to relatives and the registered providers Mr George Thomas and Mrs Margaret Thomas. The second visit was to speak to services users. The Commission received 12 service user comment cards and 14 relative comment cards. Overall the comments from service users were complimentary. Relative comments included ‘the care is excellent’, ‘first class’ and ‘I would not like my relative to live anywhere else’. The proposed registered manager has now left the employment and at the time of the inspection Mr G. Thomas and Mrs M. Thomas, The Registered Providers were in attendance. In view of the fact that the home has now been without a Registered Manager for some considerable time Mr Thomas has decided to apply to the Commission to become the Registered Manager. In the absences of a Manager the registered providers are managing all aspects of the home on a daily basis. Since the last unannounced inspection the home has made sound progress in meeting the National Minimum Standards. Ten residents were spoken to, three relatives who were visiting the home at the time of the inspection and three members of staff. The residents and relatives were spoken to in the lounge, garden and conservatory. What the service does well: The home promotes independence, and encourages service users to maintain their links with the community and outside interests. Service users and staff said that the quality of care provided is very good and relatives also said that this was the case. The home has a well-maintained garden with a green house and vegetable patch. This enables them to produce a variety of fresh vegetables. Resident’s comments on the food being provided included the freshness of the vegetables and how tasty and nutritious the home grown products are. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 6 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 Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 7 contacting your local CSCI office. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,6 The homes Statement of Purpose and Service User Guide provide residents and prospective residents with the information they need to make a decision about moving into the home. Arrangements are in place to carry out a detailed assessments of needs of residents prior to admission to the home to ensure that all care needs will be met. EVIDENCE: The Statement of Purpose and Service User Guide have now been updated. The home has implemented an assessment process, which covers all areas of health and social needs. This form is completed prior to admission to the home. Standard 6 is not applicable to this home. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 7,8,9,10 Care plans have improved but require additional information as to how objectives will be met and risk assessments require further detail to minimise the risk to residents and staff. The health care needs of residents are being met and personal care is offered in a way protect residents privacy and dignity and promote independence. The home has improved medication practices and is currently reviewing the medication policy and procedures. The absence of policy and procedures and the lack of checking written information on medicine administration sheets potentially put residents medication needs at risk. EVIDENCE: The home has improved the service user plans and implemented risk assessments however further development is required to identify how the objectives of the service users can be met. Risk assessments also require further detail to minimise the risk. The plans have been signed and reviewed on a monthly basis. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 11 Residents are able to visit their GP surgery or have home calls in the privacy of their rooms. The chiropodist and dentist also visit the home. Residents said that the staff treat them with respect and they have the freedom to come and go and they like. One relative said that the home was very supportive when his father was admitted and encouraged him to keep his independence. The home has a medication policy, which The Register Provider is currently reviewing. This is a requirement in this report to complete this policy and forward a copy to the Commission. The home must also ensure that written information on the medicine administration sheet is checked and signed off by two members of staff. Some medication training has been provided and there are two more courses booked for September. There is risk assessments in place for one resident who is able to self medicate however further development are required to identify a criteria for monitoring. Service users said that the laundry was very efficient and they clothes were returned promptly. The home has a separate laundry and sluicing facilities. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 12,13,14,15 The lack of a planned activities programme does not provide stimulating activities to meet the needs of the residents. Visitors are able to visit the home at any time and see their relative in private. The home supports residents with financial or advocacy information to promote resident’s autonomy and choice. The home provides a well balanced nutritional diet and the overall provision of meals is of a good standard. Residents confirmed choice and variety of meals and special diets are catered for. EVIDENCE: Feedback from service users and relatives suggests that there are not enough planned activities in the home. Staff said that the current service users are not very interested in taking part in many activities. The home needs to identify individual hobbies and leisure activities for each service user and implement a programme to meet their needs. Visitors are welcome in the home and there are no restrictions. This information is in the service user guide. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 13 Residents stated how they are free to access all parts of the home and go to the local shops and town. Relatives/representatives/solicitors support residents with their finances and the home supports and assists one resident. Some residents are aware to their personal records but did not express a wish to see them. Residents and relatives said the food was good and alternatives are given. Fresh vegetables are available from the garden and residents said how much they enjoyed the variety and freshness of the produce. Overall feedback from service users was positive and they felt the meals were of a good standard. They said that biscuits and coffee/tea is served and snacks are available if they are hungry and likes and dislikes are recorded. Residents are able to eat their meals in their room or in the dining room. Nutritional needs are recorded on the residents plan and special diets are provided if required. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 16,18 The home has a satisfactory complaints system and has ensured that residents, relatives and visitors are aware of the complaints procedure. Staff demonstrated their understanding of Adult protection issues and arrangements are in place for all staff to receive the appropriate training. EVIDENCE: Service users and relatives have a clear understanding of how to complain. All of the service users spoken to said they have never had cause to complain but would not hesitate to speak to the provider or staff if they had any concerns. The home keeps a complaints log but there have been no complaints since the last inspection. The home has reviewed and implemented the Adult Protection and Whistle blowing Policy. Adult Protection and physical and/or verbal aggression training is being arranged. The home is aware of the Protection of Vulnerable Adults Register and all CRB checks are in place. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 19,26 The home is well maintained and decorated ensuring that residents are living in pleasant homely environment. There are policies and procedures in place to ensure the home remains clean, pleasant and hygienic. EVIDENCE: The home is well maintained and two bedrooms have been redecorated since the last inspection. The outside of the home is also being painted and redecoration is also planned inside of the home with a new carpet to be ordered for the corridor. Residents said they are able to personalise their bedroom and the domestic staff work hard to ensure that the home is clean and tidy. The grounds are well maintained and the garden also has raised flowerbeds, a greenhouse and summerhouse. Service users sit in the conservatory and are able to walk round the paved areas of the garden. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 16 The home has separate laundry facilities, which are easily cleaned and has the required hand washing facilities. There are policies and procedures in place for infection control and the home has a sluice facility with separate hand washing for staff next door. Service users said the home is always clean and tidy. Relatives who visit regularly said that the home was always free from offensive odours. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 27,29,30 The staff have a good understanding of resident care needs. This is evident from the positive relationships, which have been formed between the staff and residents. Since the last inspection the standard of vetting and recruitment practices has improved and all checks are now in place. Mandatory training for staff is now being provided and the induction programme is being reviewed to ensure the programme is linked to the Skills for Care specification. EVIDENCE: The home is currently adequately staffed and residents said there is always enough staff on duty. Residents also said that the staff are responsive to their calls. There is an established experienced staff group at Pelham House who have worked in the home as a team for several years. CRB checks are place and staff files contained proof of identity, two references and all other information required. The home is aware of POVA checks and there have been no further recruits since April. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 18 The home has provided over 15 training courses since the last inspection in April and is continuing to update all mandatory training. Progress has been made with regard to the induction training and the Registered Provider is currently looking at methods to ensure that is linked to the Skills for Care Programme. The home is updating the training matrix and is required to forward a copy to the Commission. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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) 33,35,36,38 The systems for resident consultation are good with evidence that their views are considered and the home is run in their best interests. The home has implemented an effective financial system to support residents with their finances. Staff supervision is in place ensuring that staff are valued and supported. Mandatory training is now being provided and all safety checks have been carried out to provide a safe environment for residents to live in. EVIDENCE: A quality assurance survey has been completed and summarised. The Registered Providers both have daily contact with service users and are part of the daily running of the home. Residents confirmed that they are able to discuss the any issues of the home with the providers. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 20 The majority of residents are supported with their financial requirements by their relative, solicitor or representative. Receipts are provided for all transactions and there are some service users who are able to manage their own finances. The home has secure facilities for safe storage of all valuables, which are recorded appropriately. The home has implemented a supervision programme which needs to be include further information to cover all aspects of practice, philosophy of care in the home. Career development is included. Two members of staff have attended a supervision course. The home has more mandatory training courses booked and needs to continue to provide this training until all staff have received updates or further training. The fire book was in order, accurate and up to date and fire drills are taking place. Fire training has also been provided. All relevant safety checks with regard to Health and Safety have been carried out. The accident book was viewed and it was found that the information was recorded in the daily contact sheets of the service user plan. The Registered Provider is reviewing the induction programme to ensure that this is lined to the Skills for Care specification. Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x 3 3 x 3 Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 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 7 Regulation 15,13 Requirement To provide further detial of how to meet the objectives for residents in the care plan. To develop Risk Assessments with further detail to minimise the risk to residents and staff To record residents social care needs and implement a planned activity programme To review the Medication Policy and procedures in line Royal Pharmaceutical Society Guidelines, and forward a copy of the policy to the commission. To countersignd written information on medical administration sheets Timescale for action 31/12/05 2. 3. 12 9 16 13 31/10/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Pelham House H56-H05 S23502 Pelham House V239034 010905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU 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. 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