Inspection on 19/04/05 for Pelham House Residential Home

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 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 Residential Home 31/07/08

Pelham House Residential Home 20/09/07

Pelham House Residential Home 17/07/06

Pelham House Residential Home 01/09/05

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 Residential Home 5/6 Pelham Gardens Folkestone Kent CT20 2LF Lead Inspector Penny McMullan Unannounced 19th April 2005 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 Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Pelham House Residential Home Address 5/6 Pelham Gardens, Kolkestone, 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 01303 252145 Mr. George Thomas and Mrs Margaret Jane Thomas Care Home 22 Category(ies) of OP (22) registration, with number of places Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Registration for the category MD is restricted to one (1) resident whose date of birth is 17.02.1942 Date of last inspection 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 Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two days. The first day was spent talking to service users, relatives, the registered providers and staff. The second visit was to assess the medication standard relating to the requirements and recommendation from the joint visit carried out by the Lead Inspector and Pharmacy Inspector. The proposed registered manager was on sick leave at the time of the inspection and the registered providers Mr G. Thomas and Mrs M. Thomas were in attendance. The registered providers visit the home on a daily basis and contribute in the running of the home. The proposed registered manager has been in post for over a year but no application to become the Registered Manager has been forwarded to the Commission. Eight people who use the service were spoken to, three relatives who were visiting the home at the time of the inspection; three members of staff. The people who use the service and relatives were spoken to in the lounge and conservatory. The last inspection was carried out on 1 November 2004 and the home provided the Commission with an action plan to meet the recommendations and requirements however the implementation of the plan has not been completed. There is still further development required to comply with the regulations and to meet the national minimum standards. The Commission will therefore assess the compliance of the requirements and consider any further action, which may be required. What the service does well: The people who use the service said that the staff is wonderful and the management of the home was very good. They said that the home is an excellent place to live with very pleasant surroundings and lovely gardens. One service user said that the carers look after her well ensuring her privacy is upheld and everyone is treated as an individual. It was the opinion of one service user that the home could not do anything better. He was able to walk Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 6 to the shop, choose what he wanted to do and receive his visitors in private. Overall services users were complimentary with regard to the food and said they were happy with their individual bedrooms. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 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 Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 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 The Statement of Purpose and Service User Guide are in place and this information is being used to provide prospective service users with the required information about the home and the services being provided. The home has implemented an assessment process for service users coming into the home. EVIDENCE: The Statement of Purpose and Service User Guide are in place and require minor adjustments. 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. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 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 standard(s) 7,8,9,10 Care plans do not contain up to date, accurate, clear information and are not consistent to provide staff with the information they need to meet the service users needs. Risk assessments require a safe practice of work. The absence of policy and procedures with regard to medication, and appropriate recording of medication changes will result in the healthcare needs of people using the services not being met. Overall the lack of development of the care plans, and outstanding medication issues including accredited training put the service users safety, health care and general well being potentially at risk. EVIDENCE: There was evidence in the care plans that some monthly reviews were in place, however one service users needs had changed and this was not identified clearly in the service user plan. Staff spoken to demonstrated their knowledge in caring for the service users and meeting their needs but insufficient information was recorded in the service user plan. Risk assessments do not contain a safe practice of work and are also not being reviewed. The plans need to be drawn up with the service users as currently no service user plan is Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 10 signed. Some service users spoken to were aware of the plans but did express a wish to see their records. The home is supported by the District Nurse, Continence Nurse and access specialist services through the GP. Service users confirmed that they were able to visit their GP or receive a home visit. One service user said that the staff treats everyone as an individual and staff are very sensitive when providing personal care and respect their privacy The home has received a visit from the Pharmacy Inspector and has completed six of the requirements and 4 outstanding requirements have been partially complied with. A draft medication policy and procedure was forwarded to the Commission but this requires further development to include the procedure when drug errors/incidents occur, to ensure that there is written authority for all changes in medication and changes to medication are signed off appropriately. To ensure the policy is in line with the Royal Pharmaceutical Guidelines. Service users consent to the administration of medication needs to be recorded. There are risk assessments in place for service users who self medicate however further development is required to identify a criteria for monitoring. The home needs to provide all staff administering medication with accredited training. At the time of the inspection there was a drug error, which after investigation proved to be an incident, which had not been recorded on the day. An explanation was subsequently recorded but no incident form was completed and the home is required to ensure there is a policy and procedure to follow when drug errors/incidents occur. Mar sheets contained written changes to medication, which were not countersigned or singed off by the GP/Pharmacist. The Registered Provider stated that she had spoken to the GP to confirm this change of medication but there was no evidence to substantiate this claim. The people who use the service said that the laundry was very efficient and they clothes were returned promptly. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 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 standard(s) 15 The home is providing service users with a varied appetising menu. Choices are upheld and the people using the service are able to choose where they eat. EVIDENCE: The people who use the service said the food was good and alternatives are given. They said that they could choose where to eat and have breakfast in bed if they wish. One service user said that overall the food was good but could be better sometimes. 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. Service users are able to eat their meals in their room or in the dining room. Nutritional needs are recorded on the service use plan and special diets are provided if required. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 12 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 ensured service users, relatives and visitors are aware of the complaints procedure. Service users and staff are at risk of abuse and harm due to the lack of a robust Adult Protection Policy and training of staff in Adult Abuse and Physical and/or verbal aggression. EVIDENCE: The people who use the service and relatives spoken to had a clear understanding of how to complain. They said that they would not hesitate to speak to the provider, staff or Manager if they had any concerns. The home keeps a complaints log but there have been no complaints since the last inspection. The home has an Adult Protection Policy and Whistle blowing Policy, which require development to address all aspects of protection for vulnerable adults. The Registered Provider is aware of shortfalls and has agreed to review policy and procedures and forward a copy to the Commission. Three members of staff spoken to was aware of the Protection of Vulnerable Adults Register but have not received any training in adult abuse, physical and/or verbal aggression. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 13 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) 19,25,26 The home is well maintained and decorated ensuring that service users are living in well maintained environment. There are policies and procedures in place to ensure the home remains clean, pleasant and hygienic. EVIDENCE: The home is well maintained and the Registered Provider is in the process of planning the redecoration of the large lounge/dining room. The people who use the service said that they were 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 several service users enjoy walking around the paved walkways. The garden also has raised flowerbeds, a greenhouse and summerhouse. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 14 All radiators are guaranteed low temperature surfaces and service users said that they could control the heating in their room. The home has an emergency lighting system. The water temperature is regulated. The home has implemented a record of bath temperatures is implemented. 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 the safe handling of soiled laundry, and service users said that the laundry was a good service with clothes being returned efficiently. The home has a sluice facility with separate hand washing for staff next door. The people who use the service said the home is always clean and tidy. Relatives who visit regularly said that the home was always free from offensive odours. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 15 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) 27,28,29,30 Recruitment policies have not been followed resulting in a member of staff not receiving a CRB check and putting service users at risk. Service users are also at risk due to the lack of mandatory training for staff and the induction programme not being linked to the Skills for Care specification. EVIDENCE: There was three care staff on duty at the time of the inspection, two domestic staff, one maintenance man and the Registered Provider Mr George Thomas and Mrs M Thomas joined the inspection. The afternoon shift consists three care staff to 4pm then an additional member of staff is on duty to help during the busy period of the evening. There is two waking night staff. There was no CRB in place for one member of staff. The Registered Provider said that this had been applied for but there was no evidence to support this claim. Proof of identity for all staff is now on file and the newest member of staff confirmed that two references and a POVA first check had been carried out. Five members of staff have received moving and handling training or updates, five health and safety, seven first aid, and four fire training. All staff requires some mandatory training or updates. This was an outstanding requirement from the last inspection and The Registered Provider must implement a training programme to achieve this. The induction training requires Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 16 development to meet the Training Skills programme. The home must update the training matrix and forward a copy to the Commission. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 17 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) 31,33,35,36,38 The lack of staff supervision does not provide the staff and home with an effective leadership, guidance and direction to ensure consistent quality care. The management of the home is not completely effective resulting in poor record keeping in some areas. Development of some policies and procedures is also required. There are experienced qualified staff in the home however the lack of updates or other mandatory training potentially puts service users and staff at risk. Weekly fire testing and drills are required to be carried out to ensure the safety of the service users, staff and visitors. EVIDENCE: Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 18 The proposed Registered Manager Jackie Farrow holds a NVQ4 Care 4 qualification and is required to complete the Registered Managers Award. At the time of the inspection Ms Farrow was on sick leave and although she has been employed for over one year the Commission has not yet received an application to become the Registered Manager. Service users were very complimentary towards the providers Mr George Thomas and Mrs Margaret Thomas, and the staff. The Registered Provider stated that a quality assurance survey had been carried out but this was not able to be evidence at the time of the inspection. The people who use the service confirmed that they had completed a questionnaire and overall were happy with the service being provided. The Registered Providers both have daily contact with service users and are part of the daily running of the home. The majority of service users 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. There is currently no supervision programme in place. This was an outstanding requirement from the last inspection and although a supervision form has been devised to date no staff have received one to one supervision. The home needs to provide all staff with an update of all mandatory training. The staff have received in house training which is not sufficient. Data sheets are now in place for all chemicals used in the home. Fire testing of the points is not being carried out on a weekly basis and the home also needs to carry out a fire drill. All staff requires an update of full fire training. 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 induction programme is in place but this needs to be in line with Skills for Care specification. Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 19 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x 3 1 x 1 Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 20 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. 2. Standard 1 7 Regulation 4,5 7 Requirement To make minor adjustments to the statement of purpose and service user guide Risk assessments in Service User Plan to include a safe practice of work Service users to sign their individual plans This is a requirement from the last inspection timescale 30/11/04 To provide accredited training to all staff administering medication This is a requirement from the last inspection timescale 31/3/05 The home is required to develop policies and procedures covering all aspects of medicine management and these are signed and dated. To ensure that rsik assessment identify a creiteria for monitoringThe home ensures that they have written authority for all medicine administration and any verbal orders taken are infrequent when there is no other means avialable and verbal orders are followed up with a signature at an early date. This is a requirement from the last inspection timescale 31/12/04 To develop the Adult Protection Timescale for action 30/11/05 Revised timescale 30/6/05 3. 9 13 Revised timescale 30/6/05 4. 18 12,13 30/6/05 Page 21 Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Policy 5. 30 12 The home needs to implement a training programme in line with TOPSS for induction and foundation training and provide the commission with a training and development plan for the home This is a requirement from the last inspection timescale 30/11/04 To implement staff supervision This is a requirement from the last inspection timescale 30/11/04 To continue to update all mandatory training for all staff To carry out fire drills. This is a requirement from the last inspection timescale 30/11/04 To carry out weekly fire testing 6. 36 18 Revised timescale 30/6/05 Revised timescale 30/6/05 7. 38 13,23 8. 9. 10. 11. 12. 13. 38 13 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 18 Good Practice Recommendations To provide all staff with Adult Protection Training Pelham House Residential Home H56 H05 S23502 Pelham House V221853 190405 Stage 4.doc Version 1.20 Page 22 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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