Inspection on 20/09/07 for Pelham House Residential Home

This inspection was carried out on 20th September 2007.

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 17/07/06

Pelham House Residential Home 01/09/05

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 Residential Home 5/6 Pelham Gardens Folkestone Kent CT20 2LF Lead Inspector Penny McMullan Key Unannounced Inspection 20th September 2007 09:30 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 Residential Home DS0000023502.V348494.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 Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham House Residential Home Address 5/6 Pelham Gardens Folkestone Kent CT20 2LF 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) 01303 252145 Mrs Margaret Jane Thomas Mr George Alexander Thomas Mr George Alexander Thomas Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (21) Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration for the category MD is restricted to one (1) resident whose date of birth is 17.02.1942 17th July 2006 Date of last inspection Brief Description of the Service: Pelham House is a large detached house, located in a quiet residential area of Folkestone. The home is sited at the end of a cul-de-sac. The home environment is well decorated, comfortable and homely. 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 large accessible garden to the rear of the home. 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, all service users accommodated on the first floor, therefore, must be mobile. The majority of service users within the home are self-funding. The home offers a service to older people and has retained a stable staff group who have a broad range of health and social care experience. The home promotes independence, and encourages service users to maintain their links with the community and outside interests. The range of fees for this service are between £320-£500 per week. Information on the homes services and the CSCI reports for prospective service users/relatives is available opposite the desk in the main corridor in the home. There is currently no email facility. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 9.30am and 5.15pm. The Registered Manager assisted throughout. Residents and staff were spoken to. Observations included interactions between residents and staff. Surveys were sent to residents, relatives and professionals. Feedback was received from residents and relatives is very positive regarding the home however there are some concerns from professionals with regard to the meeting of needs of more dependent residents. Further information is detailed throughout the report. The care of three residents and staff files was tracked to gain evidence. Various records were viewed during the inspection. The Annual Quality Assurance Assessment (AQAA) was returned within timescales. Information was adequate and parts were discussed during the visit. Information supplied has been used in this report. The Registered Manager and the staff would benefit from equality and diversity training. What the service does well: Comments taken from the agency’s questionnaires/discussion with people who receive services included: Service user comments: ‘I receive excellent care and support’. The positive thinking and cheerful support I have had is almost certainly the reason for my recovery’. The staff are always very friendly and help me’. ‘The staff are attentive and come when I request’. ‘The food is excellent, lots of variety and plenty to eat’. ‘The home is very well looked after, it feels just like a home’. ‘I am really happy and settled at Pelham House’. Relatives comments: ‘They take good care and meet the needs of all the residents, always giving them very good food’. ‘I think and know that Pelham House and all the staff are one of the best in the area’. ‘Sees to peoples needs’. ‘The care given to my relative has been excellent. I find that she has been treated with affection and consideration, even during very trying circumstances’. ‘I feel that Mrs Thomas and the Manager have given my relative a lot of care and affection, and on occasions that I have been able to visit I have had lengthy chats with Mrs Thomas, the Registered Provider who very obviously loves the work she does. I have nothing but admiration for her. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 6 In my opinion she deserves a medal’. ‘I am extremely happy about every aspect of the care home. If I had to mention only one thing it would be the caring attitude and involvement of the Registered Provider and Registered Manager’. Health Care Professional comment: ‘ The Registered Provider Mrs Thomas has been in charge for many years and her leadership has resulted in consistent well observed standards’. ‘Good communication’. Care Manager comment: ‘Daily recording is very good. ‘Provide a supportive and well tightly run home for residents with full capacity’. What has improved since the last inspection? What they could do better: Relative comment: ‘Perhaps stimulate them more often’. ‘At times needs more carers’. Care Manager comment: ‘Appropriate training and awareness of dementia’. Awareness of the ability of home and skills of staff to manage and care for residents with certain conditions and if necessary decline placement’. The home has partially met some of the outstanding requirements from the last inspection in respect of Care plans, and medication however further improvements are required to meet these standards. Requirements and recommendations have therefore been brought forward for the home to address these issues. The Registered Provider and Manager need to ensure that full compliance of requirements are made in a timely manner and implement recommendations for improved practice. Feedback from staff, and one relative indicates that there is not always enough staff on duty in the afternoon and the Registered Manager must review current staffing levels against residents dependency levels using the care staffing tool. Further improvements are needed with regard to the medication policy and a requirement has been made in this report. In some areas recruitment practices have improved however further checking of records is required to meet the standard. A requirement has been made in this report. Although the home has been providing some training, mandatory training requires updating and providing. The home needs to develop the training Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 7 programme to ensure that all staff receives the required training, including any specialist training identified to meet residents individual needs. The induction training requires further evidence in line with Skills for care Common Induction Standards to ensure that staff have the competence to meet resident’s needs. A requirement has been made in this report. Recommendations for improved practice have been made in respect of: the development of PRN medication guidelines, a review of the current quality assurance system to more clearly evidence how user and staff feedback influence service development, and improved frequency and content of staff formal supervision sessions. These recommendations have been brought forward from the last inspection. 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. The summary of this inspection report can be made available in other formats on request. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users receive a care needs assessment prior to moving into the home. Standard 6 is not applicable to this home. EVIDENCE: There is a care needs assessment carried out by the management team prior to admitting new service users and there are joint assessments/care plans from the placing authority on file. The management team needs to ensure that thorough details of prospective residents are recorded and that the home can meet the needs of people who may be confused. The home also needs to ensure that they only admit residents who have been professionally assessed within the category of their registration. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 10 The people who use the service confirm that they received a visit from a Manager of the home before coming to stay and if they were unable to look round the home themselves a member of the family visited. Residents surveyed say they received information on the home before admission. Resident comment: ‘Everyone was very helpful and answered my questions’. Relative comment: ‘It was initially very difficult for me as well as my relative when she entered the residential home. The Registered Provider and all the staff helped me as well as my relative through that difficult period’. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments require further development to ensure service users needs are met. The management and administration of medication ensures that service users health care needs are met. Improvements are required to ensure that all residents’ rights and choices are promoted. EVIDENCE: Staff demonstrated their awareness of meeting service user needs including moving and handling requirements however this information is not sufficiently detailed in the care plans. Goals need further clarification and information Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 12 from the assessments/care plans needs to be more thorough. In some cases the needs have been identified but the plan does not detail how it will be achieved whilst ensuring service user choices and preferences. Residents who lack capacity do not have detailed information to manage their complex needs. The moving and handling risk assessments to do not give staff clear guidelines of a safe practice of work. The requirement from the previous report has been partially met with regard to service user being involved in the care plan. A requirement will be made in this report to address the above issues. Health care needs are monitored through the care plan and there is evidence of multi agency support in the home. Service users say that the home always calls the doctor if they do not feel well. At the time of the visit a District Nurse confirmed that the home was responsive to health care needs and are able to act on what is required. Equipment to reduce pressure sores is in place and staff discussed the care of one service user however again this good practice was not reflected or recorded in the care plan. Care Management comment: ‘There is some room for improvement with regard to mental health needs’. The medication policy has been reviewed but further detail is required to include procedures if drug errors are made, the use of over the counter medicines, auditing procedures, service user capacity to self medicate, consent, monitoring and review. The home is yet to implement a protocol re as and required medication to provide guidelines for staff to recognise when service users who may lack capacity are in pain. A recommendation will be carried forward in this report. All staff administering medication has received training. Written information on the MAR sheets needs to be consistently countersigned to reduce the risk of error. In general the records are in good order and storage of medication is satisfactory. Feedback from residents and their relatives express overall satisfaction at the care and support offered by the staff and they feel they are treated with dignity and respect. From observation it was clear that staff interact with service users respectfully and are polite and courteous. One service user says that all of the staff are very good when providing personal care. Although there has been positive feedback from relatives and residents the information received from professionals did not fully reflect this. One comment from a care manager indicates that a resident’s dignity was compromised due to lack of understanding of dementia needs. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is developing a flexible programme of stimulating activities for service users that take account of their preferences. Visitors are welcomed in the home. Further support is required to ensure that residents who may lack capacity are supported to exercise choice and control over their lives. The meals in this home are good offering both choice and variety. EVIDENCE: There are varying views with regard to activities in the home. There are some individuals who prefer not to participate and others who wish to have more stimulating activities. Three of the service users are able to visit the local town another service user has his own computer and has made a photograph Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 14 album for the home. This includes staff, service users, relatives and visitors and the photographs are taken in all parts of the home including the garden. The home has introduced an afternoon of fun and activities each Wednesday. Service user feedback was very positive, with comments as follows: ‘The skittles game really made me laugh we had a lot of fun’. Another service user was very positive, as she had won a prize at the bingo session. There is evidence in some care plans of preferences of activities. The home needs to continue to develop the programme to ensure individual’s preferences are included. Relatives visit the home regularly and can see their relative in the privacy of their own room or quieter areas in the home. Feedback from relatives indicates they are made to feel welcome in the home. Overall feedback from residents indicates their rights and choices are upheld, however the home needs to demonstrate further how they offer choice and support to residents who may be confused or have dementia. There is some evidence of good practice by ensuring that daily contact with family is provided for one resident however further improvements are required. A requirement has been made in this report. The home does not become involved in the financial affairs of service users, preferring to direct them to someone more appropriate, most users spoken with indicated that their families or solicitors manage their affairs. There are some service users who manage their own financial affairs and if required the home has systems in place for the safe keeping of valuables. The meal looked appetising and well presented. The home has a vegetable garden and vegetables are picked and serviced the same day. The cook talks to service users daily to ensure they have their choice and likes and dislikes are recorded in the kitchen. The home needs to record how residents who are less able are supported to make their individual choice when choosing their meals. All appropriate temperatures are recorded. Feedback from service users and staff indicates the meals are good. All service users spoken to say the food is good and they enjoy the fresh vegetables. Apart from two days of the week cooked teas are also provided. Drinks and water are readily available throughout the day. One staff comment: ‘The residents are bored with breakfast’. There are only two members of staff on duty when breakfast is served and the home needs to review staffing levels to ensure that residents have a varied choice. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident complaints will be listened to and dealt with appropriately. Improvements are required to ensure that residents are protected from abuse. EVIDENCE: The home has a complaints procedure, which is on display and resident’s feedback indicates an awareness of the complaints procedure and who to complain to if needed. Residents spoken to say they have no complaints but would speak to the Manager or a relative if they had any concerns. Resident comment: ‘There are many staff who I feel I can share my problems with’. There is currently an adult protection alert, which has not been concluded. This has raised issues around dignity, choice, appropriate interventions and support for a resident with dementia. Whilst this person is no longer at the home there are concerns with regard to the lack of insight and awareness demonstrated by the home in their understanding of good practice in relation to working with this client group. Staff are in the process of completing adult protection training. Recruitment records could be improved to ensure that residents receive care from staff that have been appropriately vetted. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 16 Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident benefit from an environment, which is well maintained, clean, comfortable and homely. EVIDENCE: The home and gardens are maintained to a high standard and the home has continued to renew and redecorate to improve the environment. Residents confirm they have their own personal possessions in their rooms and the home is comfortable with a relaxed friendly atmosphere. There are several different areas in the home, one large lounge/dining room area, a smaller dining area and conservatory where residents can look out on the spacious gardens. Improvements are required to ensure that staff can hear the call bell system in Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 18 all parts of the home. The Registered Manager stated that the system will be amended to ensure that the call bell can be heard in all parts of the building. The home employs two domestic staff ensuring the home is clean and free from offensive odours. Not all staff have received infection control training. Residents say the home provides a good laundry service. Feedback from surveys, and discussion with residents confirms the home is always clean, fresh and tidy. Staff feel that the home would benefit by having a domestic member of staff on duty on Sunday. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff demonstrated a good understanding of residents care needs. A review of afternoon staffing numbers has ensured resident’s needs are fully met. A programme of NVQ2 training is in place. Improvements are required to the staff recruitment and vetting practices within the home to address shortfalls. EVIDENCE: At the time of the site visit the Registered Provider, Registered Manager, three care staff, one cook and two domestic staff was on duty. In the afternoon there is only two care staff on duty supported by the Registered Provider and Manager. The current dependency of two service users requiring two carers must be considered during the afternoon/weekends should the Registered Provider and Manager not be available. The cooking of the tea and the administration of medication reduces the number of staff available to care for residents when only two members of staff may be on duty. Staffing levels therefore need to be reviewed in line with the residential forum to ensure that at all times the needs of the residents are met. The Registered Manager has Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 20 now taken action to ensure that adequate staffing levels are now in place and therefore no requirement will be made in this report. The new staffing levels to come into effect from Friday 27 September 2007. The home now has over 50 of staff who have achieved NVQ 2 or above and at the time of the site visit one carer was being assessed to achieve the award. Recruitment practices have improved and the requirement from the last inspection has been partially met, however, staff files viewed show that two application forms do not show full employment history and are not fully completed. A requirement has been made in this report. Criminal Record and POVA checks are in place together with two references and proof of identity. The training programme needs to be developed to ensure that all staff receive mandatory training. Some training is being provided and staff has confirmed they are attending training courses. The training matrix indicates that the majority of training requires updating. he Registered Manager has taken action to identify a training and development programme to address these issues. The induction for staff needs to be linked to skills for care common induction training. Staff also require specialist training such as dementia to ensure that residents needs are met. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements in the management of the home are required to ensure that resident’s benefit from a home, which is run in their best interest. Arrangements are in place to ensure that resident’s finances are protected. Improvements in the frequency of supervision of staff are required to ensure they feel supported and valued. There are shortfalls in the mandatory training and management of risk assessments, which may compromise the health and safety of residents, staff and visitors. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager Mr George Thomas has several years experience of social care and management and has attained management qualifications. As a result of the ongoing adult protection alert there are areas of care practice, which need to be addressed within the management of the home, and he would benefit from completing the Registered Managers Award. He is hoping to commence the award next year. There is a staff structure in place ensuring there is always a senior staff member on duty. The Registered Manager does not provide direct care to service users and staff feel that when there is only two members of staff on duty that they are not fully supported by the management team to meet residents needs. A review of the staffing levels should address these issues. A programme of quality assurance is in place and residents confirm that surveys are sent out to them on a regular basis. The Registered Manager and Provider are in daily contact with the residents are listen to their views and any concerns they may have. There are informal meetings but these are not recorded. Residents say that they management listen to what they say and act upon their wishes. The outcome of the surveys are not summarised, published and there is no system in place to ensure that residents are aware of the results. The home has a policy to encourage residents to have their finances managed by their family, solicitor or representative. Arrangements are in place to ensure personal possessions are recorded and secure storage is available if required. There are a small number of residents who are able to control their own finances. Staff confirm that supervision is taking place but not on a regular basis. The recommendation will be brought forward in this report. Improvements are required in providing mandatory training and risk assessments. A fire risk assessment is in place and information in the accident book was complete and tracked through to the resident care plan and appropriate action taken. Information from the annual quality assurance assessments confirms that all relevant safety checks have been completed. Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 23 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 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 24 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 13,15 Requirement To provide further detail 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. This requirement has been partially met however further development is required therefore this requirements has been brought forward in this report. Previous timescale 31/10/06 To provide evidence of how the home supports residents who are less able to make decisions and have control of their daily life 2. OP14 12 The home needs to demonstrate 31/12/07 how they ensure that the rights and choices for resident who lack capacity are promoted To ensure the Management and 31/12/07 staff have a clear understanding of Safeguarding Adults procedures and staff have the skills and experience to deal with challenging behaviour DS0000023502.V348494.R01.S.doc Version 5.2 Page 25 Timescale for action 31/12/07 3. OP18 12,13 Pelham House Residential Home 4. OP30 OP38 13 To provide specialist training to meet residents needs To ensure that the induction training is linked for skills for care common induction standards and there is evidence of staff competency 31/12/07 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. 2. Refer to Standard OP3 OP9 Good Practice Recommendations To ensure that the information from the care needs assessment/joint assessment is included in the homes assessment and care plan The home should consider the development of medication profiles and PRN guidelines for individual service users to ensure medication is administered appropriately and consistently. This recommendation has been brought forward from the last inspection report. To ensure that residents dignity is not compromised To continue to develop the activity programme Home to review existing quality assurance measures to develop a system for self audit and evidence clearly how service user and staff feedback influence development of the service. This recommendation has been brought forward from the last inspection Home to review content and frequency of formal care staff supervision sessions 3. 4. 5. OP10 OP12 OP33 5. OP36 Pelham House Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Home DS0000023502.V348494.R01.S.doc Version 5.2 Page 27 - 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. 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