Inspection on 31/07/08 for Pelham House Residential Home

This inspection was carried out on 31st July 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pelham House Residential Home 20/09/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pelham House Residential Home 5/6 Pelham Gardens Folkestone Kent CT20 2LF Lead Inspector Mark Hemmings Unannounced Inspection 31st July 2008 08:45 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.V367622.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.V367622.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.V367622.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 20th September 2007 Date of last inspection Brief Description of the Service: Pelham House (the Service) is registered to provide accommodation and personal care for 21 older people and one younger adult. The premises are two quite large properties that have been joined together on the ground floor. The accommodation is on the ground floor and the first floors. All of the people who live in the Service can have their own bedroom. Each bedroom has a private wash hand basin. Two of them also have a private toilet and bath. There is a call bell system that people can use from their bedroom if they need to ask for assistance. There are several lounge/sitting areas and there is a conservatory. This looks out onto a large garden at the rear of the building. Some of the garden is laid out as a patio. There is an adequate number of bathrooms and toilets. There are sensible things such as banister rails to help people get about. However, there is no stair-lift. This means that people have to be able to manage stairs on their own. Or they have to rely upon and to wait for assistance to go up and down. The Registered Providers are private individuals. People who might want to move in can get information in several ways. There is a Service Users’ Guide. This is a brochure that outlines the main things available in the Service. There is also a document called a Statement of Purpose. This gives a more detailed account than the Guide. The Registered Providers ensure that a copy of the most recent Inspection Report from the Commission is available for people to read. The range of fees charged currently for each person to live in Pelham House runs from £320.00 to £550.00 per week. The amount actually charged depends upon the amount of personal care needed and the bedroom occupied. The fees include all accommodation, meals, personal care, laundry and in-house entertainment. They do not cover things such as personal toiletries and hairdressing. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this Service is 2 Star. This means that the people who use this Service experience good quality outcomes. Since 1 April 2006, we have developed the way we do our inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. We arrived at the Service at 08.45 and were in the Service for about eight hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Registered Providers in their self assessment. This is called the Annual Quality Assurance Assessment (the Assessment). Further, it considered any information that the Commission has received about the Service since the last inspection. During the inspection, we spoke with one of the two registered providers. In this report we refer to him as being “the Registered Provider”. We spoke with five of the people who live in the Service. We also spoke with five care workers and with the cook. We saw the lounges, some of the bathrooms and toilets and some of the bedrooms. We walked around the grounds and we looked at a selection of key records and documents. What the service does well: What has improved since the last inspection? The individual plans of care have been made more detailed. Some of the bedrooms have been redecorated. New carpets have been put down in parts of the hallways and in the conservatory. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 6 A new training resource pack has been introduced. This enables care workers to do training that is geared carefully to the needs of the people who currently live in the Service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People who are about to move in are asked about what support they need and how they want this to be done. People who want to stay for shorter periods are helped to go back home. EVIDENCE: The Registered Providers ask people who are considering moving in about what support they need and want. This is done so that everyone can be confident that moving into Pelham House is the right thing for them. The Annual Quality Assurance Assessment recognises the importance of this process. We looked at the sorts of things that are usually considered. These are practical and Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 9 relevant. For example, they include the help that is needed for the person to use the bathroom in safety and comfort. Also included is an account of their general health and the medication they take. The Registered Provider then tells care workers about what he has learnt so that they know what to do from the start. We asked four care workers about how this all works out in practice. They say that the system works well and that they know about the support they will need to provide as soon as someone comes in. Some people stay for shorter periods of time. This can be on a planned basis or as a one-off. These shorter stays might be because they have been in hospital and are not yet ready to go home. Or, it might be so that a carer can have time to themselves. The Registered Provider says that careful attention is given to helping people to go back home so that their stays do not last longer than is necessary. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People are provided with the personal and health care they need. Medicines are dispensed in the correct manner. People are treated with respect. EVIDENCE: The people who live in the Service say that the care workers offer them all the assistance they need. There is a written individual plan of care for each person. These are important because they are one of the ways that people can say what assistance they want to have and how they want it to be done. Also, the plans give information to staff so that they know what to do. We looked at four of these plans. They give a clear account of who needs to do what and why. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 11 For example, there is useful information about things such as helping people in the bathroom, about health care and about keeping people safe. We asked five care workers about some of these requirements to check out their understanding of what the plans say. They have a good knowledge. For example, they know about one person who has been in hospital and who now needs to be encouraged to walk about. They also know about another person who needs to be encouraged to eat a little more and someone else who needs to be supported to lose some weight. The plans are kept up to date so that they are accurate. This includes a monthly review. At the moment, these monthly reviews do not actively involve each of the people who live in the Service. The Registered Provider is going to look into this so that people are more clearly invited to take part. Sensible steps are taken to ensure that people do not have any avoidable accidents. For example, one person has chosen to have bed rails fitted so that they don’t roll out of bed. The Registered Provider considered this carefully before fitting the rails. This is because bed rails can sometimes make a problem worse if they are used at the wrong time. People are helped to keep healthy. Care workers keep a tactful eye open so that medical assistance can be sought if someone is becoming unwell. Since our last inspection, a number of people have seen their doctors, some on more than one occasion. There have also been consultations with professionals such as district nurses, community psychiatric nurses and chiropodists. One person has a routine medical condition that needs to be monitored and managed in a particular way. At the moment, there is no clear written information about this. Some of the care workers are not sure about the signs that would indicate the need to contact the doctor. The Registered Provider is going to sort this out by 1 September 2008. None of the people manage their own medication. The Registered Provider says that people will be assisted to do this if this is their wish. There is a system to check that the correct medicines are received from the chemist. Once in the Service, they are stored securely. There is a procedure for administering medicines that is designed to double check that the right medicines are given to the right people at the right time. There is a record that is completed on each occasion that a medicine is dispensed. We examined three sets of these records. They are correctly completed. We looked at three medicines in more detail to see if the remaining stock matched what should have been there. Again, we found things to be in order. We asked five people what they think of the care workers. They praise them saying that they are courteous and attentive. One person summarised the general mood when they say, “the girls (care workers) are just so kind and helpful. I don’t feel that I’m a nuisance at all and I can ask them for things whenever I want. I really do want to stress how lucky I am to have found Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 12 Pelham House”. One of the visitors we spoke with says “I call, here three times or so a week to see mum and so far I am very happy with how things are going. She has a nice room and the staff are always attentive and courteous. I feel safe leaving her here and that is very important because I know she’ll be well cared for”. We noted how the care workers are relaxed and informal in how they are. We also noted how people are assisted to use the bathroom in a private manner. They are quietly helped to leave their armchairs. Once in the bathroom the door is closed to give them privacy. People are helped to wear neat and clean clothes so that they can present themselves as they wish. People are given their post promptly and they have the use of a telephone. Pelham House Residential Home DS0000023502.V367622.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): Standards 12, 13, 14 and 15. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. The calendar of social activities is not well organised. People are free to receive visitors and to spend the day as they wish. Good quality meals are served. EVIDENCE: Each week people are invited to join in a social afternoon. This gives them the chance to get together for some light hearted games, a chat and a cup of tea and cakes. We looked at the records of who attends these events and we noted that most people do go along. People say that they enjoy these afternoons. However, apart from them there is not that much going on in the Service. When we were there we saw a lot of people spending time on their own in their bedrooms. We think that the Registered Providers need to take another look at this. The Registered Provider says that he is now going to have Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 14 a chat with each person to see if they would like to have more social opportunities. He is going to do this by 1 October 2008. People are helped to keep in touch with members of their families, if this is necessary and if it is their wish. Family members and friends are welcome to call to the Service at any reasonable time. The Manager keeps in touch with family members so that they know how things are going. For example, we noted that the relative of someone who had been admitted to hospital had been contacted on the day in question. The Annual Quality Assurance Assessment says that people are encouraged to make their bedrooms their own. For example, they can bring personal things in with them like small items of furniture, ornaments and photographs. We saw examples of all these in the bedrooms we looked at. One person had almost completely furnished their bedroom with their own bed and other items of furniture. People say that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant affair. The Registered Provider and the cook say that there is a choice of dish at each meal. Some of the people who live in the Service confirm this. However, the records of the meals actually served are not detailed enough for us to know how often people are choosing an alternative to the main dish served at lunchtime. The Registered Provider is going to make sure that the record is now more detailed so that we can tell who is having what. The overall menu does provide people with a normal healthy diet. People can dine in their bedroom if they want to. Special diets can be met. Also, some people are helped by having their food cut up into smaller pieces to make it easier for them to manage. Pelham House Residential Home DS0000023502.V367622.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): Standards 16 and 18. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. There is a system for sorting out complaints. People are kept safe. EVIDENCE: There is a written complaints procedure. This explains how someone can go about raising a concern. Most concerns can be sorted out locally without things being too formal. However, people can always speak to us first if they don’t feel comfortable about talking with a member of staff. The procedure does not explain this option and it does not give our correct contact details. The Registered Provider is going to put tbis right by 1 October 2008. We asked two people about how free they feel to raise a concern with the Registered Provider or with other members of staff. They say that they are confident to approach them. They also say that there was no need to do so at the moment, because they do not have any concerns. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 16 Neither ourselves nor the Registered Providers have received any formal complaints since our last inspection visit to the Service. There is a written statement of the Registered Providers’ commitment to making sure that the people who live in the Service are safeguarded from being abused in any way. For example, this might involve being bullied or taken advantage of in some way. We asked four care workers about this matter. They have a good knowledge of things to look out for that might be a cause for concern. None of them have any concerns about how things are going. The people who live in the Service say that they feel safe in Pelham House. Pelham House Residential Home DS0000023502.V367622.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): Standards 19, 22, 25 and 26. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. The accommodation in general is homely and comfortable. However, bathrooms and toilets are rather bare. Better equipment could be provided to help people get about. EVIDENCE: On the outside, the building is well maintained. The gardens at the front are neat and attractive. At the back, there is a walled garden. This is planted out with various shrubs. There is a large patio area. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 18 On the inside, the accommodation including the bedrooms is homely. The decoration and the furnishings are of a good standard. However, the bathrooms and the toilets are clean but rather bare. More could be done to make them into welcoming spaces. The premises are fitted with an automatic fire detection system. This provides a high level of fire safety protection. It is understood that the Kent Fire and Rescue Service says that the system meets the national standard. The Registered Provider has prepared a fire risk assessment. This has been done to make sure that there is nothing that might reduce the level of protection in place. Since it was done a new keypad lock has been fitted to the front door. This might be fiddly to use if there is a fire and there is lots of smoke around. The Registered Provider is going to look into ways of sorting this out. One option might be to fix the lock so that it opens automatically if the fire alarm sounds. The problem is going to be sorted by 1 October 2008. This will be included in an updated version of the assessment that will be sent to the Kent Fire and Rescue Service so that it can check that the solution is okay. The local Department of Environmental Health inspected the kitchen just before our own inspection. It said that two minor things needed to be put right. The Registered Provider says that both of them have been done. One of them involved the need to record fridge temperatures to make sure that food is kept cold enough. We looked at the records in question and we found them to show the cold storage to be working all right. The kitchen is well equipped, clean and well organised. The cook does sensible things to ensure good food hygiene. For example, once food is opened it is covered. Then a date is written on it to make sure that things are not allowed to hang around too long. People who need it are helped to get about. There are banister rails in corridors. At key places there are assistance poles. These are fitted to the wall and they are there for people to hold onto for extra support. Help is also given in the bathroom. The baths are fitted with seats that rise and fall. However, these are a rather old fashioned design. These seats are fixed and so they cannot swivel to make it easier for people to get on and off. The Registered Provider says that he will look into replacing at least one of them with a more up to date version. As we said earlier, the Service does not have a passenger lift or a stair-lift. To get to the first floor, you have to use one of two staircases. Most of the people who have their bedrooms on the first floor can manage to use the stairs, although most need a guiding hand to help them. However, two people can’t use the stairs. When they want to come downstairs they have to use a motorised chair that climbs up and down each step. This device needs to be used in a certain way. The Registered Provider has decided that it should only be used when he can do it. We don’t think that this motorised chair is a good idea at all. It is slow and cumbersome. It is necessarily less safe than a stair lift. It doesn’t make for normal living and it can only be used when the Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 19 Registered Provider is around. We think that stair-lift is a much better idea. The Registered Provider says that he will look into this as a matter of priority. We asked people how warm the accommodation is kept. They say that they are always comfortable even during the coldest weather. The radiators are fitted with guards. This has been done so that there are no heated surfaces that might burn someone. The hot water taps are fitted with thermostatic valves. These are designed to reduce the temperature to a level that is not likely to scald someone. The laundry has a commercial grade washing machine. This has an extra cycle for items that need an especially hot wash. There is also a large dryer. The laundry is organised and clean. The Registered Provider is going to check that the laundry complies with new regulations about preventing used water from leaking back into the main pipe-work. This will be done by 1 October 2008. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. There are enough staff around. There are some shortfalls in the recruitment system. Care workers know what they are doing. EVIDENCE: From early in the morning until the early afternoon there are three care workers on duty. This number reduces to two care workers until the night time cover starts in the evening. There is a cook and a housekeeper. We looked at the written roster for the three days before out visit. All of the shifts described to us had been filled. The tea time arrangement is that the cook starts off the tea before she leaves after having done the lunch. Then one of the care workers goes into the kitchen at tea time to finish off preparing the meal. We think that this arrangement might result in care workers being rushed. This is because Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 21 they’ve got all their normal work to do in addition to fiddling around in the kitchen. The Registered Providers need to keep this matter under careful review. At the moment there are only 16 people in residence. Certainly, an additional care worker will be needed at tea time once the number living in the Service increases. The Registered Providers complete a number of security checks on new care workers. These include things such as confirming their identity and doing a police check. This is done to ensure that they are trustworthy people who are suitable to have unsupervised access to the people who live in the Service. We looked at the records for two of the care workers. Most of the checks have been completed. However, for both of them the employment histories do not give a full account of what work they have done. This means that we cannot be sure that all of the necessary references have been requested. We do know that one reference for Care Worker A is missing. The Registered Provider says that these shortfalls will be put right by 1 October 2008. New care workers receive introductory training before they work on their own. We asked two care workers about their introductory training. They say that it was very useful. They say that they were introduced to the people who live in the Service and that they were told about each person’s needs for support. After their introduction, care workers are provided with ongoing training. This is designed to develop further their ability to provide a high quality residential care experience. We looked at some of the records of this extended training provided for care workers. These show that care workers have done training on relevant things such as first aid, food hygiene, helping people to move about safely and on keeping people safe. The training is being done using a new resource pack. This involves care workers watching dvds, discussing issues and receiving advice. Then they complete tests to see what they have learnt and what more they might need to learn. We think that this sort of hands-on training is a very good idea. This is because it is directly related to the needs of the people who live in the Service now. There is a total of eight care workers. Of this number, six have completed a National Vocational Qualification at Level 2 in health and personal care. This qualification is important because it helps care workers deliver high quality residential care services. We spoke with five care workers to find out about their knowledge and skills. They know a lot about how each of the people who use the Service like to be supported. They also know about important points of detail. For example, they know about helping older people to take care of their skin and about the important contribution that good hygiene makes to health and safety. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 22 Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. Things are well managed. People are asked what they think, but this needs to be a little more organised. People are helped to say what they want. A part of the fire safety regime needs to be strengthened. EVIDENCE: The Registered Provider we met also manages things. He has a management qualification. He is in the Service most days and he has a detailed knowledge Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 24 of how things are going. Care workers feel that they can talk to him without being formal or wary in any way. He also has a good relationship with the relatives. One relative sums up the general mood when they say “(the registered providers) are excellent with all the residents and I would highly recommend them and Pelham House”. The care workers say that there is good teamwork between them. There are handover meetings at the beginning and end of each shift. These are held so that care workers can be kept up to date with developments. We looked in on one of these. It was informal but organised. The care workers talked about things such as people’s health care needs and forthcoming medical and social appointments. Care workers say that the small size of the team helps. This is because people meet each other quite regularly and talk about things to do with the Service. There are team meetings every now and then. We looked at the records of the last two of these. They show that useful things are being considered such as how the individual plans of care can better be kept under review. Several things are done to ask people what they think about their home. These include informal discussions as part of daily life. The people who live in the Service or their relatives are invited to complete questionnaires about once a year. We looked at the most recent questionnaires. There were 13 of these and they show that people are quite happy with how things are going. There are no criticisms as such. One person would like to see more social activities. There are some shortfalls in the consultation arrangements. Members of staff are not included. Also, there is no organised system to tell contributors what is going to be done to respond to any improvements that they may have suggested. The Annual Quality Assurance Assessment recognises the importance of asking people what they think, without really having a plan to strengthen how this is done. The Registered Provider says that the system will now be strengthened. This will be done in time for us to be told about it when the Registered Providers send us their next Assessment in 2009. The Registered Providers help some of the people to manage their personal spending monies. They have been asked to do this by the people concerned. It involves them paying for things such as seeing the hairdresser and then billing relatives every now and then. We looked at one set of records. This was done to see if there is a receipt to cover one of the items included in the bill sent to the relative concerned. We found the receipt to be there and the bill to be correct. Regular checks are completed to ensure that the Service’s fire safety equipment remains in good working order. This includes a weekly test of the fire alarm bells. More detailed periodic checks are completed by a contractor. There should be fire drills twice a year. The last one was held in June 2007. The Registered Provider says that the drills were stopped on the advice of a fire safety consultant. This advice is not right and the Registered Provider says Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 25 that the drills will now be started again. There is an annual fire safety lecture. The last one was held in December 2007 and most of the care workers were there. The Registered Providers are now going to strengthen this arrangement by making sure once every six months that all members of staff know how to reliably follow the Service’s fire safety procedure. This is important because the level of fire safety protection in the Service largely depends whether or not members of staff do the right things at the right time. The Registered Provider says that the improved system will be up and running by 1 October 2008. There are up to date reports from engineers about the gas appliances and the electrical wiring that say that they are safe to use. The bath seats we mentioned earlier have not been inspected and serviced for several years now. There is some uncertainty about what checks need to be done. The Registered Provider is going to contact the manufacturer to sort this out. Any checks that are recommended will be done by 1 October 2008. We looked at the record of accidents that have occurred in the Service since the last inspection. There is nothing in the frequency or in the nature of the accidents that causes us concern. The Registered Provider says that he checks the premises and the accommodation to ensure that there are no hazards that might cause someone to have an accident. We looked at the records of the most recent check. These show that sensible things are being looked at. For example, he looks to see that wardrobes are secure and won’t topple over on someone. He says that there are no obvious hazards. We didn’t notice any. Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 26 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 2 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pelham House Residential Home DS0000023502.V367622.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone 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.V367622.R01.S.doc Version 5.2 Page 29 - 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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