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Inspection on 16/01/06 for Pelham Lodge Residential Home

Also see our care home review for Pelham Lodge Residential Home for more information

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Pelham Lodge is run efficiently and in the interests of the residents. Residents live in comfortable and pleasant surrounding that are well maintained, refurbished as required and provide all the resources they need. There is a calm and pleasant atmosphere and residents are happy and contented. They are well cared for, like living there, are treated well and are safe.

What has improved since the last inspection?

There were no requirements or recommendations from the last inspection. However, ground floor rooms have been refurbished.

What the care home could do better:

When the complaints procedure is reviewed a timescale of up to 28 days for the home to respond to a complainant must be included. In addition, staff files must include recent photographs of the staff. Also all relevant information, including two references must be kept together in this file so that they are easily accessible. It is also recommended that records of induction are signed and dated when the actual training takes place, with further records kept to evidence that the member of staff was reviewed after a period of time to check their competence.

CARE HOMES FOR OLDER PEOPLE Pelham Lodge Residential Home 52 Pelham Road Gravesend Kent DA11 0HZ Lead Inspector Wendy Jones Unannounced Inspection 11:00 16 January 2006 th 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 Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pelham Lodge Residential Home Address 52 Pelham Road Gravesend Kent DA11 0HZ 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) 01474 334954/351127 Pelham Lodge Limited Mrs Balbir Kaur Dosanjh Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: Pelham Lodge is a residential care home for up to ten older people. Each service user has a single bedroom, which is equipped with en-suite facilities (some including a shower unit). There is a stair lift to the first floor. Bedroom accommodation is on the ground and first floors. The garden at the rear is suitable for use by frail older people. The owner/manager is a registered nurse and is undertaking the registered managers award. A comprehensive training programme for members of staff is underway. Twenty-four hour care is provided. Service users have ready access to all health services. The premises are close to Gravesend town centre. Car parking is available at the front. Public transport facilities are nearby. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by Wendy Jones, Regulatory Inspector between 11:00am and 1:45pm. Judgements are based on conversations with residents, management and staff, reading of care plans and a tour of the home. What the service does well: What has improved since the last inspection? What they could do better: When the complaints procedure is reviewed a timescale of up to 28 days for the home to respond to a complainant must be included. In addition, staff files must include recent photographs of the staff. Also all relevant information, including two references must be kept together in this file so that they are easily accessible. It is also recommended that records of induction are signed and dated when the actual training takes place, with further records kept to evidence that the member of staff was reviewed after a period of time to check their competence. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 the following standard(s): 3, 4, 5 Prospective residents and their relatives have the opportunity to visit the home and are assured their needs can be met. EVIDENCE: Two new residents have moved into the home over the past week. One has stayed at the home for respite previously. Daily records showed that these residents’ needs had been assessed. A new resident spoken with said that they are “well looked after and made to feel special”. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Residents’ health, personal and social care needs are fully met and they are treated with respect. Medication procedures and storage arrangements protect the residents. EVIDENCE: Residents care plans contained details of their health and personal care needs and all other appropriate information. Residents’ medication is securely stored in a locked cupboard. A small fridge is used for medication. The fridge contained medication that was labelled “store under 25 degrees”. The suitability of keeping this medication in a fridge at a temperature so much lower than 25 degrees was discussed. The manager agreed that the temperature in the home was not above 25 degrees and this medication was removed from the fridge. Medication records were not inspected on this occasion but this standard had been met at the previous announced inspection on 28 January 2005. Residents said that all their needs are being met and they are very happy with the help and support they get. Staff on duty were clear about the help and Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 10 support residents need and treated them with respect. Residents clearly trusted and had a good relationship with them. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: All standards in this section were met when assessed at the previous announced inspection on 28 July 2005. It was noted, however, that care staff carry out cooking and domestic tasks in addition to providing care. Residents spoken with commented that they were “looking forward to their lunch”, that they “will always eat it” and “the food is very good and we have some good cooks”. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 the following standard(s): 16 Residents are confident that their complaints are taken seriously and acted upon. However, they would benefit further if they knew the timescale in which the home undertakes to respond to their complaints. EVIDENCE: There have been no complaints since the last inspection. The complaints procedure does not include a timescale for the home to respond to a complainant. A timescale for investigating complaints of up to 28 days must be included in the procedure. The manager advised that the complaints procedure is due to be reviewed very soon and would ensure that this was done. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 the following standard(s): 19 - 26 Residents live in a clean, pleasant, safe, comfortable and well-maintained environment. EVIDENCE: Pelham lodge has 10 single rooms, all with en suite facilities and some with shower units. There is one large lounge with comfortable chairs, music, a television and a dining area at one end with room to seat all residents. One resident said that they preferred to eat their meals in their room. The kitchen leads from the lounge. There is one communal bathroom with a mobile bath hoist. A call bell system is installed in all bedrooms and communal areas for residents to call for assistance if needed. Downstairs rooms have recently been refurbished. The first floor is reached by a set of stairs that have two stair lifts fitted. Fire doors are situated at the top and bottom of these stairs. The doors are kept Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 14 open with doorstops that are connected to the fire alarm and release so that the doors close if the fire alarm sounds. Residents’ rooms were comfortably furnished and contained their personal furniture and effects. Everywhere was extremely clean and there were no offensive odours. The laundry is in the basement and contains one industrial washing machine and one dryer. Clean and dirty laundry is kept separate and clean laundry is taken back to the residents room as soon as it is dry and ironed. Clean bed linen is kept in a separate area of the basement. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Residents are protected by the home’s recruitment process and an appropriate number of skilled and competent staff are on duty at all times. However, the recruitment process would be further improved if all required documentation is kept in the staff file and easily accessible. EVIDENCE: There were 10 residents living in the home. The senior carer, one carer and the manager were on duty. The staffing was appropriate to meet the needs of the residents living in the home at this time. Staff were able to carry out their duties unhurriedly and efficiently and had time to speak with residents. Staff files seen included all relevant information but did not contain photographs of the staff. In addition, the file of a member of staff who had been recruited recently did not contain copies of two references. The manager was clear that two references had been received and recalled receiving the reference that was missing. She said that this must have been omitted from the file, and she would locate it and make sure it is filed in the staff file. Training and induction records were seen. The home uses the ‘Mulberry House’ induction programme. Records of induction for the newest member of staff were seen. Although the subjects had been ‘ticked’ as completed neither the member of staff or the trainer had signed and dated to evidence when this had been completed. The manager explained that this is done after a period of time after which the member of staff is assessed to ensure they are Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 16 competent. These records must be signed and dated when the actual training takes place and further records kept to evidence that the member of staff has been reviewed to check their competence. The manager confirmed that the induction covered a six-week period and it was suggested that the expected time frame for completing the subjects listed be included i.e. what is covered on the first day, first week etc. There are 10 members of staff including the senior carer. Four staff have completed NVQ2 in Care and 3 are due to start the course shortly. The senior carer is currently completing the final unit of the NVQ 3 in Care. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 Residents benefit from living in a home which is well managed and safeguards their best interests. EVIDENCE: The registered manager is very experienced and runs the home competently and in the best interests of the residents. She is a registered nurse and has achieved the Registered Managers Award. The atmosphere in the home was calm and pleasant and residents spoken with were happy, contented and felt they were well looked after. Although financial records and accounts were not seen on this occasion there was evidence that the home was financially viable and the structure and contents of the home were in good condition. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 18 The registration certificate was prominently displayed. Appropriate insurance cover is provided and a current insurance certificate is displayed. Small amounts of cash are kept securely for residents in separate envelopes. Records kept clearly show the money put in the safe for each resident, what has been spent and what this leaves. Supervision records were seen which evidenced that regular staff supervision is being carried out. All staff were clearly competent and aware of the help and support that residents needed. All records seen were stored securely and confidentially in locked cabinets. Training records showed that staff had received initial, in depth, manual handling training to avoid injury to residents or themselves. The manager explained that regular updates will now be provided to make sure staff are kept up to date. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 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. 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x x Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 (4) Requirement The complaints procedure must contain details of the timescale within which the complaint will be investigated. This must be within 28 days after the date the complaint is made. Staff files must contain two satisfactory references and a recent photograph of the member of staff. Timescale for action 31/01/06 2. OP29.1 19 (1)(b)(i) 31/01/06 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 OP30 Good Practice Recommendations Induction records should include the signature of the trainee and trainer and the date when each subject is covered. Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pelham Lodge Residential Home DS0000059218.V269851.R01.S.doc Version 5.0 Page 22 - 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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