Inspection on 16/01/07 for Pelham Lodge Residential Home

This inspection was carried out on 16th January 2007.

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.

Other inspections for this house

Pelham Lodge Residential Home 16/01/06

Pelham Lodge Residential Home 28/07/05

Pelham Lodge Residential Home 16/08/04

Pelham Lodge Residential Home 29/04/04

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 Lodge Residential Home 52 Pelham Road Gravesend Kent DA11 0HZ Lead Inspector Marion Weller Key Unannounced Inspection 16th January 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 Lodge Residential Home DS0000059218.V326544.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 Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 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.V326544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Pelham Lodge is registered to provide care and accommodation for up to 10 older people. The premises are close to Gravesend town centre with public transport facilities nearby. Limited car parking space is available for visitors at the front of the building. Residents’ bedroom accommodation is on the ground and first floor. There is a stair lift to the first floor for residents use. The home does not provide a passenger lift. Each service user has a single bedroom, which is equipped with en-suite facilities (some including a shower unit). The garden at the rear of the property is suitable for use by frail older people. The owner/manager is a registered nurse and has completed the registered managers award. The home employs care staff working a roster, which provides 24-hour cover. The home does not offer nursing facilities. Care staff also undertakes catering and cleaning duties in the home. Current fees range from £316-£360 per week according to assessed personal need. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector between 9:30 am and 3:35 pm. During that time the inspector spoke with some residents, the owner/manager and some of the staff on duty. Some judgements about the quality of life in the home were taken from observations and conversation. Some records and documents were looked at. In addition a tour of the building was undertaken. Four survey responses were received prior to the inspection. Responses from residents indicated that they were very satisfied with the standard of care the home provided. One respondent however felt the home did not offer sufficient activities and another had some concerns that the single downstairs toilet was not sufficient to accommodate residents’ needs at certain times of the day. Statements on surveys included: “Pelham Lodge is always exceptionally clean and tidy” “When it is required, I receive medical support quickly” “There is a problem with the downstairs bathroom when occupied by other people, you have to wait.” “Activities take place once a fortnight, would like more” The owners and staff gave their full cooperation throughout the visit. What the service does well: Pelham Lodge is run efficiently and in the interest of the residents who live there. Residents receive a very personal service and live in comfortable homely surroundings that are well maintained. There is a calm and pleasant atmosphere in the home and residents spoken with felt they were treated well and were very happy and content. The owner/ manager was said to respond very positively to any comments or concerns raised with her by residents or their representatives. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pelham Lodge Residential Home DS0000059218.V326544.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 Lodge Residential Home DS0000059218.V326544.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): 12356 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accessing and using this service have the information they need to make an informed decision about whether the service is right for them. The personalised pre admission assessment means that residents’ diverse needs are identified and planned before they move into the home and they are given a contract that clearly tells them about the service they will receive. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, which provide residents or their representatives with the information they need to make a firm decision about moving to the home. The documents had a last review date of November 2006. The manager stated that the home’s information documents are reviewed annually or more frequently if there is a need. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 9 The home’s complaints procedure had been revised to include details of the timescale within which a complaint would be investigated, as required in the last inspection report. The revision clearly shows that complaints will be responded to within 28 days. The complaints procedure would further benefit from adding a brief statement that informs residents or their representatives that the Commission can be involved at any stage of a complaint and not just as a final resort. The manager stated her intention to rectify this issue. Residents and their representatives are able to visit the home before deciding to move in. Residents have a full pre admission assessment prior to moving in to ensure their needs can be met by the home. Completed assessments were seen on residents’ files. Each resident has signed a contract with the home for their care, this outlines the terms and conditions of their stay and clearly shows the rights of residents and the responsibilities of the home. Fees charged to individuals for their care were available for inspection and were detailed on each contract in resident’s files. The manager was aware that The Dept of Health has changed regulatory requirements recently to clarify in more detail the type of general information about fees and related services that care home providers must include in their information documents. The manger stated her intention to review the home’s documents in line with this updated guidance. The home does not provide intermediate care and therefore standard 6 is not applicable to Pelham Lodge. Pelham Lodge Residential Home DS0000059218.V326544.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): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are clearly set out in their care plans ensuring that these needs will be met. Residents are largely protected by the home’s policies and procedures regarding medication. They can be confident that where shortfalls exist the home will review its arrangements and facilities in light of good practice advice to secure their safety and protection. Residents’ privacy and dignity is considered important and their independence is promoted. EVIDENCE: Care plans were seen to be individually maintained in the home and were made available to staff for guidance. Some were inspected closely. The Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 11 content was easy to understand and covered the health; personal and social care needs of individuals. Care plans had been regularly reviewed and changes had been made to the main plan where it was necessary. Residents or their representatives had signed care plans to evidence both their involvement in its formulation and their agreement to it. Residents’ daily records were being maintained. These were kept separately from individuals’ plans of care. Consideration must be given to ensuring residents’ information is not fragmented around the home. Daily records were seen to be comprehensive and reflected plans of care. Residents weight and nutritional records were being maintained and were regularly updated. Generic and individual risk assessments were seen to be in place, which paid particular attention to the avoidance of falls. Referrals to falls clinic were seen for individual residents. Residents are supported with their care and hygiene needs where necessary, but are also encouraged to retain as much independence as possible. Timely access to health care professionals was also seen to have been arranged. The home offers a small, intimate service and deals predominantly with individuals who have low dependency needs. Most residents are mobile and transfer independently. The home has no mobile hoists but maintains a bath hoist which allows for ease of transfer for individuals getting in and out of the bath and whom only need minimal assistance. In respect of this, the manager regularly reviews dependency levels and care needs to ensure that the home can continue to meet residents’ needs. Medication is basically managed well in the home but there are some areas regarding storage and administration that are currently being looked at and improved upon. The fridge for storage of medicines was a ‘can cooler’. Cold storage records were being maintained with medicines being stored within the optimum temperature range, however, it was not a fridge, neither did it have a lock and was therefore not fit for purpose. The manger spoke of her intention to replace the item quickly. Medication administration sheets were being completed well, with no obvious gaps. Second signatures were in place for handwritten entries. The home currently has no lockable facilities for the storage of Controlled Drugs but neither are there any residents currently prescribed medicines that require specialist storage and administration. Medicines are currently stored in a locked cupboard in the manager’s office on the second floor. The room is kept locked when not occupied. The facilities for storage could be improved upon and the manager has plans to address this. Residents are given the choice of self-medication within a risk assessment framework and have lockable facilies in their rooms for the storage of the medicines they retain. They must be reminded to lock medicines in their care away or individual capacity to retain medicines safely must be reassessed. On some medication rounds staff come to the office and Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 12 put medication for individual residents in pots and then transport them downstairs to the communal living areas. This is technically ‘double dispensing’ and should cease. This matter has not been raised with the manager on previous inspections. The home had up to date guidance documents and a comprehensive medication policy. The owner/manager and some staff had recently attended a 12-week Asset course on the safe administration of medication. More medication administration training is planned. The remainder of staff are qualified to NVQ Levels 2 & 3 and this area of knowledge is covered on the course. When the medication issues were objectively discussed with the manager there was an instant response that she would purchase the necessary items to resolve the issues and review practice to meet good practice guidelines immediately. As the manager/ owner is also a trained nurse. I am confident the minor practice issues discussed will be resolved without delay and therefore no formal requirements will be issued in the interests of proportionality. Staff were seen to treat residents with dignity and respect. And residents evidenced this in conversation. One resident said, “ I simply can’t fault them, they are kind and caring and they understand what I need to be helped with and what I don’t.” The privacy and dignity of individuals in care practice and the handling of privileged information is sound. All residents have a single room, some with baths, others with toilet and wash hand basin. The home carefully considers end of life care and the manager is proposing to develop care plans still further in this direction. This standard was not comprehensively inspected on this occasion. Pelham Lodge Residential Home DS0000059218.V326544.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 1 4 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and opportunities for mental stimulation are regularly offered both individually and collectively to residents. These diversions provide variation and interest. An opportunity to further review activities currently offered would be beneficial in ensuring that residents view the arrangements as being sufficiently regular to meet their wishes and expectations. Residents are enabled to maintain contact with friends and family who are made welcome in the home. EVIDENCE: The home contracts with an activities organiser who attends the home once a fortnight to offer craft sessions and other activities to residents’ such as quizzes. Staff also offer activities in the afternoon when that is possible. Staff stated that they play cards or board games with interested individuals. This was supported by comments made by residents. There is a large screen TV/ DVD/ video player and radio in the residents lounge. Most residents on the day of the inspection went for a lay down or to spend time in their bedrooms Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 14 after they had eaten lunch. The manager spoke of recent trips out for individuals. Newspapers were purchased daily by the home. Some individuals were said to not always share this resource with others. The manager had offered to purchase papers for individuals, but this had been refused. There was a professional Pantomime laid on at Christmas, which residents had enjoyed and was spoken about during the site visit. Two service users said they would like more activities. Staff said they were aware that when these are offered, it was often declined. The manager said that the activities organiser used to come weekly but some residents chose not to attend sessions, so provision was cut back. As far as practicable the home does as much as they can to stimulate and offer diversionary activities. It was suggested to the manager that the issue of activities is further discussed at future residents meetings. Residents meetings have just started in the home and the minutes of the first meeting was viewed. Issues raised had been recorded openly and honestly. Residents liked having the meeting and spoke about their discussions on the day. All those spoken with said they were basically very happy with the service offered to them. The home’s menus are varied and nutritious. The printed menus did not state there was a choice of meal, but residents evidenced that they can always ask for an alternative meal. Alternatives to the day’s menu were seen being dished up during lunch on the day of the site visit. There is a blackboard in the residents dining room which displays the ‘meal of the day’ and tomorrows menu. It was discussed with the manager that alternative choices of meal should be displayed on the home’s printed menus in future. The manager has recently reviewed the menus and tried to introduce more variation. Residents discussed trying dishes such as Curries and Spaghetti Bolognaise. One resident said it was “nice to try some new things”. The home’s menus are changed seasonally twice a year and regularly reviewed following residents’ feedback. Food had been discussed at the recent residents meeting. Routines in the home were flexible wherever it was possible. Residents had control over most aspects of their life. For instance, diet, time of getting up, going to bed, when to have baths, receiving visitors, involvement in activities. One lady attends a local Bingo club every week locally. Residents’ personal choices and likes and dislikes were recorded on the care plans seen. Individual resident profiles were well put together in care plans and gave some insight into residents past lives, work and interests. Family and friends are always made welcome in the home. There is a small visitors lounge available for residents’ use, which the manager is reminded should be kept free of the home’s stored items and staff belongings. Pelham Lodge Residential Home DS0000059218.V326544.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know how to make a complaint and know that their concerns will be taken seriously and acted upon. They are protected from abuse but would be further safeguarded if all staff were trained in the protection of vulnerable adults. EVIDENCE: The home has received no complaints since the last inspection. Because of the small size of the service at Pelham Lodge issues of concern tend to be picked up and dealt with before they reach the formal complaints stage. The timescale of 28 days for the home’s response to complaints received had been included in the home’s revised complaints procedure. This was in line with the requirement issued at the last inspection. This is now fully resolved. It was recommended to the manager that the home make a further minor change to the complaints procedure by indicating that the Commission can be involved at any stage of a complaint and not just as a last resort. The manager does not currently record minor concerns raised with her. When discussed further she was able to see this practice would inform the future development of the home and aid the quality assurance process. The manager Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 16 stated her intention to record issues in future and continue to hold and further develop residents meetings. Residents were all aware who to complain to and said they felt safe and secure. They knew the staff would listen to their concerns and respond appropriately. Two residents said the staff were very trustworthy and always listened carefully to anything that was worrying them. The home’s complaints procedure was on display in the home and is included in the home’s information documents. The manager and her deputy had recently received Adult Protection training. Records were checked. The manager has plans to extend ‘up date’ external training to the entire staff group. This should be a priority. Adult protection is included in the home’s induction for new staff and the manager evidenced a very clear and practical knowledge of what action to take if evidence or suspicion of abuse was raised in the home. The home could evidence guidance and good practice documents such as ‘No Secrets’ and Kent & Medway Adult Protection procedures. Staff understood the importance of reporting any concerns immediately. The home has an Adult Protection Policy document, which has been reviewed to reflect changes to legislation and good practice guidance. There have been no referrals under the POVA scheme. Pelham Lodge Residential Home DS0000059218.V326544.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, well maintained, and clean environment in which good standards of décor and furnishings are maintained. EVIDENCE: All 10 residents have single bedrooms with ensuite facilities. Some offer a bath or a shower, as well as a WC. Others have a WC and a wash hand basin only. Bedrooms have been personalised to reflect individual tastes and interests and were seen to be comfortable and well presented. A call bell system is installed in all bedrooms and communal areas for residents to call for assistance if needed. There is one communal bathroom with a bath hoist. One resident on their survey return said they sometimes have to wait for access to the communal Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 18 WC facilities on the ground floor, which can present a problem on occasions. This complaint was not substantiated on the day of the site visit when the WC was vacant for most of the time. Perhaps this is an individual concern that the home needs to manage better for the individual in question. There is one large lounge with comfortable chairs, music, a television and a dining area at one end with room for all residents to sit down at a dining table. This area has been recently refurbished and is very attractive and pleasant to sit in. The home’s kitchen leads from the lounge. The kitchen is clean and well maintained. Food was stored properly and opened items were date marked and discarded regularly. The manager has a system of monitoring records that staff complete every day to ensure this is attended to. The first floor accommodation is reached by a set of stairs that have two stair lifts fitted. Fire doors are fitted at the top and bottom of these stairs. The doors are kept open for ease of access by the use of doorstops, which automatically close if the fire alarm sounds. Radiators in all resident areas are protected. The home was extremely clean and there were no offensive odours. The laundry is in the basement and contains one industrial washing machine and one tumble dryer. Clean and dirty laundry is kept separate with clean laundry being taken back to the residents’ rooms as soon as it is dry and ironed. Clean bed linen is stored in a separate area of the basement. Care staff also undertake domestic and catering duties in the home. This appears to work well in this small establishment. All of the home’s equipment is regularly serviced and maintained and PAT testing, had been recently completed. Residents spoken with liked the home and felt that it fully met their needs. One resident said she had previously stayed in Pelham Lodge for respite. Events followed which had taken her to another home in the area for long term care. At that time she made a positive decision to move back to Pelham Lodge as soon as they had a vacancy. She continued to be content with the decision she made. Pelham Lodge Residential Home DS0000059218.V326544.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a dedicated staff team who are well supported and supervised. The home continues to effectively train and develop its staff to ensure residents’ needs are met at all times. Residents would further benefit from all staff having received Adult Protection training and the home formulating a training matrix that gives a clear overview of staff training needs. EVIDENCE: There was sufficient staff on duty to meet the needs of residents on the day of the inspection. Residents spoke highly of care staff and said they were caring and respectful. It was obvious from conversations held with residents that close bonds have formed between individual staff members and themselves. One resident stated, “It would be difficult for them to be any better.” A key worker system exists in the home, which appears to work well in practice, and is to the benefit of residents. Staff spoken with were aware of their roles and responsibilities. There are clear lines of accountability in the home. Staff appeared happy working there and felt they had the necessary skills to meet the requirements of their role. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 20 Staff had no issue with undertaking cleaning and catering duties as well as carrying out their caring role and felt they had sufficient time to undertake the tasks required of them. The continuing success of this approach relies on the manager monitoring residents dependency levels closely. The manager is in the home most days and has a deputy whose skills she is developing. Suitable staffing rosters are in place. The home’s substantive staff work additional hours to cover vacant shifts. No agency staff are used in the home. Staff files inspected contained two references and a staff photograph. CRB and Pova checks were in evidence. The requirement issued at the last inspection for the home to evidence the content of staff files met all the requirements of regulation has now been resolved. No new staff had commenced employment since the last inspection. However, the home has a revised induction record, which in practice will now accommodate and reflect the signature of the trainer, the inductee and the date on which the training was given. The recommendation made at the last inspection to improve the home’s induction pro formas has now been met. Training takes a high profile in the home with the manager also attending and updating her skills on most mandatory courses. The staff have attended Asset courses (West Kent College) in the safe administration of medication, dementia care, infection control, healthy eating and food hygiene and more are planned. Staff fire training has been completed and a high proportion of the staff hold first aid certificates. 90 of staff holds a qualification in care at NVQ 2 or above, which is commendable. It is a recommendation that the owner introduces a training matrix to provide the home with a clear overview of staff training completed, training planned and update training required for staff. No overview of staff training needs currently exists. The manager stated her intention to undertake this work. Staff files held individual training records and certificates gained. Staff supervision and appraisal was seen to take place on a regular basis. Staff files could be better organised for inspection purposes. Further training for all staff in Adult Protection is now a priority. Pelham Lodge Residential Home DS0000059218.V326544.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 32 33 35 36 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Residents benefit from the home being managed by someone who is experienced, competent and resident focussed. Residents’ financial interests were protected and their welfare promoted through regular maintenance and equipment safety checks. Residents benefit from the staff group who receive formal supervision and regular support. EVIDENCE: The owner/manager is experienced and runs the home competently and in the best interests of residents. She is a registered nurse and has also achieved Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 22 the Registered Managers Award. She is motivated and keen to further develop the service in line with good practice and the demands of Regulation. Residents and staff said they found her approachable, supportive and knowledgeable. Residents knew she was a trained nurse and although not practising as such in the home, her knowledge and experience of caring for frail older people, gave them a feeling of additional safety and security. The atmosphere in the home was calm and pleasant, residents spoken with were happy, contented and felt well looked after and cared for. All of the home’s policies and procedures seen were comprehensive and had been reviewed regularly in line with good practice advice and current legislation. There was discussion on the day of the inspection about improving some areas of medication administration and storage in the home. The manager stated her intention to address the issues raised by the inspector and discussed as quickly as possible. The home’s registration certificate was prominently displayed and there was sufficient insurance cover in place. Certificates were on view in the entrance hallway of the home for the residents and visitors to view. The contents of the home were in good condition. Small amounts of cash are kept for residents in the home and the money is kept securely with records maintained of balances. All of the home’s records were stored securely in locked cabinets and in a room, which was kept locked when unoccupied. All staff understood how important it was to maintain privacy and confidentiality in a small home such as Pelham Lodge. All staff were clearly competent and aware of the help and support residents needed. Training records evidenced almost all mandatory training and updates having been completed by staff. The manager and her deputy had undertaken recent adult protection training. It is now a priority that all staff receives this training as well. This was further discussed with the manager on the day of the inspection. The manager evidenced a high level of commitment to staff training and development. She finds it good practice to attend training with her staff so she can reinforce good practice advice. She regularly undertakes staff supervision and annual appraisal. Records were seen on staff files inspected. The manager undertakes an annual quality assurance exercise to inform forward planning for the service and also speaks regularly with residents and their representatives as to the service offered to them. The first formal residents meeting had recently taken place in the home. The minutes of the meeting were available to view and had been shared with residents. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 23 The home notifies The Commission in timely manner of any issue that affects the welfare of service users. Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 24 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 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 25 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 OP30OP38 Regulation 13 (6) Requirement ‘The registered person shall make suitable arrangements, by training staff to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse.’ In that: • The manager must arrange for all staff to receive adult protection training by the timescale given. Timescale for action 01/06/07 Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations It is strongly recommended that the manager fulfil the stated intention of reviewing the medication administration practices and storage facilities in the home in line with good practice advice to secure residents safety and protection. It is recommended that the manager reviews with service users the activities offered to them both within and outside the home, in order to ensure that they view the arrangements as being sufficiently regular to meet their wishes and expectations. It is recommended that alternative choices of main meal be displayed on the home’s printed menus. It is recommended that items of the home’s equipment and staff-training portfolio’s do not impinge on residents’ communal living areas (visitors room) or placed in a position in communal rooms that can be potentially detrimental to their safety. 2 OP12 3 4 OP15 OP22 Pelham Lodge Residential Home DS0000059218.V326544.R01.S.doc Version 5.2 Page 27 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. 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