Inspection on 28/07/05 for Pelham Lodge Residential Home

This inspection was carried out on 28th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pelham Lodge Residential Home 16/01/07

Pelham Lodge Residential Home 16/01/06

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 TN11 OHZ Lead Inspector Eamonn Kelly Announced 28 July 2005 11:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pelham Lodge Residential Home Address 52 Pelham Road Gravesend Kent DA11 0HZ 01474 334954 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pelham Lodge Limited Mrs Balbir Kaur Dosanjh Care Home 10 Category(ies) of Old Age (10) registration, with number of places Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 August 2004 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 manager’s 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 H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit consisted of meeting all service users, meeting with the owner and members of staff and visiting bedrooms and other areas of the home. Some individual care plans were checked as well as maintenance and associated records. Completed quality assurance questionnaires were used in writing the report. The report also uses information provided in writing (ie. pre-inspection questionnaire and self-assessment) by the owner prior to the inspection visit. Some service users accepted a copy of the Commission’s “Is the care you get the care you Need? What the service does well: What has improved since the last inspection? An effective key worker system has been introduced. The number of staff has been increased to enable a flexible staffing rota to be maintained. The training programme has given members of staff more confidence and increased ability to deal with emergencies. This has also given them the opportunity to selfassess their personal effectiveness in caring for service users and anticipating or reacting to their care requirements. Individual care plan records were clear and up-to-date. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 6 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. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 6. The statements made about the home’s services and facilities in pre-admission documents (ie statement of purpose/service user’s guide) are being met in practice. Service users benefit from effective admission procedures. EVIDENCE: Suitable written information is provided to prospective service users about the home’s services and facilities. A personal contract is given to all new service users. All prospective service users are encouraged to visit the home at least once prior to admission, to meet other service users and members of staff and to see their bedroom and other areas of the premises. Recently admitted residents spoke positively about the support they received in settling in to their new environment. Individual care plan records showed how thorough pre-admission assessments are carried out. Intermediate/recuperative care is not provided although respite care would be given if a place were available. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 Service user’s health and personal needs (which are carefully set out in care plan records) are met by the home. EVIDENCE: In the individual care plans seen, there was sufficient biographical information, a dependency chart, inventory sheet, medication requirements (including “homely”), weight monitoring chart, risk assessment and care planning and review details. The individual assessments of the interests, abilities and aspirations of residents (in the examples seen) were clearly written and informative. The daily record sheets (maintained separately from care plan files) were up-todate and clearly written. A chiropodist and optician visit on request. Service users have good access to all social and health services. Members of staff explained how they had closely monitored issues of resident’s failing health (specific examples were discussed in detail). A new key-worker system (that enables specific members of staff to liaise more closely with specific service users) is operating. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 10 The owner described how triage nurses visit the home. A monitored dosage system of medication, supported by medication administration sheets, is kept in a locked cupboard. A copy of the BMA,s “New Guide to Medicines and Drugs” and the BNF “Medication Manual” is available to members of staff. Accredited training (i.e. “Intermediate Certificate in Safe Handling of Medicines” via Croydon College) is underway for all members of staff. Members of staff spoke about how informative and effective this form of training has been. The wishes of residents relating to continuing care are identified and a record is kept of any specific plan or request. Members of staff stated that they are able to care for people who are seriously or terminally ill: support is available to them from the owner, relatives, GP’s and nurses and, if necessary, hospice nurses. Discussions with staff and service users and observation of practices strongly indicated that service users are cared for with respect. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13,14 and 15 Service users are able to exercise control over their lives and they of range of activities and opportunities for physical and mental stimulation. They benefit also from the availability and provision of meals that offer choice and variety and cater for special diets. EVIDENCE: Service users have a settled routine and they discussed how they spend their time. Members of staff are aware of each person’s preferences and encouragement is given to help service users develop and maintain a comfortable lifestyle. The routines of each service user were discussed during the inspection visit and it was clear that each is satisfied with the opportunities both available and accepted. Care plan records indicated in broad terms the interests and capabilities of service users. Service users may have visitors at any reasonable time. There is a communal phone and some service users have their own private phone. Service users said that they are encouraged to maintain contact with their families and friends. Service users are recommended at admission stage that they or an advocate should look after their financial and legal affairs. Advice and assistance is provided to those who may Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 12 be losing the capacity to exercise personal autonomy. Meals are served in a comfortable setting (lounge/dining area) and service users said they enjoyed their food. The owner’s objective is to provide very good food and meals; considerable time was spent with service users at lunchtime and it was clear that members of staff made commendable efforts to provide excellent meals. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has sufficient measures in place to protect service users. EVIDENCE: Service users and their supporters returned completed copies of the Commission’s quality assurance feedback questionnaires. They are also encouraged to complete the home’s quality assurance questionnaires. All such records seen carried positive comments. Copies of the CSCI’s leaflet “Is the Care You Get the Care You Need?” were accepted by some service users. Reports are made to the CSCI of all notifiable incidents under Care Home Regulation 37. All members of staff have been checked under appropriate recruitment and retention procedures (ie. references, application form, CRB/POVA scheme, probation, induction training, supervision). The home follows the Kent & Medway Policy for Adult Protection. A complaints’ procedure is in place (a précis is included in pre-admission documents) . Meetings with service users indicated that they are confident in expressing their views to members of staff and visitors. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24, 25 and 26. The premises are suitable for the needs of service users. EVIDENCE: Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 15 The premises are safe, comfortable and well maintained. The kitchen is safe and well equipped. A copy of risk assessments in relation to premises and environment was seen. Each service user has his/her en-suite facility (some with a shower unit). There are suitable communal facilities and a ground floor bathroom is equipped with a manually operated hoist. A call-bell system is installed in bedroom and communal areas. There are 2 stair-lifts. Bedrooms were well decorated and service users had their own possessions in their rooms. The sizes of bedrooms (some of which are under 10 sq m) are shown in pre-admission information to enable potential service users to determine their care and accommodation requirements. Radiators are fitted with covers. Where service users have requested additional (portable) radiators appropriate risk assessments are carried out to monitor their continued safety. Water from hot-water outlets used by service users is thermostatically controlled. The home was tidy and free from offensive odours. Training in infection control and cross infection is part of the training scheme planned with a local college. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 &30 Service users have the benefit of being in the care of staff whose training needs are being actively addressed. EVIDENCE: Twenty-four hour care is provided (a member of staff is on duty at night: the level of staffing has been improved by the owner/manager who is “on-call” when not on duty.). A staffing roster is kept. Members of staff carry out cleaning, caring and domestic duties. Two members of staff were on duty. There was evidence of a co-ordinated approach to training and staff development. An induction process is in operation for all new members of staff. Training needs are identified on a day-to-day operational basis and through a staff supervision process. A trainer/assessor has provided a general course on caring matters at the home for all members of staff. Core training is provided (ie. first aid, food hygiene and safety, moving and handling, administration of medication). Training in infection control is scheduled for September 2005. NVQ Level 2/3 in Care courses are underway (some members of staff have completed their courses). Members of staff indicated that the training and personal development support received has made them feel more confident and competent in dealing with day-to-day care matters and in dealing with emergency situations. The owner is planning to re-decorate and re-equip the 2nd floor as a training area and staff/visitor facility. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 17 Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 Service users benefit from the development of safe working practices and other procedures that emphase service user’s interests and expectations. EVIDENCE: Service users are encouraged to discuss their concerns and expectations with the owner and members of staff. Examples of this were identified in feedback from them in CSCI “comment” cards and in the home’s survey questionnaires. In meetings with all service users, several outlined their views about how they felt they were being cared for. Meetings with members of staff indicated that they should address as a priority the individual preferences of service users. Other examples of good practice included the identification of foods (or additives in some foods) that appeared to have an adverse effect of service user’s health. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 19 The pre-inspection questionnaire submitted by the home included a declaration about maintenance and associated records. Those checked (including portable appliance tests, stair lifts and Legionella checks) were up-to-date and satisfactory. The current procedures for staff training and development underlined the progress by the home in promoting effective systems and procedures. Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None 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. 1. Refer to Standard None Good Practice Recommendations Pelham Lodge Residential Home H56-H06 S59218 Pelham Lodge V229990 280705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent 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. 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