Inspection on 16/01/07 for Pelham Manor

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 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 Manor 30/12/08

Pelham Manor 05/12/05

Pelham Manor 21/06/05

Pelham Manor 12/01/05

Pelham Manor 13/07/04

Pelham Manor 11/03/04

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Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Pelham Manor 31 Pelham Road Gravesend Kent DA11 0HU Lead Inspector Graham Cummings Unannounced Inspection 16th January 2007 09:30 Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 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 Manor DS0000024004.V320377.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 Adults 18-65. 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 Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham Manor Address 31 Pelham Road Gravesend Kent DA11 0HU 01474 352591 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) Vanessahalfacre@nas.org.uk National Autistic Society Ms Claire Meredith Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Pelham Manor is a care home providing personal care for seven adults with Autistic Spectrum Disorders (ASD). Pelham Manor is owned and operated by the National Autistic Society (NAS). The service was first registered in January 1996. The home is a large detached house close to Gravesend town centre. Shops, pubs, main post office, banks, places of worship, adult education college and other amenities are easily accessible. Bedroom accommodation comprises seven single rooms, three on the ground floor and four on the first floor. One bedroom has an en-suite bathroom. Communal rooms consist of two lounges and one dining room. The home does not have a passenger or stair lift. The property blends into the surrounding area and there is nothing to suggest it is anything other than a family house. There is a small garden at the rear of the property. A small parking area is available at the front of the property. In addition to the residential accommodation the NAS provides workshops in a variety of locations in the Gravesend area for residents from this home, as well as from the community and two other associated care home’s. The fees range from £1150 to £3250 per week. The overall quality of the service provided is good. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was carried out on the 16th January 2007 to complete the home’s first Key Inspection. The Inspector completed the report using information from past inspections, comment cards received from relatives, care managers and health professionals, touring the property, looking at documentation and talking to the manager and staff. The home follows good practice procedures when considering prospective Service Users with Pre Placement Assessments and visits to the home. The Inspector looked at three care plans and found them to be clear and comprehensive containing the individuals preferred support and risk assessments. Service Users attend the companies day centre from Monday to Fridays and participate in age appropriate activities including, swimming, dancing, bowling, and going to pantomimes, concerts and theatre. All Service Users have their healthcare needs met and their wishes regarding illness and death have been addressed. There have been no complaints received since the last inspection, and staff have attended Vulnerable Adult and Behaviour Management training. All financial transactions relating to Service Users have 2 staff signatures. The environment is clean and there are no offensive odours. The home is well decorated and Service User bedrooms are furnished with some personal belongings. The home is well staffed and they receive good training from the company, staff recruitment processes are good with three references requested and all telephone checked. A staff member spoken to said ‘all staff treat the Service Users with dignity and respect’. The home is well run by the Manager who according to the staff spoken to is ‘approachable and supportive’. The documentation and records seen were all signed and dated. What the service does well: The home provides a good quality of support and care to the Service Users living there. A staff member spoken said that ‘the staff team is strong’ and that ‘all staff treat Service Users with dignity and respect’. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 6 The records were clear and comprehensive and the documentation signed and dated. Service Users attend the companies day centre from Monday to Fridays and participate in age appropriate activities including, swimming, dancing, bowling, and going to pantomimes, concerts and theatre. The kitchen is adapted to allow for a Service User with mobility difficulties to participate with the preparation and cooking of meals. 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 Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Prospective Service Users can access information needed to make an informed choice. Prospective Service Users’ needs are assessed and they have an opportunity to visit the home prior to placement. Individual contracts are kept but information not fully available to Service User. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector looked at three Service User files. All contained Pre placement Assessments carried out by the manager and funding authority assessments and the placements last care plan and review notes. The Manager went through the process of how the last placement was made, this included visits to the Service User’s placement to observe and talk to staff, visit the family home observe and talk to family and at least three visits to Pelham Manor prior to the placement becoming permanent. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 9 The Manager informed the Inspector that Service User’s did not have a copy of their contract as it was kept at the companies head office at Bristol. Service Users had a Service User Guide that covered most of the information set out in Standard 5, but there was some shortfall, the Manager agreed that all of the information required would be included in the individuals Service User Guide. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Service Users’ assessed and changing needs are addressed in their individual plans and they make decisions about their life with assistance where needed. Service Users are consulted on daily life in the home and are supported to take risks as part of this. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector looked at three Service User files and found that they were comprehensive and informative giving the reader a good picture of the care the individual required. Documentation included a pictorial communication passport, pen portrait, All About Me booklet and a comprehensive guide on essential information required for immediate support, likes and dislikes. One file also had a stage by stage guide from the parent relating to epileptic seizures. The Inspector noted that their were 6 monthly reviews on file and that evaluations changes had been signed and dated. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 11 Risk assessments were on all files and behavioural management guidance was also available. The Inspector saw the completed risk assessment for the bedrails, this had been signed by all parties including the family, care manager and Manager. Wherever possible Service Users had participated in the making of their care plan and had initialled/signed the document. The Manager informed the Inspector that regular meetings take place with Service Users and this was later confirmed when the Inspector spoke to a member of staff. Each Service User has a key-worker. The Inspector was shown an activities programme that was on a noticeboard showing the activities on offer to a Service User and the member of staff responsible for ensuring that activity was offered and available for the Service User to participate in. Activities included, cooking the evening meal, shopping, bowling, cinema, theatre, ice skating, concerts, wrestling, pubs and personal laundry. Part of the kitchen had a low level work surface so the Service User with mobility difficulties could participate in the preparing and cooking of meals. Wherever possible Service Users were made aware of the documentation about them and where it was stored, Each Service User had a separate storage area within a cupboard/unit. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Service Users have opportunities for personal development and they take part in age and peer appropriate leisure activities. Service users are involved in the local community and have appropriate family contact. Service Users are respected and have a healthy and nutritious diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service Users activity and care plans allow for individuals to have the opportunity for personal development. Service Users are encouraged to participate in the cleaning of their bedrooms and using the washing machine for their own laundry. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 13 Service Users attend the company day centre along with other company home’s Service Users from 10am to 3:30pm. Staff also attend the centre with them. The day centre has structured activities and trips out on a regular basis. Activities carried out by the home include, cooking the evening meal, shopping, bowling, cinema, theatre, dancing, ice skating, concerts, wrestling and pubs. One parent commented ‘there are more activities now that the extension and garden have been completed’. Activities are centred around Service Users wishes, one Service User who enjoys dancing goes to a club and has purchased a ‘disco ball’ and lights and has regular 1-1 dance nights in the home. A themed bi-monthly craft evening has been introduced where Service Users choose a theme, so far they have had St Patrick’s Day, Xmas, Easter and the next one is a Burns night. Service Users agree the menu weekly on a Sunday and participate in the preparation and cooking of the evening meals as much as possible. The menu seen showed that there were 2 options of meals every day. The staff member spoken to confirmed that Service Users are involved in making the menu and are encouraged to participate in the making of the meal. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Service Users receive personal support in the way they prefer and have their health needs met. Service Users’ wishes regarding illness and death are handled with respect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector looked at three Service User Plans and found they all contained individuals likes and dislikes and preferred support in personal care. Service Users are all involved in choosing their activities and menus. All of the Service Users are registered with a local Doctor, Dentist and Optician with a chiropodist visiting approximately every six weeks. None of the Service Users currently self medicate but the home does have a policy and procedure to follow should this ever be required. Letters from the GP were seen confirming the appropriate use of non prescribe medication. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 15 The Inspector found relevant paperwork on Service Users files requesting information from family relating to the wishes of the Service Users regarding illness and death. Some of the families have not returned the information yet and this is recorded on the file. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Service Users views are listened to and they are protected from abuse Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service Users have regular meetings where the daily running of the home is discussed including activities and menus. The views of Service Users and their families are listened to and taken into account when the care plan is agreed. Four of the five relative comment cards returned showed that the home’s complaints procedure was known. Neither the home or CSCI have received any complaints since the last inspection. Staff have attended training on the Protection of Vulnerable Adults and there is a robust system in place regarding Service User finances. All monies are checked twice daily at handovers and any transaction has two signatures. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29,30 Service users live in a homely, clean and well decorated home that is safe and comfortable. Service Users have ample bathrooms and specialist equipment that maximise their independence and privacy. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a cleaner and the Inspector noted that they were wearing protective clothing as recommended at the last inspection. The home was welcoming, homely and clean. The entrance carpet has been removed and wood flooring laid. The environment has been improved since the last inspection with new flooring in the entrance hall, new lounge furniture and curtains, 2 new beds and a Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 18 bedroom decorated and re-carpeted to the Service Users choice of 2 blue and 2 pink walls and a blue carpet. The Inspector looked at several bedrooms and they were well furnished and decorated, Service Users also had personal belongings on display. There are 3 bathrooms for 6 Service Users and 1 en-suite bedroom that has a hoist to improve the Service Users mobility. When the extension was completed, this gave the home an extra lounge and this has meant that more 1-1 work can be carried out and gives the home a music area. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Service Users benefit from having a trained, competent and effective staff team who have clarity of staff roles. Service Users are protected by the supervision, support and staff recruitment processes. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has four staff on duty in the morning and evening Monday to Friday and at weekends four in the morning and three in the evening since it is usually the case that that two Service Users go home. The Inspector saw signed and dated job descriptions and each member of staff has nine booked supervision sessions in a year with the Manager. The Manager said that the staff recruitment process followed included taking interview notes, three references (all telephone checked), POVA and CRB Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 20 checks, one week of observation and supernumerary and 6 months probation period. The company has it’s own training department and they run regular statutory course in the area for all of the local homes including, First Aid, Food Hygiene, Moving and Handling, Health and Safety, Communication, Report Writing, Epilepsy, Skip, Infection Control and Medication Administration. The Inspector when speaking to staff was informed that the ‘staff team was good and supportive’ ‘Service Users are treated with respect and dignity’ ‘Service User meetings take place weekly and staff meetings monthly’ ‘Bank staff attend training with full time staff’ ‘the manager is supportive and approachable’ ‘the home is warm, comfortable and welcoming’. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42,43 Service Users benefit from living in a well run home where their views underpin the running of the home. Service Users’ best interests are safeguarded by the home’s policies and procedures and record keeping systems. Service Users’ health, safety and welfare are promoted and they benefit from competent management. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager is well organised and knowledgeable about the National Minimum Standards. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 22 They were aware of the need to involve the Service Users in the daily running of the home as much as possible with appropriate support. This is done through Service User and 1-1 key worker meetings. The home is owned by the National Autistic Society who have comprehensive policies and procedures that are individualised to the home, the home have also added some local and individual procedures to ensure the safety of Service Users. The home’s record keeping is good with all of the documentation seen by the Inspector signed and dated by staff and wherever possible by Service Users. The home has an appointed Health and Safety officer who carries out weekly checks, the company also have an Area Health and Safety officer who carries out regular checks on the home, there are also Safety Action Group meetings with the Area Safety Officer and all NAS home’s safety officers. Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 3 3 3 Pelham Manor DS0000024004.V320377.R01.S.doc Version 5.2 Page 24 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 Home’s 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. 1. 2. 3. Refer to Standard YA5 YA32 YA37 Good Practice Recommendations That all Service Users have an individual contract or Statement of Terms and Conditions with the home, this can be in the Individual Service User Guide. Fifty percent of practitioners must be trained to NVQ level II care. Mrs Meredith must successfully complete all management units in respect of the Registered Managers Award. 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