Inspection on 05/12/05 for Pelham Manor

This inspection was carried out on 5th December 2005.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pelham Manor 30/12/08

Pelham Manor 16/01/07

Pelham Manor 21/06/05

Pelham Manor 12/01/05

Pelham Manor 13/07/04

Pelham Manor 11/03/04

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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 Elizabeth Baker Announced Inspection 5th December 2005 09:30 Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 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.V259943.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V259943.R01.S.doc Version 5.0 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) ClaireMeredith@nas.org National Autistic Society Ms Claire Meredith Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 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 ensuite 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 homes. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on the 5 December 2005 and lasted just over four hours. At the time of arrival residents were preparing to go to their respective workshops. In preparation of this inspection a visit was made to three of the workshops operated by NAS – the Robbie Centre, Artrack Centre and Sands on the 25 November 2005. Two Pelham Manor residents were spoken with at the Robbie Centre and a number of others at the Sands Centre. Members of staff were also spoken with at the workshops. Some judgements about the quality of care, life and choices were taken from conversations with residents and staff, as well as direct and indirect observations. Some records were seen as part of case tracking and to assess work on the requirements and recommendations made at the last inspection. In respect of the announcement of this inspection the Commission received a total of 15 completed comment cards from Residents (4), Relatives/Visitors (6), Care Managers (4) and one Health Care Professional. Some of their comments have been incorporated into this report. This is the second inspection of this home for the year 2005/06. Not all key standards have been inspected on this occasion, where they were met at the first visit. This report should therefore be read in conjunction with the inspection report dated 21 June 2005. What the service does well: The visit to the workshops demonstrated that residents receive structured activities to maximise their potential to reflect their individual skills and talents. A replica Wurlitzer, which has been made by residents from this and the other two care homes takes pride of place in the refurbished diner in one of the workshops. Two residents from this home were occupied at the Robbie centre cake making and painting. Other Pelham Manor residents were seen engaged in life skill activities at the Sands Centre while others were preparing to go off to a nearby leisure centre for a swimming session. Good procedures are in place for introducing prospective residents to the home and its associated workshops. Comment card respondents’ additional remarks included “My [relative] is happy”, “My [relative] has multiple disabilities. The care staff have always treated [them] as an individual with respect and care”. “Communication has improved”; “I have always had good communication from managers and observed excellent client focused care. The service has gone out of its way to ensure my client has structured and enjoyable activities to do, which also take Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 6 into account health and staffing considerations”; “I like living at Pelham, like [going to] pubs, bowling, shopping and doing puzzles”. 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. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 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.V259943.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 The home’s pre admission process ensures prospective residents and their advocates know all about the home and associated workshops, prior to deciding on whether to move into Pelham Manor. EVIDENCE: The home has good procedures for assessing and introducing new residents to the home. This includes inviting prospective residents to visit the home at different times, for different periods. Prospective residents also partake in activities at the different workshops operated locally by the organisation. The manager visits the resident in their current environment to meet them and their carers. Existing residents are kept informed of the situation and encouraged to share their views and thoughts. A review is carried out at the end of a three month trial period to establish whether a permanent place is appropriate. The prospective resident is provided with lots of information, in the form of a service user guide. The document is available in different formats depending on the ability of the resident. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Residents know their views are listened to and that their records will be kept securely maintaining confidentiality. EVIDENCE: The manager has worked hard to develop care plans to include much more detail of the actual level of support residents require. The system is now set up and about to be implemented. This will assist practitioners effectively monitoring the progress of residents in achieving their ultimate goals and aspirations. To assist residents in making choices, visual prompts are widely available. This is particularly usual for residents with communication problems. A new system of storing care records has been introduced. Residents are aware information is kept on them and that sometimes this is shared with others on a need to know basis. Care records inspected contained risk assessments. However the care records for a resident who uses bedrails, was not comprehensive of this. As the provision of bedrails could be construed as restraint, a full risk assessment must be carried out, with input from all those involved in the resident’s care, including GP, Care Manager, advocates and practitioners, as well as the resident herself. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 10 Residents openly shared their views and experiences during the visit to the workshops and the home. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/I EVIDENCE: All these standards were met at the last inspection. The standards were not re-inspected on this occasion. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 Care is offered in a way to protect residents’ privacy and dignity and promote independence. Medicine storage has greatly improved but would be enhanced further by the provision of proper refrigeration facilities. EVIDENCE: Medication administration record (MAR) charts were inspected. Handwritten entries had been signed and countersigned in accordance with good practice. The review identified some residents are taking regular “supplements” including fish oil and cranberry juice capsules, which have been obtained and provided by residents’ advocates. Practitioners administer these and record details on the residents’ MAR charts. The records did not demonstrate guidance had been obtained from the residents’ GP or dispensing pharmacist as to the suitability of these supplements for the respective residents. One care file inspected included a GP letter dated 2002 authorising a number of homely remedies that the resident could take. The remedies were not specific, for example Lemsip was stated. However Lemsip comes in a range of compounds, including paracetamol and ibuprofen. Precise details of the homely remedies must be stated to ensure such medicines do not interact with the residents’ prescribed medications. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 13 Not all care records contained information in respect of resident’s choices in respect of death, dying and last rites. The manager is aware of the need to obtain this information and record the outcome. The security of medicines has improved substantially with the acquisition of a proper medicine cabinet. However the facilities for storing medicines, which require refrigeration, are not of a type now expected in care homes. Indeed the temperature record book for this fridge records temperatures fluctuating between 2 and 12c, which could adversely affect the medicine. Drug fridges also need to be lockable to maximise security. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a satisfactory complaints system in place, although some relatives/visitors are unsure how to access it. EVIDENCE: Although the home’s complaints procedure is available in various formats for residents’ information and use, three of the six returned comment cards from relatives/visitors indicated they did not know how to make a complaint. The manager said residents and advocates would be re-issued with this information. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30 Recent investment has significantly improved the home’s facilities, creating a comfortable and safe environment for those living there. EVIDENCE: Since the last inspection a new bedroom with full ensuite facilities has been built and registered. This has been specifically provided for a particular resident with increased physical disabilities. The home and organisation should be congratulated on this facility, which has undoubtedly improved the resident’s quality of life. As part of this extension, communal facilities for all residents have increased. The ground floor bathroom has been re-vamped and re-designed. This allows practitioners to provide safer assistance to residents when required. The existing sitting room and dining room have been redecorated and the furniture and TV in the sitting room have been renewed. Despite this, the poor state of the hall carpet may give the wrong impression of the home to new visitors, as this is the first place they see on arrival at the home. Bedrooms inspected are kept and furnished as per residents’ wishes. Residents are responsible for keeping their bedrooms clean and tidy as part of their structured routines and practitioners support residents in this. Apart Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 16 from one tall wardrobe in a particular bedroom, rooms visited and furniture checked were dust free. Bedrooms are currently “spring-cleaned” during residents’ holiday absences, and the frequency depends on this. However the manager is currently reviewing staffing levels and tasks as part of the shiftplanning annual review. This will ensure that appropriate levels of assistance are available for tasks for which residents may require more regular support from practitioners than they currently have. The new system will also help the manager monitor these jobs more effectively. The cleaning lady spoke enthusiastically about her role and how much she enjoys working at the home. However it is has not been her practice to wear protective aprons or overalls, when carrying out her duties. The cleaning lady cleans bedrooms, bathrooms as well as the kitchen. The cross infection implications of this were discussed. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Staff like and feel supported working at this home. EVIDENCE: During the visit to one of the workshops a member of staff said “this is the best place I have worked, I have never been so well supported and receive lots of training”. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 42 The manager has a good understanding of what needs to improve in the home and actively strives to achieve this. EVIDENCE: Residents were aware of the announced inspection and spoke openly about how they spend their time, what they are currently doing and of their plans for the Christmas and next years holidays. The manager said she has completed her Registered Managers Award course and is awaiting feedback from her assessor and external verifier. The organisation is committed to ensure its workforce is appropriately trained. Twenty percent of practitioners are now trained to NVQ level II care. The manager ensures aids and equipment are kept in good order by carrying out regular tests and checks and organising appropriate servicing. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 19 An Officer of Kent Fire and Rescue Service inspected the home following the completion of the extension. This resulted in some requirements being made. The manager reported that apart from one, the requirements have been complied with. Action is currently being taken to finalise the outstanding matter. Pelham Manor DS0000024004.V259943.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 4 X 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pelham Manor Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 X X X 2 X DS0000024004.V259943.R01.S.doc Version 5.0 Page 21 NO 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 YA9 Regulation 13 Requirement Bedrails must only be provided after a full risk assessment with multi disciplinary input has been carried out and the details recorded A proper lockable drug fridge must be obtained to appropriately store medicines requiring refrigeration All work required by Kent Fire Brigade must be completed. Timescale for action 31/01/06 2 YA20 13 28/02/06 31/03/06 3 YA42 23 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 YA20 YA20 YA21 Good Practice Recommendations Homely remedies authorised by the GP must be specifically stated. Recorded evidence must be available of guidance obtained from GPs or dispensing pharmacists as to the appropriateness of non-prescribed supplements Details of residents’ preferences in respect of death, dying and last rites must be obtained and recorded in their care records. DS0000024004.V259943.R01.S.doc Version 5.0 Page 22 Pelham Manor 4 5 6 7 YA24 YA30 YA32 YA37 The hall carpets should be replaced or made good The cleaning lady should be provided with appropriate protective cleaning to minimise cross infection and contamination 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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