Inspection on 01/12/09 for Pellon Lane Care Home

This inspection was carried out on 1st December 2009.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pellon Lane Care Home 08/04/09

Pellon Lane Care Home 09/04/08

Pellon Lane Care Home 11/04/07

Similar services:

Carentan House

Ravensworth Lodge

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for older people Name: Address: Pellon Lane Care Home 200 Pellon Lane Pellon Halifax West Yorkshire HX1 5RD     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Paula McCloy     Date: 0 2 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Pellon Lane Care Home 200 Pellon Lane Pellon Halifax West Yorkshire HX1 5RD 01422342002 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): pellon.care.centre@fshc.co.uk Four Seasons Homes (No 4) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) care home 100 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: Birkshall Mews Unit - Care home with nursing. 30 x DE(E). Elderly persons over 55 years of age. Brackenbed View Unit - Care home with nursing. 35 OP. Elderly persons over 60 years of age. Pellon Manor Unit - Personal care only. 34 x DE(E) and 1 x MD. Maximum number 35. Date of last inspection 0 9 0 4 2 0 0 9 0 1 0 Over 65 64 0 35 Care Homes for Older People Page 4 of 27 Brief description of the care home Pellon Lane Care Centre is situated off Pellon Lane in Halifax. There are two retail parks with shopping facilities nearby and Halifax Town Centre is within easy reach by public or private transport. The centre is divided up into three units. Each unit has its own lounges, dining rooms, single bedrooms with en-suite toilet facilities, bathrooms and toilets. There is a central kitchen and laundry. The three units offer the following accommodation and care: Brackenbed View is a 35-bedded unit that provides 24 hour nursing (including intermediate care,) and personal/ social care for older people. Pellon Manor provides care and accommodation for up to 35 older people with mental health needs, in particular people with dementia. Birkshall Mews provides 24 hour nursing and social care for up to 30 older people who have dementia. In addition to the weekly fee, additional charges are made for chiropody, hairdressing and newspapers. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The current weekly charges range from £392.50 - £558 per week. Additional charges are made for hairdressing, chiropody and newspapers. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection. Two inspectors conducted the visit over two days and spent approximately 12 hours in the home. During the visit we spoke to 10 people living in the home, 8 members of staff and the manager. We also observed staff delivering care, looked at various records and looked around the home. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been Care Homes for Older People Page 6 of 27 deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 27 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can visit the home to see for themselves if they think it is suitable. No one moves into the home unless staff are sure they can meet their needs. Evidence: A member of staff from Pellon Lane Care Home will go and assess anyone thinking of moving into the home. There is an assessment document that staff complete, which means that peoples needs are identified and that staff are sure they can meet those needs before people move in. We looked at the files for three people and found all of the assessment information we would expect, together with a care plan for each. People can visit the home themselves to look around so that they can see for themselves if they think the home is suitable. There are designated nurses and care staff running the intermediate care unit. This service is used by people who want to live in their own homes, but need specific, short Care Homes for Older People Page 11 of 27 Evidence: term support in order to achieve this. Health and local authority staff provide additional support. For example physiotherapists, occupational therapists and rehabilitation staff to work with people to get them back home. We spoke to two visiting professionals who told us that the intermediate care service is well managed and that staff work well with them, following the advice that is given. This means that people get the support that they need. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are being met. Evidence: We looked at six care plans because we wanted to see what individual needs had been identified and what action staff have to take to meet these needs. The information in the care plans is important because a lot of people living in the home have dementia and may not be able to tell staff what they need or about their personal preferences. We found that the care plans were detailed, up to date and contained good information. All of the necessary risk assessments have been completed and staff are writing down the action they need to take to reduce or eliminate that risk. For example one person had been identified as being at risk of malnutrition. There was a clear plan in place to monitor their food and fluid intake. We saw that this person had also been weighed regularly and was putting on weight. Peoples health care needs are being identified and met. Staff are vigilant and GPs and other health care professionals are being involved as necessary. Details of any visits Care Homes for Older People Page 13 of 27 Evidence: by health care professionals are clearly documented in the residents care plan, together with the advice that has been given. Generally people looked well cared for. The care plans contain information about the clothing people like to wear and how often they like to go to the hairdresser. This means that peoples appearance is how they like it. For example one persons care plan stated that they liked to wear trousers and a colourful top, we saw that they were wearing those clothes. The medication system is well managed. People are receiving their medication at the prescribed times and records are well maintained. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are activities available to keep people stimulated. The meals at the home are good offering choice and variety. Evidence: There was some detailed information in the care plans about peoples preferences and their likes and dislikes. There were no life histories in any of the care plans we looked at. It is important that this information is written down to make sure staff know about peoples past lives and experiences. There is a dedicated activities co-ordinator on Brackenbed View who arranges a wide variety of activities and outings for people living in that unit. The acting manager has recruited two more activities staff one for Pellon Manor and one for Brackenbed View. This will make sure that there are dedicated staff in post to develop activities in these two units. We found some information in the care plans about peoples interests and activities that they enjoy, although we did not find any specific plan about how staff were going to meet these needs. We discussed this with the acting manager who told us that the activities co-ordinators will be doing this. We did see a variety of activities taking place Care Homes for Older People Page 15 of 27 Evidence: in all of the units and could see that people were enjoying them. This means that people are being stimulated and kept active. Meals at the home are good and that there is a choice available for every meal. People choose where they eat and staff made sure that the people who needed assistance got the help that they required. The care plans contained details of peoples likes and dislikes and other information that was relevant to individuals. For example one care plan stated that the person should be given their tea in a white mug because if they were given a patterned mug it distracted them and they may not finish their drink. We saw that staff gave this person an appropriate mug to drink from. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager needs to make sure that the systems that are in place to protect people from any possible abuse are used properly, otherwise people will be left at risk. Evidence: The home has a complaints procedure. This is in place so that if people are dissatisfied with the service they know that they can complain and can expect a response. We looked at the complaints file. We could see that some complaints that had been made had been investigated and there were copies of the letters on file that had been sent to the complainant. There was one complaint recorded that had been made verbally. There was no documentation about any response or details of any investigation. Staff told us that a verbal response had been given to the relatives but there was no evidence of this. It is important that all complaints are fully investigated and details of the investigation and findings are clearly recorded together with the action taken and outcome. This will make sure that all complaints are taken seriously and dealt with properly. People living in the home are not consistently being kept safe from possible abuse. We found an incident recorded that should have been referred to us and the safeguarding team but hadnt been. We referred this ourselves. The home had not dealt with this properly. The recruitment of staff has not been robust and has left people at risk of being cared for by people who may not be suitable. We also found information Care Homes for Older People Page 17 of 27 Evidence: recorded about a carer but there was no evidence that management had acted upon the information and investigated the concerns that had been raised. Recently two members of staff have been dismissed for gross misconduct. The home has not formally told us about these incidents. Some of the accident reporting isnt detailed enough. For example one person sustained an injury before we visited on the second day. The acting manager did refer it to safeguarding, but there was a lack of information recorded by the night staff. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable, clean, tidy and generally well maintained. Evidence: Pellon Lane Care Home is situated on Pellon Lane in Halifax. It is close to two retail parks with a range of shopping facilities. Halifax Town Home is easily accessible by public transport. There are three homes on the site, each has its own car park and garden area. The kitchen has been awarded 4* for hygiene by environmental health. This means that the standard of hygiene is good. The home is due for some major refurbishment early in 2010, which will include the communal areas. This will make sure the accommodation is maintained to a good standard. The home was clean and there were no unpleasant odours. The laundry is well equipped and there are infection control procedures in place. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff on duty to meet peoples needs. The homes recruitment practices are poor leaving people at risk of being cared for by unsuitable staff. Evidence: Pellon Manor, Birkshall Mews and Brackenbed View all have their own staff teams. The acting manager is aware that she needs to keep staffing levels under review as peoples needs change and when new people are admitted. When we looked at the duty rotas we saw that there a number of staff working across the three homes who are related. The acting manager told us that family members do not work together. The acting manager needs to keep the rotas under review to make sure that neither staff or people living in the home are left in a vulnerable position because of these relationships. We looked at the recruitment files for two new members of staff and found that all of the necessary checks had been completed before they started working at the home. However, when we looked at three other files we found that the recruitment process had been poor and was leaving people at risk of being cared for by unsuitable staff. The pre employment form asks staff if they have any criminal convictions or cautions. If people answer yes to this question it will allow you to explore their suitability for the Care Homes for Older People Page 20 of 27 Evidence: post at interview. In one of the files we looked at this form hadnt been completed. If staff are employed that have a record with the police then a risk assessment must be completed, in line with the companies procedures, to show that you are protecting people in your care. None of the files we looked at had a photograph of the staff member. There are only 15 of the care staff team who have completed their National Vocational Training (NVQ) at level 2 or 3 in caring for older people. This means that they have been assessed as being competent to do their job. There are another 14 of care staff who have started this training. We expect that 50 of the care staff team have an NVQ qualification. The home have not achieved this. We spoke to the area manager about this she told us that the company are dealing with this issue and have put plans in place to make sure that staff undertake this training. We asked a new member of staff about their induction training when they first started working at the home. They told us that their induction had been good and covered everything they needed to know. All staff are offered training one of the administration team makes sure that peoples training is kept up to date and courses are arranged as necessary. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management need to develop the management systems in the home to make sure people are kept safe. Evidence: There has been no registered manager at the home since April 2007. A permanent manager was recruited but left the home before they were registered. Since then the home has been managed by one and then another of Four Seasons peripatetic managers. A permanent manager has now been recruited and has been in post for a few weeks. She is a nurse who has 12 years experience of managing a home and has achieved her registered managers award, which means she has been assessed as competent to manage a home. we received an Annual Quality Assurance Assessment from the home before the last inspection in Apriil 2009. This gave us information about the servcie and what it provides. Care Homes for Older People Page 22 of 27 Evidence: Four Seasons have quality monitoring systems in place and surveys have been sent out this year to get peoples views about the service. We were told that these have been collated and that there is a report on the findings, however, when we asked some of the staff no one had seen it. It is important that the findings of the surveys are circulated so that people can find out what the results were and what action is being taken to address any areas that people thought could be better. The home does hold money on behalf of people living in there. We looked at the records and found that they were accurate with receipts available. This means that people are protected from any financial abuse. We looked at three members of staffs supervision records and appraisals, because we wanted to see how staff are given formal feedback on their performance. One person had only received one supervision in over 11 months and another only two supervisions over the same period of time. Neither member of staff had received a formal appraisal. In all three cases the supervision records indicated that their performance could be better. All three were confirmed in post after a probationery period without any formal documentation about how they were doing the job. The home need to use their supervision and appraisal system more effectively and make sure that it feeds into peoples probationary period and if necessary this can be extended before people are given a permanent job. This will make sure that peoples suitability to work with older people is fully explored. There is a rolling programme of training to make sure staff are kept up to date with safe with safe working practices. There is no one currently living in the home who is subject to a deprivation of liberty authorisation. It is important that staff receive training about the Mental Capacity Act and Deprivation of Liberty Safeguards so that they understand the implications in their day to day work with people. We looked at the accident reports for October 2009. It was not possible to find out from all of the forms in which unit the accident had happened. It is important that this information is added so that a proper analysis of accidents is completed. We found that there had been 38 accidents reported that month and saw that 26 of these had occurred at night. There were no reports to show that the accidents had been analysed or any action taken to look at how accidents could be reduced. It is important that this is done so that staff are continually looking at ways of reducing the risk to individuals. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 16 All complaints must be fully investigated and details of the investigation and findings are clearly recorded together with the action taken and outcome. This will make sure that all complaints are taken seriously and dealt with properly. 24/12/2009 2 18 13 The safeguarding procedures 24/12/2009 must be followed. This will make sure that people are kept safe. 3 29 19 Staff must be checked properly before they start working in the home. This will make sure they are suitable and safe to work with older people. 24/12/2009 4 29 19 A recent photograph of each 24/12/2009 staff member must be added to their recruitment file. Care Homes for Older People Page 25 of 27 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will make sure that each staff member can be easily identified. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 29 All of the staff recruitment files should be audited to make sure they contain all of the required documentation. This will make sure that all the required information is being held. The acting manager needs to apply for registration with us. This will make sure there is someone legally responsible for the management of the home. It is important that the findings of the surveys are circulated so that people can find out what the results were and what action is being taken to address any areas that people thought could be better. Staff should receive supervision six times per year. This gives staff the opportunity to discuss their practice and their development needs. Accident reports should be analysed on a regular basis and risk reduction measures put in place. This will make sure that staff are always looking at ways to prevent accidents. All staff should complete Mental Capacity Act and Deprivation of Liberty training. This will make sure that they fully understand the implications in their day to day work. 2 31 3 32 4 36 5 38 6 38 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!