Inspection on 28/09/05 for Pelsall Hall

This inspection was carried out on 28th September 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 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

Pelsall Hall 25/03/09

Pelsall Hall 22/12/06

Pelsall Hall 03/03/06

Pelsall Hall 04/03/05

Pelsall Hall 24/08/04

Pelsall Hall 22/03/04

Pelsall Hall 17/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Pelsall Hall Paradise Lane Pelsall Walsall West Midlands WS3 4JW Lead Inspector Mrs Amanda Hennessy Unannounced Inspection 28th September 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pelsall Hall DS0000020827.V268147.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 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. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pelsall Hall Address Paradise Lane Pelsall Walsall West Midlands WS3 4JW 01922 693399 01922 685525 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) Greensleeves Homes Trust Mrs Bridget Ann Ingleby Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4/3/05 Brief Description of the Service: Pelsall Hall is a large detached property within in its own extensive grounds. The house has been converted to provide residential care for up to twenty-nine older people. The home has a large lounge/ dining room with a small quiet lounge and conservatory off it. Laundry and kitchen are provided within the home. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by two Inspectors. The inspection was undertaken between 09.30 and 13.45. The inspection included talking to service users and staff and a review of records. Care records were reviewed as part of the “case tracking” of four residents. The home is privately owned by Greensleeves Homes Trust. The home’s manager is Mrs Bridget Ingleby. Eight of the previous thirteen requirements were found to have been addressed, seven new requirements were made as a result of this inspection. The inspection was positive and found that service users are happy living at Pelsall Hall and are well cared for. What the service does well: What has improved since the last inspection? The Manager and staff at Pelsall Hall demonstrate a clear desire to continually improve the care their residents receive and are eager to receive and follow advice given to them by other Professionals . Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 the following standard(s): 3 Detailed assessment of needs prior to admission ensure that the home is able to meet service users needs. EVIDENCE: Three service user care records were reviewed. All care records seen had a detailed assessment of their needs enabling staff to plan appropriate care alongside the service user . The pre admission assessment of needs is undertaken by either the Manager or another senior member of care staff. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 Service user’s care plans and care risk assessments are detailed enabling staff to deliver care that is both appropriate and relevant. Medicines are administered safely. Service users privacy and dignity is maintained. EVIDENCE: All service users care records seen had a detailed care plan and risk assessments which included manual handling and falls assessments. All care plans are reviewed on a monthly basis and both service user and relatives are involved in this process. Service users are able to access other health professionals such as doctor, specialist nurses, dentist, opticians and chiropodists. Care plans also include religious observance and details of each service users preferred social activity. There is however no plan for oral care of each service user this should be given consideration during care planning. The home has appropriate policies and procedures for the safe handling and administration of medicines. Procedures in relation to medicines are satisfactory and safeguard the service users. Staff check the minimum fridge temperature but they must ensure that this is done daily so that medicines are stored safely and at the correct temperature. The treatment room is well Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 10 organised and the storage and administration of medicines was checked and found to be appropriate. Medication administration charts were also completed appropriately with no gaps seen. Service users spoken to said that all of the staff treated them with respect and always ensured that their dignity was maintained Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 the following standard(s): 12, 15 Service users find that the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. Service users receive tasty and nutritious home cooked food in pleasant surroundings. EVIDENCE: The home has a range of entertainment and leisure opportunities available for its residents. Leisure opportunities include fortnightly movement to music sessions and monthly bingo and which service users say they thoroughly enjoy. Residents also have visits from local clergy, video afternoons, visits by the community library with the delivery of library books as well as jigsaws and card games. There are visiting entertainers two to three times a month which including a visiting pantomime which has been booked for January following its success with residents earlier this year. It was also pleasing to see that staff ensure that a life biography is available and also record residents preferred social interests. The home has a four weekly menu which offers choice tasty and nutritious Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 12 Breakfast is served from 8.45 until approximately 10.30am Lunch is served around 12.30 Tea is served between 17.00. Supper around 19.00. Service users and staff confirm that snacks are also available should they require anything later in the evening. Service users are asked for their choice of main meal and tea for the next day. There is a wide choice also available at breakfast with some residents having a full cooked breakfast, whilst others preferring tomatoes or poached egg on toast, bacon sandwiches or simply porridge or cereal and toast. Residents are also able to choose from a range of sandwiches which are made up and plated up for them individually. Residents appetites are stimulated by the beautiful smell of baking with home made raspberry and apple pie and cakes being made on the morning of the inspection. The Cook makes home made cakes and puddings for the residents every day. Inspectors were very impressed by the extensive choice of food available with six different choice of pudding being available for residents which included the home made raspberry and apple pie, tapioca pudding, fruit and cream, ice cream, mince meat plait and lemon meringue pie. The home also prepares soft and diabetic meals for its current residents. The kitchen was found to be clean and well organised with all required food safety records being maintained. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 the following standard(s): 16, 18 The home has appropriate and comprehensive policies and procedures to highlight concerns and complaints, to safeguard residents from abuse. EVIDENCE: The home has a detailed complaints procedure. The complaints procedure is displayed in the main reception area of the home and is also included in the service user guide. The home has received no complaints in the previous twelve months. Residents spoken to said if they had any concerns they would discuss them with the Home Manager. The home also has appropriate policies for staff to highlight concerns whilst feeling safe to do so. Comprehensive adult protection procedures are in place and identify appropriate contact with the Police, Social Services and the Commission for Social Care Inspection. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 the following standard(s): 2 The home is clean, homely and well maintained with a beautiful garden for service users to enjoy. Infection control practices are generally satisfactory. EVIDENCE: The home was found to be clean, homely, and welcoming. A major extension and refurbishment of the home is planned to commence early in 2006 although there is an ongoing refurbishment with the main lounge, dining room several bedrooms and the stairway and landing recently redecorated, new chairs have also been provided for the lounge. There is large lounge / dining room with a small quiet lounge “ snug” and conservatory off it. The home has a full staff call system and a variety of aids and adaptations such as grab rails assisted baths and a wheel in shower available for dependent service users. The home is generally odour free however an unpleasant odour was noticed in two residents bedrooms, the mattress and bed frame in room of the rooms was found to be stained. The home has an extensive garden which is well maintained and is mainly lawns with a small patio area with mature trees and shrubs and trees. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 15 Infection control procedures within the home generally meet required guidelines and requirements. It was noted that flannels and towels were being washed at too low a temperature to minimise the risk of cross infection, this was immediately brought to the attention of the Deputy Manager. There is also a need that the laundry floor and walls can be easily washed again to reduce the risk of cross infection. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Whilst staffing levels and skill mix meet residents needs care provided could be further enhanced by a review and increase in staffing levels. Recruitment and selection procedures are robust and safeguard service users from being cared for by unsuitable people. EVIDENCE: The home has the following staffing levels: 08.00-14.30 1 Senior Care Assistant and 2 care staff 14.30-21.00 1 Senior Care assistant and 2 care staff 21.00-08.00 2 care staff The home has a very low turnover of staff and has 72 of its staff with an National Vocational qualification which is an excellent achievement and is a probable reason in the high standards of care within the home. No concerns about staffing levels were highlighted by staff, residents or the Inspectors. A review of the home’s staffing levels against a national recognised benchmark since the inspection has identified a deficit in staffing hours. The Manager has agreed to review staffing levels with her staff. The Manager has Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 17 agreed to discuss and review staffing levels alongside her staff. The home also has domestic, laundry and catering staff employed daily. numbers and the skills and expertise of staff meet the needs of residents. The home is staffed with the following staff Staff records were reviewed and generally met the requirements of the regulations and safeguard the residents. No photograph was available of the two most recently appointed staff members. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 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 31, 33, 35 and 38 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 Service users benefit from having appropriately supervised and supported staff. EVIDENCE: Care staff receive regular supervision sessions. Supervision records are detailed and show that staff are supported to develop their knowledge and further enhance the care that they provide for the residents. Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x x STAFFING Standard No Score 27 2 28 4 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x x Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP8 OP9 OP9 Regulation 15 3(2) 13(2) Requirement Service users plan of care must include oral care. The drugs fridge temperature must be recorded daily The registered manager must ensure that Care Staff have received accredited medication training. This requirement was partially met. It should have been addressed by 31/7/05 4 OP16 17(2) Record and investigate all complaints. This requirement was not assessed as no complaints have been received since the previous inspection. The stained mattress and bed stand in room 2A must be replaced All areas of the home must be free from offensive odour. Provide storage area for aids and equipment, including wheelchairs. Not met – Additional storage has been identified within the new DS0000020827.V268147.R01.S.doc Timescale for action 30/11/05 15/10/05 31/12/05 31/12/05 5 6 7 OP19 OP19 OP22 13(3) 16(2)(k) 23(2) 31/10/05 15/10/05 31/03/06 Pelsall Hall Version 5.0 Page 21 8 OP26 12(1), 23(d) 9 10 OP26 OP26 13(3) 13(3) 11 12 OP27 OP38 18 13(4)(a), 23(4) extension. Provide a suitable regularly cleaned, washable floor covering and ensure an even floor level in the hairdressing salon. Not met The laundry floor and walls must be continuous and easily cleanable. Laundry must be laundered at the required temperatures to minimise the risk of cross infection. Staffing levels must be reviewed. Provide safe, secure, suitable (fire safe) storage of stacked paperwork etc in the hairdressing salon. Partially met, but paperwork is still stored in hairdressing room 31/03/06 31/12/05 31/10/05 31/10/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. Extracts may not be used or reproduced without the express permission of CSCI Pelsall Hall DS0000020827.V268147.R01.S.doc Version 5.0 Page 23 - 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!