Inspection on 03/03/06 for Pelsall Hall

This inspection was carried out on 3rd March 2006.

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

Other inspections for this house

Pelsall Hall 25/03/09

Pelsall Hall 22/12/06

Pelsall Hall 28/09/05

Pelsall Hall 04/03/05

Pelsall Hall 24/08/04

Pelsall Hall 22/03/04

Pelsall Hall 17/11/03

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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 3rd March 2006 11:00 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.V285738.R01.S.doc Version 5.1 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.V285738.R01.S.doc Version 5.1 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.V285738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th September 2005 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.V285738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection undertaken by one Inspector. The inspection was undertaken between 11.00 and 16.00. This Report is a product of observations made during a tour of the Home, discussion with residents, the Registered Manager and staff members, together with a review of care related documentation and a range of documents/records reflecting the general operation of the Home. The home is privately owned by Greensleeves Homes Trust. The home’s manager is Mrs Bridget Ingleby. Six of the previous twelve requirements were found to have been addressed, three new requirements were made as a result of this inspection. High standards of direct care provision and overall management are provided in a friendly and open atmosphere for residents. What the service does well: What has improved since the last inspection? Staffing levels have been reviewed. The programme of staff training is ongoing with all staff recently completing a medication awareness training programme. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 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.V285738.R01.S.doc Version 5.1 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.V285738.R01.S.doc Version 5.1 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): No standards were assessed in this section. EVIDENCE: Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 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 Service user’s care plans and care risk assessments are detailed enabling staff to deliver care that is both appropriate and relevant. EVIDENCE: Care records are complete and consistently reflect all service users needs. Care records are regularly audited to ensure that staff continue to meet the care requirements and that care plans are comprehensive and appropriately updated. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 10 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): 13,14 Service users are helped to exercise choice and control over their lives and are able to maintain contact with their family and friends. EVIDENCE: Residents are able to exercise choice and have autonomy over their lives whilst living at Pelsall Hall. Residents specifically stated that they get up and go to bed when they want to, choose where they had their meals and what they had to eat and the activities that they take part in. The home has open visiting with visitors coming to the home throughout the day. Visitors say that they are always made welcome. Visitors are able to visit their relative in either their own room or in one of the lounges, in addition a number of service users have visitors who regularly take them for trips out. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 11 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): No standards were looked at in this section during this inspection. EVIDENCE: Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 12 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): 19 The home has considerable character and is clean, homely and well maintained with a beautiful garden for service users to enjoy. EVIDENCE: Pelsall Hall is an old building with considerable character and charm which is set in its own and considerable grounds. The home is clean homely and well maintained. Limitations of the environment of the home will be addressed by the new and considerable extension. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 13 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): 28, 30 Staff have regular and required training giving assurance of their expertise. EVIDENCE: The home has 75 of its care staff with a National Vocational qualification which is an excellent achievement and gives assurance of staff expertise. All new staff have induction training to National Training Organisation standards. Staff are encouraged to enrol to undertake their NVQ qualification when they complete their induction training . Staff receive at least three training days each year. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 14 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): 31, 33, 35, 38 The home is well and effectively managed. Service users financial interests are safeguarded. The health safety and welfare of service users and staff is promoted and protected. EVIDENCE: The Home has an experienced Manager who has over twenty years care experience and of which fifteen years have been at a senior management level. Discussion with staff and service users both during this and previous inspections identify that the home is well and effectively managed. Whilst the home does not have a formal quality assurance system in progress, it is evident that service users are consulted about their views of the home. A service user survey has been undertaken and needs now to be analysed and shared with all interested parties. The required monthly reports are undertaken by the registered proprietor that comprehensively review the home and Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 15 provide excellent guidance for the manager and staff further development of the home. Secure facilities are available for the safe keeping of service users personal money and valuables. Written records are available for all transactions which detail the reason for the withdrawal and receipts are available as proof of purchases only one signature is available to confirm the transaction. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water although a record of the temperature that the hot water both stored and distributed around the home is required. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and protection of vulnerable adults. Maintenance records and contracts were reviewed and were found to be up to date. The registered manager has undertaken a satisfaction survey / questionnaires for service users and relatives to gain their views on the home. All policies and procedures were reviewed in July 2005. There is a need to review and audit key areas such as accidents and incidence of pressure sores which is not currently undertaken. Work is also still required mostly to address standards 33.2 and 33.3 as the home has no formal quality development plan in place. Their relatives or social services department either manages service user’s finances. The home holds in safe keeping small to moderate amounts of money for service users. The inspector randomly checked the balances of a number of the service users money held in safe keeping, against the actual money held, money was correct. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. There is a need that the storage and distribution temperature of hot water for each hot water cylinder is recorded monthly. Records identify that the majority of staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and protection of vulnerable adults. Staff do not all have two fire drills each year as required. The home has been experiencing problems with the central heating system, this has almost been resolved but as a result no service certificate was available. Maintenance records and contracts reviewed were found to be up to date with the exception of the five yearly electrical installation test certificate. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 4 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 2 Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP16 Regulation 17(2) Requirement Record and investigate all complaints. This requirement was not assessed as no complaints have been received since the previous inspection. 2 OP22 23(2) Provide storage area for aids and equipment, including wheelchairs. Not met - Additional storage has been identified within the new extension. 3 OP26 12(1), 23(d) Provide a suitable regularly cleaned, washable floor covering and ensure an even floor level in the hairdressing salon. Not met will be addressed when the new extension is completed The laundry floor and walls must be continuous and easily cleanable. Not met will be addressed when the new extension is completed 31/10/06 31/10/06 Timescale for action 31/03/06 4 OP26 13(3) 31/10/06 Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 18 5 6 7 OP33 OP33 OP35 24 24 13(6) 8 OP38 13(4)(a), 23(4) The home must have a formal quality assurance tool. The service user survey is analysed and shared with all interested parties. Two signatures one of whom when ever possible must be the service user must be available to confirm transactions of service users money. Provide safe, secure, suitable (fire safe) storage of stacked paperwork etc in the hairdressing salon. Partially met, and will be fully addressed by the new extension. A record must be available of the storage and flow of hot water. 30/04/06 30/04/06 31/03/06 31/10/06 9 OP38 23 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations Receipts of service users money are numbered. Pelsall Hall DS0000020827.V285738.R01.S.doc Version 5.1 Page 19 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.V285738.R01.S.doc Version 5.1 Page 20 - 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. 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