Inspection on 10/02/06 for Pelton Grange Care Home

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Pelton Grange Care Home 12/02/09

Pelton Grange Care Home 15/02/07

Pelton Grange Care Home 22/08/05

Pelton Grange Care Home 23/03/05

Pelton Grange Care Home 04/08/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Pelton Grange Care Home Front Street Pelton Chester Le Street Durham DH2 1DD Lead Inspector Stephen Ellis Unannounced Inspection 10th February 2006 1:30 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 Pelton Grange Care Home DS0000000732.V274123.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. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pelton Grange Care Home Address Front Street Pelton Chester Le Street Durham DH2 1DD 0191 370 1477 0191 370 2580 pelton.grange@fshc.co.uk 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) Four Seasons Health Care (England) Limited Miss Alicia Scott Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (47), Terminally ill (47) of places Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability. Persons with a physical disability may be accommodated commensurate with the home`s statement of purpose. 22nd August 2005 Date of last inspection Brief Description of the Service: Pelton Grange is an established care home providing personal care and accommodation for up to 47 people. It is registered to provide care (including nursing care) for older people, people with physical disability, people who require palliative care, and people who require convalescence. People with or without nursing needs may be accommodated. People with nursing needs are accommodated on the first floor, but have access to all communal facilities throughout the home. It is part of the Four Seasons Health Care group. The home is purpose built, in the centre of Pelton. It is within easy reach of the shops and town centre amenities. The home offers mainly single bedroom accommodation, although a small number of double bedrooms exist. There are no en suite services, but ample bathing and toilet provision is distributed across the home. There is a good range of communal sitting and dining areas. The home is surrounded by well-maintained gardens, has a very pleasant, accessible patio area, plus ample car parking space available for visitors. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4.75 hours. The home’s registered manager was present throughout. The inspection process included a tour of the building, an examination of a number of records, plus discussions with 16 service users, 8 relatives and 5 members of staff. What the service does well: What has improved since the last inspection? Over the past year, the home’s statement of its terms and conditions of residence has been updated and clarified. All hot water outlets used by residents have had thermostatic mixer valves fitted (to prevent scalding). Corridors and a first floor lounge have been redecorated. The home has applied to its Estates Department for permission to convert a fifth bathroom into a shower room with hairdressing basin. The home is in the process of recruiting an activities organiser (20 hours per week). Regulation 26 reports (of the provider’s monthly visits to the home) are being sent to the CSCI. Pelton Grange Care Home DS0000000732.V274123.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. Pelton Grange Care Home DS0000000732.V274123.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 Pelton Grange Care Home DS0000000732.V274123.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): 3 and 6. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Intermediate care (for intensive rehabilitation) is not provided. EVIDENCE: Residents said that the home met their needs very well, in accordance with the assessment of needs carried out prior to their admission, and as updated by periodic review. Residents said that they were involved in any assessment of their needs. These views were reflected in the comments received from relatives. Residents’ plans of care (four were examined) showed that comprehensive assessments of needs had been carried out and that the home was meeting those assessed needs. Plans of care were being systematically reviewed, at least once a month. Pelton Grange Care Home DS0000000732.V274123.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, 8, 9 and 10. Residents’ health, personal and social care needs are fully met. Residents are treated with respect and their privacy and dignity are promoted. There are good arrangements for dealing with people’s medication requirements. EVIDENCE: Residents spoke very highly of the arrangements for meeting their health, personal and social care needs. They believed that the staff understood their needs and made sure that these were met in a caring and supportive way. They felt they were treated with respect and their right to privacy was upheld. Comments from residents included: “It’s lovely here…the staff are very caring…it’s a very good home…it’s home from home…very well managed…don’t think I could have got anywhere better.” These positive comments were reflected in the attitudes and practices of staff observed on the day and in the comments received from relatives. Typical comments received from relatives included: “The staff are brilliant…the staff are very caring…the manager lets you know straight away if there’s a problem…we have peace of mind and contentment (knowing that our relative is well looked after).” They were also confirmed by reference to the residents’ Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 10 plans of care (4 were examined), which were detailed and comprehensive. These showed that residents’ needs were carefully identified and addressed, involving external agencies (e.g. healthcare centres, hospitals and specialists) appropriately. There are good arrangements for the safe administration of medicines. Most nursing and care staff members have completed the Safe Handling of Medicines course. There is good support from a local Pharmacist who supplies the medication in Monitored Dosage form (blister packs). There are good storage systems and staff check all medication when it is received into the home. Medication is kept securely in lockable cabinets and trolleys. Residents may attend to their own medication, but in practice most prefer to delegate this responsibility to staff. Unwanted medicines are returned promptly to the Pharmacist or disposed of via a waste management agency, as required for care homes with nursing, and the home is careful not to stockpile large quantities. Senior staff members carry out medicine audits routinely. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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, 13, 14 and 15. Good arrangements exist for daily life and social activities, but the employment of an activities organiser would enhance the social and recreational activity programme. EVIDENCE: Residents and relatives spoke very highly of the atmosphere in the home that was conducive to wellbeing and fulfilment. A positive and enabling culture has been established, where people are treated with respect and their individuality is recognised. People are encouraged and supported to make choices that suit them. For example, in their daily routines people choose how to spend their time, what times to get up and go to bed and what clothes to wear. A number of residents had personal fridges in their rooms, which they enjoyed using. Some also had their own telephones. Most had their own televisions. In the reception area there is comfortable seating, an aquarium and pleasant music playing in the background. Some residents were playing dominoes, others preferred watching TV or listening to tapes, or reading. They told me that there was a basic programme of activities and social events available, although it had been a bit intermittent recently (e.g. bingo had not been held due to the ill health of the bingo caller). Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 12 The programme includes board games, bingo, weekly visiting hairdresser, occasional social events (e.g. visiting entertainer) plus personal activities. One or two residents said they would like more opportunity to go on outings, in a minibus for example. Another resident and relative said: “This is a tip-top, cracking home…just wish there was more going on in the home”. The manager is recruiting for a part time activities organiser, to try to improve the provision of social and recreational activities. All residents thought the catering arrangements were either good or very good. Personal choice and preferences were catered for. Meals were served in attractive dining areas on both floors. In 2005, the kitchen received an award from the local District Council for high standards of food safety, for the fourth year running. Fresh fruit and vegetables are served each day, along with salads and fruit juice. Birthdays are always celebrated with a birthday cake. Residents said that their visitors were always made welcome. They could visit at any reasonable time and some chose to take a meal if their visit coincided with a mealtime. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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): 18. Residents are protected from abuse. EVIDENCE: Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau and Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to ensure that unsuitable people are not employed to care for vulnerable adults. New staff members go through induction and foundation training so that they have the right knowledge and skills to do their jobs competently. All nursing and care staff members undergo Protection of Vulnerable Adults training. Residents reported a caring, supportive atmosphere in the home, which is well established. There is very good leadership and teamwork evident and these features reinforce the caring culture and provider policies concerning adult protection. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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): 19 and 26. Service users live in a safe, well-maintained environment, although a handful of bedroom doors require repair so that they shut properly. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the building revealed it to be well maintained with the exception of a small minority of bedroom doors that did not shut properly (3 on the first floor). These need to shut properly in the interest of fire safety, as they are fire doors. Thermostatic mixer valves were fitted to the ground floor wash hand basins last year, so that all hot water outlets to which residents have access are controlled. Also, the first floor lounge and corridors on both floors have been redecorated, creating a more light and airy feeling. A full time maintenance officer carries out safety checks and these are recorded. He is also involved in carrying out and/or organising repairs and redecoration. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 15 Residents and relatives expressed satisfaction with the quality of the premises. Many of the bedrooms had been personalised by their occupants. There were no unpleasant odours and the home was found to be clean in all the areas inspected. Nursing and care staff members have completed training in Health and Safety, Infection Control and Food Hygiene. Paper towels and liquid soap were provided in toilets and bathrooms in wall-mounted containers, to promote hygienic practices (although residents have personal flannels and towels in their rooms). Residents said that they were pleased with the premises, finding them clean, comfortable and homely, as well as practical. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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 and 30. Staffing numbers and mix of skills are appropriate for the needs of residents. Care staff members are trained and competent to do their jobs, with approximately 50 having NVQ level 2 or above. The home’s recruitment policy and practices support and protect residents. EVIDENCE: The home is staffed in accordance with the staffing notice agreed with the original regulators. At the time of inspection, there were 39 residents being accommodated. Typically, for the 22 nursing residents, there are 4 carers and one registered nurse on duty during the early part of the day, plus 3 carers and one nurse during the latter part. In addition, for the 17 non-nursing residents, there are 2 care staff on duty during the day. At night (8 pm – 8 am) there is one registered nurse on duty plus 3 carers across the whole home. The registered manager is supernumerary (her hours are not included in the clinical or care hours provided). There is a dedicated administrator and separate maintenance officer, plus catering and domestic staff in sufficient numbers for the needs of the home. The manager is actively recruiting a part time activities organiser, which is pleasing to report because the absence of an activities organiser has been highlighted in previous inspections as being significant. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 17 Comments received from residents and relatives indicated satisfaction with staffing levels and competence. There were many complimentary comments about the kindness and caring practices of staff. Staff training and development programmes are appropriate for the training needs of staff and include induction and foundation training, safe handling of medicines and positive dementia. Approximately 50 of care staff have achieved NVQ level 2 or above in care (10 out of 23 care staff currently, with others registered for the award). Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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): 31, 33, 35 and 38. The manager of the home is fit to be in charge, of good character and able to discharge her responsibilities fully. The home is run in the best interests of residents. Residents’ financial interests are safeguarded in those situations where the home is involved. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager is experienced and competent in her role. Residents, relatives and staff spoke well of her leadership skills and commitment to good outcomes for residents. She was described as being approachable and caring. She is due to complete her Registered Manager’s Award at NVQ level 4 in the near future. Good accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving residents’ personal monies, in Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 19 which the home is involved, wherever practicable. Relatives look after the personal monies of many residents. In those situations where the home helps look after residents’ monies, such as pocket monies, clear individual accounts and records are maintained. Comments received from staff and management confirmed that there are good health and safety policies and practices that promote the health, safety and welfare of residents and staff. All staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. This helps reinforce the registered provider’s written policies on Health and Safety. Health and Safety issues are also discussed at regular staff meetings. There are 3 bedroom doors on the first floor that do not close properly and these have been identified as a potential fire risk. The fire safety officer from the Local Authority has been asked to assess the risk and advise on any corrective action. Residents, relatives and staff expressed satisfaction with the way the home was run and the good standards that were evident in many instances. They said they believed the home was safe and run in the best interests of residents. For example, there are frequent consultations with residents and their families plus written surveys concerning residents’ satisfaction. Their comments and suggestions are welcomed and acted on where practicable. The registered provider’s representative reports on the findings of her monthly, unannounced visits to the home, in keeping with regulation 26 of the Care Homes Regulations 2001. Copies of the report are sent to the Commission for Social Care Inspection and the home’s manager, as well as key members of the registered provider organisation. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 20 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 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 21 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 OP19 Regulation 23,13 Requirement A minority of bedroom doors require repair so that they shut properly. These are fire doors and must close and seal fully. This requirement is outstanding from the last inspection. The missed deadlines for completion were 01/06/05 and 30/11/05. Timescale for action 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 OP12 Good Practice Recommendations Provision of an Activities Organizer is highly desirable in this home and would reinforce the good practice achieved in other standard areas. Provision of outings in mini-buses should be considered for those service users who would benefit. Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Pelton Grange Care Home DS0000000732.V274123.R01.S.doc Version 5.1 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. 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