Inspection on 15/02/07 for Pelton Grange Care Home

This inspection was carried out on 15th February 2007.

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

Pelton Grange Care Home 12/02/09

Pelton Grange Care Home 10/02/06

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 Denise Huscroft Unannounced Inspection 15th February 2007 10:30 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.V327552.R01.S.doc Version 5.2 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.V327552.R01.S.doc Version 5.2 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) of places Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 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. 10th February 2006 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. Current Fees Residential Rate £364.50 Nursing Rate £412.00 Private Nursing Rate £480.00 Continuing Health Care £576.00 Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It took place over 6 hours and included a site visit, 3 resident file inspections, 2 staff file inspections and interviews with 3 staff, 4 residents, 3 relatives and 2 visiting professionals. A pre inspection questionnaire, resident and relative surveys were received before the site visit. The manager of the home was present during the inspection. What the service does well: What has improved since the last inspection? The home has recently employed a Diversional Therapist to promote activities within the home. Various activities are now provided to include games, physical and mental activities, crafts and relaxation. Individual support is also offered for those residents wishing to go to the shops, pub or the cinema. Some bedroom doors have been repaired so that they close and seal properly. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 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.V327552.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have individual written contracts. Residents needs are fully assessed before moving into the home. EVIDENCE: Prospective residents have an assessment by the Local Authority and a pre admission assessment which is carried out by the manager or a senior member of staff to make sure the home can meet all of their needs. Residents and families are then invited to look around the home before making a decision. The files of 3 residents confirmed assessments had been carried out before placements began although they could have included more details regarding personal likes and dislikes. All residents had detailed individual contracts on file.One relative said “The manager came to the house to talk to Mam, it was very much Mam’s decision to stay there.”A statement of purpose and service user guide are made available to residents and families on request. However it will be a requirement of this inspection that the home Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 9 review their policy of only making service user guides available on request and bring practice more in line with the regulatory requirement to supply a copy of the guide to each resident. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal and social care needs are fully met. Residents health needs are fully met. The home has procedures in place to store and administer medication. Residents privacy and dignity is upheld. EVIDENCE: Each resident has an individual care plan which is written in consultation with residents and their families. This includes moving and handling, sexuality, nutritional and risk assessments. Files examined showed evidence of monthly reviews and very clear, detailed daily notes. Relatives and residents confirmed they had been very involved in this process. The home has a weekly visit from a nurse practitioner who sees any resident registered with the practice with any health concerns. The home also has input from district nurses as and when required. Professionals said “The care is very good. They know their residents inside out and don’t sit on anything they’re unsure of.” Staff were Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 11 said to be “very good at keeping records” and “following things through”. Relatives said they always felt well informed of their relatives condition and were confident they would be contacted if staff had any concerns. The home has policies and procedures in place regarding the administration and storage of medication. A selection of residents’ records were examined and found to be in order. The manager carries out a monthly audit of the residents’ medication. The home uses the Monitored Dosage System and any unused drugs are returned to Boots. The disposal of controlled drugs is signed for by 2 nurses and for other drugs 1 nurse must sign. All staff handling medication have a Certification of Safe Handling in addition to Boots own training which is regularly updated. During the inspection the residents all seemed happy and well cared for. A visiting professional said “The staff always take the residents to their rooms for treatment for privacy and dignity” Residents comments included ”I’m treated with respect, definitely and with privacy. I love living here.” Staff said they “treated residents as individuals, always calling them by their chosen name” and “treating them how they’d like to be treat.” Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place for daily life and activities. Residents are encouraged and supported in maintaining contact with family and friends. Residents exercise choice and control as far as they are able. Residents enjoy a tasty nutritious menu. EVIDENCE: A recommendation of the last inspection concerned the provision of an activities co-ordinator which has now been met. The home has recently employed a Diversional Therapist to promote activities within the home. Various activities are now provided to include games, physical and mental activities, crafts and relaxation. The therapist intends to organise events and parties such as summer/Xmas fairs, barbecues and a selection of live entertainment. The home are sometimes able to use a mini bus to take residents on outings and some residents commented that this is something they’d like more of. Individual support is also offered for those residents wishing to go to the shops, pub or the cinema. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 13 Regular services are held in the home by the Christian Fellowship which are well attended. There are some residents who take private communion in their rooms from a Catholic Priest. The home has an open visiting policy with relatives and friends being made welcome at any time convenient to the resident. Visitors comments included “I always find it very welcoming” and “I’m often offered a cup of tea.” One resident has had family visit monthly from Scotland and the home provide a full 3 course meal, chosen by the resident, for them all to share at a separate, private table. A telephone is provided for those residents who do not have their own and calls can be made in private if they want to. During the inspection staff were observed giving residents choices as to what they wanted to eat/drink and where they wanted to be, either in the lounge with the others or in their bedroom. Several residents chose to eat their meals in their rooms. Residents comments included ”You’re not pushed around or told what to do. We’re pretty much free to do what we want.” And “It’s smashing. I couldn’t be in a better home.” The home provides a nutritious four weekly menu which has a selection of hot food, deserts, light meals, sandwiches and snacks. When a new resident moves in the cook goes to discuss the menu with them to find out if they have particular likes or dislikes so that they can be accommodated. Each day staff ask each resident what they would like for the following day however if anyone changes their mind when the meal is served an alternative is offered. All food is homemade on the premises and fresh fruit is always available. One resident said “Foods great, cooked breakfast, lovely lunch, lovely tea and Horlicks at night.” A questionnaire is completed by residents every 3 months regarding their views on the variety and quality of the food. A selection of these were seen and most were positive with comments such as “meals are very good at all times” and “even though the main meal is on an evening the midday meal is very substantial.” Any dietary needs are catered for with one professional saying “they bend over backwards to accommodate.” Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place which residents and relatives are confident of. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure which is found in the service user guide and also displayed in the unit. Surveys showed that relatives and residents were aware of the procedure and those spoken to during the inspection felt confident that any complaint would be acted upon. The complaints recording showed any complaints are monitored and the outcome recorded. All residents spoken to could explain the complaints procedure, comments included “They’d do their best to sort it out” and “ they are caring, they would listen to you.” Relatives said “ there’s a copy of the complaints on display and leaflets are around” Everyone seemed confident action would be taken if necessary. The home has policies and procedures in place to protect residents from abuse. Training records confirmed that staff have training to make sure they are aware and understand the procedures. Those spoken to during the inspection agreed they understood the training which included Protection of Vulnerable Adults and whistle blowing. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 15 Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident the home is safe and well maintained. The home is kept clean, pleasant and hygienic. EVIDENCE: The pre inspection questionnaire showed that all maintenance checks were carried out within appropriate timescales. A selection of records and certificates were examined during inspection and found to be in order. A requirement of the last inspection concerned the repair of bedroom doors so they shut properly. They are fire doors and must close and seal fully. This requirement has been met. In the kitchen a wall was found to have a great number of tiles missing which the manager stated was being addressed by the estates department. The drive leading up to the front door has a hole in it where a tree has been removed. A contractor has been consulted and the work Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 17 is expected to be carried out in the near future. One of the upstairs bathrooms and separate toilet is going to be converted into a shower room with hairdressing basin. This facility will be fully accessible. A tour of the building, upstairs and down, showed it was clean and well maintained. with new carpeting throughout. The reception is very large and well decorated with several sofas, an aquarium and quite background music playing. It has a lovely, welcoming atmosphere. There are airy communal lounge/dining rooms upstairs and down, a pleasant conservatory. and several small private seating areas around the building. The bedrooms had many personal possessions in evidence including pictures, photos and furniture. The bathrooms and toilets were all clean and fresh. The laundry was also found to be very clean and tidy. The residents were all satisfied with the cleanliness with comments such as “The cleaners are very good, always hovering, dusting and cleaning windows” “We get clean towels and flannels every day” and “They definitely keep the room clean” Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers and mix of skills meet residents’ needs. Residents can be confident they are in safe hands. The home has recruitment policies and procedures in place to protect residents. Staff receive training and support to help them do their jobs. EVIDENCE: The pre inspection questionnaire provided staff rotas which show there is sufficient staff with a range of skills to meet the residents needs. Resident and relative surveys showed most people felt there were enough staff available when they are needed. The home has a training programme in place to ensure staff have the appropriate training to enable them to do their jobs. All staff have mandatory training and those spoken to had a good understanding of protection issues. Staff receive regular supervision from management who were said to be supportive and approachable. Training, supervision and appraisals are all recorded in separate staff files. At the time of the inspection less than 50 of care staff had completed National Vocational Qualification level two, although those spoken to said they had received encouragement and support from Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 19 management to do so. It is a recommendation of this inspection that 50 of care staff complete NVQ level two. The home has recruitment policies and procedures in place to ensure residents are supported and protected including Criminal Record Bureau checks, Protection of Vulnerable Adult checks and two written references. The application form also asks for a full employment history but those files examined did not have exact dates of former employment and therefore were not following the procedures correctly. The manager is aware of this and it will be a recommendation of this inspection that future applicants supply these details. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a person fit to do so. It is run in the best interests of the residents. Residents financial interest are protected The health safety and welfare of residents is protected. EVIDENCE: The registered manager has worked in the home for 18 years, with 6 years as manager. She is a Registered General Nurse and has a Registered Managers Award and NVQ level 4.The manager was present throughout the inspection and was able to provide all the documentation required to show the minimum Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 21 standards were being met. She appeared to have good relations with staff, residents and visitors alike. Residents, relatives and staff all thought the home was well run in the interests of the residents. Comments include “Carers do a fantastic job, They work very hard” “They’re wonderful. Can’t speak highly enough of them.” The manager operates an open door policy and welcomes any comments regarding the running of the home. Questionnaires are used to gather views as well as resident/relative meetings which are advertised in the home. Some relatives said they weren’t aware of these meetings and would have liked to attend so the manager is considering other ways of letting people know about them. The home has policies and procedures in place to protect the financial interests of the residents. An inspection of a selection of residents’ records found them all to be in order. The organisation’s Regional Support Administrator carries out random audits. Social services handle the financial affairs of three residents and carry out an annual audit which found records to be accurate. Three residents have Court of Protection orders to oversee their affairs and statements of their finances are sent to their solicitor to monitor. Health and Safety policies and procedures are in place to promote the health, safety and welfare of residents and staff. Records of the registered providers Regulation 26 (of the Care Homes Regulations 2001) visits were available to the inspector and areas of concern had been acted upon. Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 22 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 23 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 Standard OP1 Regulation 5 (2) Requirement The home must review the policy of only making service user guides available on request. Timescale for action 15/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP29 OP28 Good Practice Recommendations Recruitment procedures should ensure there are no gaps in the dates of previous employment 50 of care staff should be qualified to NVQ Level 2 Pelton Grange Care Home DS0000000732.V327552.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V327552.R01.S.doc Version 5.2 Page 25 - 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!