Inspection on 01/06/05 for Pendlebury Court Care

This inspection was carried out on 1st June 2005.

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 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

Pendlebury Court Care 05/07/07

Pendlebury Court Care 13/07/06

Pendlebury Court Care 08/11/05

Pendlebury Court Care 01/02/05

Pendlebury Court Care 23/09/04

Pendlebury Court Care 31/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Pendlebury Court Care St Mary`s Road Glossop Derbyshire SK13 8DW Lead Inspector Eileen McHale Unannounced 01 June 2005 10:00 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 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. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pendlebury Court Care Address St Mary`s Road, Glossop, Derbyshire, SK13 8DW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 429 0307 Pendlebury Healthcare Limited No registered manager Care Home 31 Category(ies) of Dementia (19), Old age, not falling within any registration, with number other category (31) of places Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 7/3/05 Brief Description of the Service: Pendlebury Court is a care home registered for 31 places for the care of older people including 19 places for persons with dementia. the home is situated in the town of Glossop in the High Peak. It is withihn walking distance of the main high street where there are many shops and amenities ,including the post office, chemists and newsagents. The home offers single accommodation, with 25 bedrooms having ensuite facilities. The home has a shaft lift. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day . During this time an inspection of the building took place and the inspector spoke briefly to a number of residents. The care of two residents was examined in more detail although their contribution to this was also brief. Staff files were examined. The inspector spoke to an aromatherapist who provided a service to residents in the home. Where in the body of the report, reference is made to “the manager” this does mean in this instance the acting manager, as at the time of the inspection the formal registration of the manager had not been completed although the application was being processed. The acting manager and her deputy had been in place since the beginning of February. They had undertaken a systematic programme of change of all aspects of the running of the home. This work was still underway at the time of the inspection. What the service does well: What has improved since the last inspection? Considerable investment has taken place in improving the communal rooms and bedrooms in the home. At the time of the inspection work to up date the first floor bathroom was almost complete. Since the last inspection, the numbers of residents in the home had increased and lounge dining areas on the first floor had begun to be used, giving more space and facilities to residents. The cook had negotiated contracts with local providers and was confident the he was providing more high quality fresh food. A new plan of activities had been developed, which included the services of a qualified aromatherapist. Additional staff members had been recruited which ensured better staff cover and reduced the risks of staff members working excessive hours. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 6 Major improvements had been made in essential record keeping, from care plans to staff records and the management of residents’ monies. Management systems were being developed further as the manager and her deputy resolved previous concerns. 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. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 standard(s) 1,3,6 The manager sought assessment information before residents were admitted and added to this information following admission. EVIDENCE: The home does not provide intermediate care. From inspection of a sample of care plans, it was confirmed that some residents entering the home had extensive assessment information and that the home built on this through contact with family members so that information on the person’s history and preferences was available. In one instance the home had admitted a resident from hospital. In this case although there was information on the person’s physical needs there had been no way in which the home could determine the resident’s previous history. Routines and preferences had to be assessed when the resident was in the home. The manager was aware of the importance of having some personal history, especially for residents with short term memory loss or dementia. Since the last inspection changes had been made to the service user guide to reflect current management arrangements within the home. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 The health and social care needs of residents were met and the relevant records of how they were met were improving. EVIDENCE: Since the last inspection further improvements had been made in the content of care plans and the key worker system had been introduced in the home.. It was noted however by the inspector that for the two case files examined, not all aspects of the care plan documentation had been completed, these included daily routines, risk assessments and records of inputs from health care professionals. In one instance social relationships in the home were known to be key to the good progress made by a resident but were not recorded in the resident’s care plan. The inspector acknowledges that the care plans examined were for residents who had been more recently admitted to the home and the observation is made in the context of clear improvements in care planning and recording. It was noted that the home assessed residents’ nutritional needs, tissue viability, moving and handling needs and the risk of falls and that these were reviewed. The manager and deputy manager could demonstrate that the emotional and social needs of service users were known, understood and acted upon even Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 10 where these had not been fully addressed within the care plan. Service users whose care was examined in detail were positive about the quality of care given within the home. It one instance the resident indicated that she was happy and settled in the home whereas assessment documentation had indicated that she was depressed on admission. The manager had undertaken monitoring of falls and accidents, taking steps to reduce risks. The result had been a major reduction in falls over 5 months. The home had the MDS system of medication, which was securely stored. Although the home provided appropriate storage for controlled drugs, none were in use at the time of inspection. Records of administration were well maintained. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 standard(s) 12,15 The home provided opportunities for residents to make friends and interact with different groups of resident. The home provided mainly fresh food of a good quality. EVIDENCE: Since the last inspection additional residents had been admitted to the home. The additional numbers had enabled the manager to bring into use a lounge dining area on the first floor. As a result residents had a greater choice of areas in which they might spend their time and others with whom they might associate. Opportunities were increasing to provide some additional choices of activities. As a proportion of the residents in the home had dementia, issues had arisen about the behaviours of service users. The manager and her deputy indicated that since there was use of additional communal facilities, those more agitated residents were more settled within a smaller group. It was noted that a small group of residents had formed a close friendship group with two residents being caring and solicitous for the third who had higher needs. This group was supported sensitively by staff and had lead to improvements in the morale of all three residents. Discussion took place with the manager on the need for risk assessments to ensure safe support systems to these nurturing relationships. Since the last inspection the manager had provided an activities board, which was on display in the reception area, providing information about planned Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 12 activities for residents, their families and friends. The inspector met a qualified aromatherapist who provided a regular service within the home. She indicated that the manager and staff in the home were very receptive to the benefits of her services to residents. The manager confirmed that her interventions calmed and relaxed even those residents with a tendency to be agitated. Since the last inspection changes had been made to the purchasing of food for the home, with the cook purchasing fresh food including meat from local suppliers. He reported improvements in the quality of food purchased. The home had a three-week rotating menu, which was said to be under review. Soft diets were provided for a small number of residents. The cook indicated that within the current resident group, fish was popular and was generally provided at least once a week. The kitchen was equipped to a satisfactory standard and new equipment had been purchased.. Care was taken to ensure good presentation of meals with attractive table settings. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 standard(s) 16,18 The manager and staff effectively use procedures, which are in place to protect residents. EVIDENCE: The inspector was aware that prior to February 2005,significant complaints had been made to the Commission about a range of issues within the home. No complaints had been received after February when an unannounced inspection took place and the new manager was appointed.. The home had a complaints procedure, which was available for residents and their friends and relatives. There was no record of complaints since 2002, although the inspector was aware of complaints that had been made prior to recent months. The inspector was aware of an adult protection matter, which had arisen between residents. This had been appropriately referred for investigation by the Social services department. Since that time risk assessments and agreed procedures had been put in place to protect a resident. The home had received information on Derbyshire’s joint procedures for the protection of vulnerable adults. The manager and her deputy had booked places on a training course provided by the authority and intended to cascade the training to staff members. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 standard(s) 19,20,22,24,26 Residents live in a home that is clean, attractive and well maintained. EVIDENCE: There was evidence in the home of an on-going programme of redecoration and refurbishment, which has resulted in considerable improvement in the standards of communal accommodation, reception and circulation areas. These improvements were continuing and with the refurbishment of bedrooms and the preparation of empty rooms for occupation in line with the increased demand for places. The investment of the proprietor was enhanced by the provision by the manager and staff of a whole range of homely features such as flowers, pictures and pottery. The home benefited from the service of a carer who was also employed to provide additional handyman hours. The first floor bathroom had been remodelled. This was not completed on the day of inspection as it required redecoration.. There was a planned replacement of a shower facility. Although equipment was provided for a resident who was blind, no loops or other environmental equipment was available for residents with hearing loss. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 15 The home was maintained to a high standard of cleanliness. The quality of resident’s personal laundry to a good standard. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Proper steps are taken to check the fitness of staff and increased recruitment has ensured that staff cover is maintained. The home has insufficient staff members with a recognised qualification in social care. EVIDENCE: Since the last inspection additional staff had been recruited to the home, including a number of staff who had previously been employed there previously but had left. One staff member was on maternity leave. On examination of the rota there were found to be 3 staff members on duty between 8 am and 8 pm. Although night staff came on duty at 8 pm, one member of day staff stayed on duty until 10 pm. Two staff were on duty at night. The manager and deputy manager provided cover over the 7 days. The manager was aware that as resident numbers rose she would need additional staff, she was confident that numbers of applicants were increasing. An additional cook had been recruited. A sample of staff files was inspected. The sample provided evidence that statutory records were maintained with the exception in one instance of a photograph. These included CRB checks and references. Since the last inspection the company training manager had left her post. As a result, previous training records were not available. The manager indicated that all staff had been trained in dementia care. She reported that 4 staff had NVQ2 and one staff member was qualified to NVQ3(National Vocational Qualification). Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 17 Of two adaptation nurses employed in the home, one was due to undertake adaptation training within a few months and the other had indicated a preference to gain further experience before undertaking the training. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,38 Residents’ monies are managed safely. The home had insufficient information on past training to plan for future staff training. EVIDENCE: The manager is currently managing the home in an acting capacity although she has applied for registration and her application was being processed at the time of the inspection. Residents’ monies were held separately and stored within the safe. Only the manager and deputy had access to these monies. Full records were maintained with two signatures. At the time of inspection there were no records available for all mandatory training. The manager indicated that staff were trained in moving and handling and this was on-going, but that not all staff had received training in first aid, food hygiene and infection control. The home had a video for fire training and recorded fire drills. It was agreed that new staff required training and night staff required training for a second time within the year. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 19 Since the last inspection work had been completed following an assessment of the risks of Legionella and the manager was aware that continued regular water test would be required. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 2 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x 3 x x 2 Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? 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 OP30 Regulation 18 (1)c Requirement The acting manager must ensure that staff members are supported to undertake National Vocational Qualifications. The acting manager must ensure that care staff receive current training in emergency first aid. The acting manager must ensure that staff receive training in infection control. The acting manager must ensure that staff handling food receive training in food hygiene. The acting manager must ensure that staff members employed in the home receive training in fire prevention as required by the Fire Officer. Timescale for action 31 March 2006 30 September 2005 30 September 2005 30 september 2005 30 September 2005 2. 3. 4. 5. OP38 OP38 OP38 OP38 13(4) 13(3) 13(3) 23(4)(d) 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 OP7 Good Practice Recommendations The acting manager should ensure that new care planning documentation is consistently completed and all staff are aware of best practice in the home. C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 22 Pendlebury Court Care 2. 3. 4. 5. OP7 OP12 OP22 OP30 The acting manager should monitor the recording of services provided by health care professionals. The acting manager should ensure that the lifestyle choices of residents are supported by clear risk assessments where these are required. The acting manager should investigate and incorporate in the home appropriate environmental aids for residents with hearing loss. The acting manager should ensure that records of staff training are maintained. Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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 Pendlebury Court Care C52 C02 S28409 Pendlebury Court V233561 010605 Stage 4.doc Version 1.30 Page 24 - 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. 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