Inspection on 13/07/06 for Pendlebury Court Care

This inspection was carried out on 13th July 2006.

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

Pendlebury Court Care 05/07/07

Pendlebury Court Care 08/11/05

Pendlebury Court Care 01/06/05

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 Brian Marks Key Unannounced Inspection 13th July 2006 08:30 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 DS0000028409.V302560.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. DS0000028409.V302560.R01.S.doc Version 5.2 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 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) 01457 854599 Pendlebury Healthcare Limited Josiane Celine Mycock Care Home 31 Category(ies) of Dementia (19), Old age, not falling within any registration, with number other category (31) of places DS0000028409.V302560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 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 and is within walking distance of the town centre where there are many shops and amenities, including the post office, chemists and newsagents. The home offers single room accommodation, with 25 bedrooms having en suite facilities. The home has a shaft lift. DS0000028409.V302560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of 7 hours. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a structured plan for the inspection. At the home, apart from examining documents, care files and records, time was spent speaking to the proprietor, the deputy manager and 6 of the staff working at the home during the visit. The care records of 3 people who use the service were examined and 2 of these were interviewed individually along with a group of residents in the upstairs lounge. Three visitors who were at the home during the morning were also spoken to. The Registered Manager was on sick leave at the time of the inspection. What the service does well: The home continues to be well run by an efficient and approachable management team and the owner is at the home regularly to monitor the care provided. Most staff are local to the home and with the recent new recruits work well together as a team; they were very positive about the manager and deputy manager’s approachability and support given to them, and improvements made at the home over the past 12 to 18 months. The home was purpose built in the early 1990’s and gives a comfortable and homely environment, and residents that were spoken to were satisfied with the care provided. Occupancy at the home has steadily built up and there have been a number of referrals in recent week, including for respite care. The meals provided were praised by the residents and visitors that were spoken to. There is a clear commitment to staff training at the home and nearly all of the staff, apart from one of those recently appointed, had undertaken at least the NVQ 2 Care qualification, which was above the requirements of 50 and should be commended. The administrative systems of the home have been well developed and the staff’s care activities are supported by clear and well laid out care plan documents. DS0000028409.V302560.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. DS0000028409.V302560.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 DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care needs of people coming to the home are properly looked at so that they can be reassured that the home is suitable for them to live in. EVIDENCE: The home does not provide intermediate care. All of the care records examined at this inspection contained initial assessments of the needs of residents with further additional assessments of areas of risk such as safe moving, skin breakdown and pressure sores, and falls. These allowed for the development of caring activity in a planned way, and the latter – ‘risk assessments’ – had mostly been reviewed annually to make sure they are based on up to date information. Further information on the person’s history and preferences is obtained through contact with family members, although this was not available in some of the files examined and the levels of information did not give a full picture of the whole person. From discussions with residents and the visitors present, people wanting to come DS0000028409.V302560.R01.S.doc Version 5.2 Page 9 and live at the home are give opportunities to visit before coming to stay, as part of the assessment procedure. DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans and risk assessment records promote safety and consistency in caring for residents and their health, social and personal care needs are met. EVIDENCE: The care records of 3 residents were examined in detail including 1 resident who had been recently admitted to the home. Each has a detailed service user plan in place and it was indicated that all the separate elements had been reviewed regularly, although not at the recommended monthly interval. Any changes to a resident’s needs are amended through this process. The care records indicate where residents require access to health care services such as chiropody, district nurse and GPs, but these were not always recorded in detail; neither were all the records of these visits taking place. Residents are assessed to identify their risk of developing pressure sores, although there were none with this condition at the time of the inspection, and all have their weight monitored. The complex care needs of a resident were described by a relative and how staff at the home had resolved the difficulties with a special diet that had been causing severe problems before she came to DS0000028409.V302560.R01.S.doc Version 5.2 Page 11 live there. ‘A proper programme of treatment was organised, I can’t praise them highly enough’. Another resident who is a wheelchair user described how ‘Staff help me with what I need’. All residents or their relatives spoken to commented that staff care for them in ways that respect their dignity and privacy and this was echoed by entries in the care plans. Examination of the arrangements for the receipt, storage and administration of medicines to residents indicated these to be generally satisfactory. Medication is stored securely and the home uses the ‘Monitored Dosage System’ for administration; all entries are properly checked, signed and dated, although this was not the case for some handwritten entries or where the doctor had given verbal instructions for a change. There were no controlled drugs being administered at the home at the time of the inspection. All senior staff, as well as the manager, have undertaken medication training. DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents in the home enjoy lifestyles, routines and meals that meet their requirements. EVIDENCE: The residents and visitors spoken to confirmed that they had a happy life in the home and were able to do much as they liked. They reported that there were some organised activities such as entertainment and religious services and that they had access to newspapers and magazines. One resident reported that he had been a reader of history books before he came to live at the home but had ‘not read a book since I’ve been in’. The deputy manager agreed to take up this issue after the inspection. Residents confirmed that they had daily routines that suited them, and that they had the free run of the home; staff confirmed this within the boundaries of safety. The manager also reported that aromatherapy was a new activity that was proving to be very successful in promoting relaxation and wellbeing. However, staff said that sometimes residents were difficult to motivate. Contact with families is encouraged through an ‘open door’ policy, and good numbers were seen at the home during the inspection. Those spoken to were positive about relationships with the home’s staff ‘I can’t praise them highly DS0000028409.V302560.R01.S.doc Version 5.2 Page 13 enough’ ‘All her friends can come and visit her now because she’s always ‘at home’ ’. ‘The staff are brilliant – friendly and helpful’. ‘If I’ve got any worries they’re sorted’. During a visit made to the kitchen and from discussion with the cook it was evident that good standards in the catering service have continued, with all the recommendations made at the last visit by the Environmental Health Officer dealt with. The cook takes care to spend time each day with other staff and residents and also family members, so that he has good grasp of preferences and any issues over the food being served. A choice was available at the main meals, and this was conformed by comments from the residents and relatives spoken to, who were very positive about the quality of food served. Arrangements are made by the cook for people with special dietary needs, including people with diabetes, and he has worked particularly closely with the relatives of the resident referred to in the previous section whose dietary difficulties have been successfully resolved. DS0000028409.V302560.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a clear complaints procedure for residents and their representatives to use, and staff and managers of the home protect residents from harm. EVIDENCE: The home had a complaints procedure, which was available to residents and their friends and relatives. There was no record of any formal complaints being made recently but the deputy manager described some everyday problems that had been resolved informally; these had not been included in the records other than in individual files, which would aid monitoring. She described an open attitude in her dealings with relatives and advocates and also a healthy attitude of involving families in the home, in order to give some continuity with the resident’s past life. The relatives spoken to confirmed this and reported that they are comfortable in approaching the home’s management at any time and are confident that they will always be listened to. The home had received information on Derbyshire’s joint procedures for the protection of vulnerable adults, and the manager and her deputy have completed training provided by the local authority that is intended to help them pass the training on to members of the staff team. All current staff have had training in relation to this issue and those spoken to were aware of the issues and their responsibilities. A recent adult protection matter that had arisen at the home, and in which the statutory procedures were used, was discussed; steps taken by them home’s managers were properly carried DS0000028409.V302560.R01.S.doc Version 5.2 Page 15 through and awareness of this important responsibility has been improved within the staff group. DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a clean comfortable and well-maintained home. EVIDENCE: The home was purpose built in the early 1990’s and is spacious, light and airy with wide corridors and doorways for easy access. The home has continued to be maintained to a good standard and there has been an on-going programme of redecoration and refurbishment, with new carpets fitted in communal areas last year; communal areas and bedrooms had been refurbished as part of the on-going process. The manager and deputy manager have also paid particular attention to providing pictures, vases of flowers and table settings. The outside patio area has been improved to give a comfortable area for residents to use in periods of good weather. Some items of maintenance were noted during a tour of the building: The enamel in the downstairs bathroom is damaged. The paintwork in upstairs shower room is badly stained with mould. DS0000028409.V302560.R01.S.doc Version 5.2 Page 17 The lights in the upstairs and downstairs toilets are not working. Cleaning standards of the home and with the laundry were high on the day of the inspection, and the person on housekeeping duties described how this standard is maintained. DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff group is well trained, experienced and competent and staff are on duty in good numbers; this makes sure residents needs are met. EVIDENCE: The manager has continued to build up the staff group, with 2 vacancies recently filled by staff on full-time contracts; this will enable the home to be staffed to a good standard without staff working excessively long hours. The latter has been an issue recently with the staff vacancies, sickness and holidays, particularly for the deputy manager, but she was confident that steps being taken would solve the difficulties. Staff rotas demonstrated that adequate cover was normally available. Since the last inspection the numbers of staff undertaking NVQ training had increased, with 3 completed NVQ3 and 4 NVQ2. This is well above the target requirements of 50 of the staff group and should be commended. All staff have recently completed training in the protection of vulnerable adults, and a session on dementia awareness was provided by a member of the local mental health service. Staff spoken to felt that there was a commitment to their continued development on the part of the home’s management, and that standards of resident care is improved by doing so. Staff training records are held on individual files rather than within an overall record, which would allow for better monitoring of achievements. DS0000028409.V302560.R01.S.doc Version 5.2 Page 19 There had been 2 new staff recently appointed since the last inspection and the staff file of the most recent was checked. All the required checks had been undertaken including two written references, a Criminal Record Bureau (CRB) check and a comprehensive application form. Staff reported that they followed a satisfactory induction programme at the start of their employment. DS0000028409.V302560.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed with residents’ and relatives’ views being considered; a homely, safe and open environment has been created as a result. EVIDENCE: The manager completed the registration process during 2005 and has also gained the Registered Manager’s Award. She has, since appointment in 2004, put in place good management structures and developed an effective staff team. She has overseen the introduction of good recruitment systems and improved staff support. The proprietor has responded by continuing to invest in the home’s environment. DS0000028409.V302560.R01.S.doc Version 5.2 Page 21 Systems for managing resident monies are satisfactory; these are held separately and stored within the safe. Only the manager and deputy have access. Full records were maintained with two signatures. From an audit of Health and Safety practice in the home, records indicated that all matters were satisfactory apart from the annual servicing of fire safety equipment, which is now due. Of particular note is the standard of staff training, which includes ‘top-up’ training in all the required subjects, although there are a number of relatively new staff who have not received training or instruction in emergency first aid and safe food handling, which could lead to unsafe practices. DS0000028409.V302560.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 X 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 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 X X 3 X X 2 DS0000028409.V302560.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. 2. Standard OP19 OP38 Regulation 23(2) 23(4) Requirement The lights in the upstairs and downstairs toilets must be mended. The fire safety equipment must receive its annual service. Timescale for action 31/07/06 31/08/06 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 OP3 Good Practice Recommendations Information obtained during the initial assessment period of people coming to live at the home should present a more complete picture of that person and their previous lives, as well as their care needs. Care records should include a photograph of the resident, should record clearly all healthcare issues regarding that resident and should record all visits by health care professionals. Care plans should be reviewed, and revised where necessary, every month. The manager should ensure that staff receive training in hearing awareness in order to promote appropriate assessments and the provision of aids. 2. OP7 3. OP8 DS0000028409.V302560.R01.S.doc Version 5.2 Page 24 4. OP9 5. 6. 7. OP16 OP19 OP38 Where handwritten entries are made in the medicines record they should be signed and dated by the person responsible. All medicine records should contain a photograph of the resident. Informal complaints, concerns and problems should be recorded in the complaints record to assist with monitoring of the home’s services. Items requiring maintenance in the bathrooms and toilets should be attended to. All staff should receive training/instruction in emergency first aid and safe food handling. DS0000028409.V302560.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000028409.V302560.R01.S.doc Version 5.2 Page 26 - 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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