Inspection on 08/11/05 for Pendlebury Court Care

This inspection was carried out on 8th November 2005.

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 13/07/06

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 Eileen McHale Unannounced Inspection 8th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000028409.V265160.R01.S.doc Version 5.0 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.V265160.R01.S.doc Version 5.0 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.V265160.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 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. It is within 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 en suite facilities. The home has a shaft lift. DS0000028409.V265160.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the home and met a group of residents in their own communal lounge and spoke privately with a visitor to the home. Records were inspected of routine health and safety checks and information provided on progress on staff training. Evidence was seen that CRB checks had been made. What the service does well: What has improved since the last inspection? The appearance of the home continues to improve with investment in the fabric of the building and the commitment of the manager to provide pictures, ornaments and flowers to lift the impression to a good domestic level. Progress has been made in staff training and increasing numbers of staff are undertaking NVQ training. DS0000028409.V265160.R01.S.doc Version 5.0 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. DS0000028409.V265160.R01.S.doc Version 5.0 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.V265160.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed on this occasion. DS0000028409.V265160.R01.S.doc Version 5.0 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): 7,8,10 Residents benefit from good attention to their needs including their health care needs and their appearance. EVIDENCE: At the time of the last inspection improvements had been made in the content of care plans and a key worker system had been set up. However the standard of care planning was patchy and in some instances areas of the care plan format had not been addressed. Since this inspection, the deputy manager had ensured that all residents had key workers; that care plans were reviewed monthly and attempts had been made to fill in any gaps within them. The manager indicated that staff had become more confident in completing care plans and detailed support had been given to less experienced staff. At the previous inspection it was not clear that all health inputs had been recorded within the residents’ notes. The manager confirmed that although District nurses kept their own notes all health inputs were now recorded within the residents’ own daily records. The inspector spoke to a visitor and a number of residents and was told that when needed staff were quick to seek medical and nursing assistance. Respondents also confirmed that residents were treated with respect and their DS0000028409.V265160.R01.S.doc Version 5.0 Page 10 privacy was maintained. In particular some people pointed out that the home provided laundry to a good standard so that they always looked clean and smart. DS0000028409.V265160.R01.S.doc Version 5.0 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 Residents in the home enjoy routines and meals which meet their preferences. EVIDENCE: Residents with one exception confirmed that they were happy in the home and were able to do much as they liked. Their views on what was available were mixed, with some able to identify entertainment and religious services which were provided and other confirming that they had access to books and magazines. They confirmed that they had daily routines, which suited them. One service user indicated that she had lost a hearing aid some time ago. She said that she was bored but on further discussion confirmed that she wanted the company of her own family only. All service users were very positive about meals provided within the home. The range of need of service users varied considerably with some services users being well oriented and others having significant memory loss. One visitor confirmed that meals in the home were very good and that the person she visited was eating much better. This visitor was also able to confirm that the resident’s independence was encouraged in the home and as a result her mental well-being and mood had improved significantly since admission. She indicated that she visited very regularly and was always made very welcome with the manager and deputy manager always happy to discuss any issue with her. DS0000028409.V265160.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed on this occasion. DS0000028409.V265160.R01.S.doc Version 5.0 Page 13 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): 19,26 Service users live in a clean comfortable home. EVIDENCE: The home was maintained to a good standard of cleanliness and there was an on-going programme of redecoration and refurbishment. Within the last year communal areas and circulation areas had been redecorated with new carpets where necessary and some bathrooms and bedrooms had been refurbished as part of the on-going process. The manager and deputy manager had also paid particular attention to providing pictures and vases of flowers to give the home a welcoming and comfortable appearance. Similarly table settings were attractive. As mentioned the home provided a good laundry service for linen and service users clothing. DS0000028409.V265160.R01.S.doc Version 5.0 Page 14 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): 27,28,29,30 Service users needs are met by properly recruited and trained staff. EVIDENCE: The manager continues to build a staff group, which included bank staff and enabled the home to staffed to a good standard without staff working excessively long hours. Staff rotas demonstrated that adequate cover was available. Since the last inspection the numbers of staff undertaking NVQ training had increased, three were undertaking NVQ3 and 6 NVQ2. In addition one staff member was undertaking training to be an NVQ assessor and a further staff member undertaking expert witness training for NVQ. The manager and her deputy had undertaken training for trainers on adult protection and were planning sessions in the near future, which would lead to their own accreditation as trainers. All staff in the home had provided evidence of identity, references and CRB checks. New contracts have been drawn up and some staff member have already received theirs. DS0000028409.V265160.R01.S.doc Version 5.0 Page 15 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): 31,38 Service users benefit from systematic safety checks and staff training in health and safety issues. EVIDENCE: Since the last inspection the manager has completed the registration process. She has also gained the Registered Manager’s Award. The manager has in the past year 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 investing in the home’s environment. The home has a programme in place for mandatory training. Training in Emergency First Aid is planned for the end of November for staff who are not trained or who require updates. All but two staff have completed a distance learning course on infection control most staff have completed food hygiene DS0000028409.V265160.R01.S.doc Version 5.0 Page 16 training but some will receive the required up date. Fire training has been provided to staff members through a video course with questions. Night staff are trained twice a year. The manager ensured that fire drills took place monthly and were recorded and that new staff undertook a fire drill within their first week of appointment. Staff had been trained in moving and handling on 13/10/05Full records were maintained of staff training. Full records were maintained of fire checks, and fire equipment, fire alarms and emergency lighting were checked as required. Systems were in place to check the safety of electrical equipment and electrical wiring and the home had a current gas safety certificate. Certificate. The home retained copies of checks and certificates for the shaft lift and other lifting equipment. A risk assessment had been completed for Legionella and procedures and information was in place for the control of substances hazardous to health. The deputy manager and maintenance man had undertaken training in risk assessment in order to complete required risk assessments for residents and the environment. DS0000028409.V265160.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x 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 x x x 3 DS0000028409.V265160.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations The manager should ensure that staff receive training on hearing awareness in order to promote appropriate assessments and the provision of aids. DS0000028409.V265160.R01.S.doc Version 5.0 Page 19 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. 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