Inspection on 15/05/07 for Pendleton Court Care Centre

This inspection was carried out on 15th May 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pendleton Court Care Centre 27/02/07

Pendleton Court Care Centre 14/07/06

Pendleton Court Care Centre 08/02/06

Pendleton Court Care Centre 28/06/05

Pendleton Court Care Centre 04/11/04

Pendleton Court Care Centre 29/06/04

Pendleton Court Care Centre 01/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Pendleton Court Care Centre 22 Chaplin Close Salford Manchester M6 8FW Lead Inspector Rukhsana Yates Unannounced Inspection 15th May 2007 09:30 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 Pendleton Court Care Centre DS0000006726.V335764.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. Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pendleton Court Care Centre Address 22 Chaplin Close Salford Manchester M6 8FW 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) 0161 743 9798 0161 737 8080 www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited vacant post Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (56), Physical disability (2) of places Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons requiring nursing care at any one time shall not exceed 25 older persons, aged 65 years and over. That the number of persons requiring accommodation for personal care only at any one time shall not exceed 38 older persons aged 60 years and over within the overall maximum occupancy of 58. The service users requiring nursing care may be accommodated on the ground floor only. 2 named individuals requiring nursing care as a result of physical disability are accommodated on the ground floor. The registration will revert to older people if either of the service users leave or reach the age of 65. 27th February 2007 3. 4. Date of last inspection Brief Description of the Service: Pendleton Court Care Centre is a care home registered to provide accommodation for up to 37 older people requiring nursing care and 21 places for older people requiring personal care only. The home is owned by Southern Cross Healthcare Limited. The home is a converted mansion house situated in an elevated position at the rear of a residential estate. Accommodation is on two floors in single en-suite bedrooms. A passenger lift provides access to each floor. The home is within walking distance of a local park and shops. The home is close to the local bus routes into Manchester city centre and Salford/Eccles and is close to the motorway network. The current scale of charges at the home are £355-52 to £425 per week. Costs in addition to the fee are hairdressing, chiropody(private) and newspapers. Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In order to find out about the experiences of people living at Pendleton Court, a visit to the home took place without letting anyone at the home know beforehand. A total of 7 hours were spent at the home. The time was spent talking with people about their daily life in the home, watching the ways in which staff supported them, talking with the manager and looking at paperwork relating to care and safety. The findings of the inspection take account of comments made by people living and working there, visitors, and also written information received from the manager. A pharmacist inspector looked at how medication is managed. The service was inspected against key standards for homes for older people to see how well it was meeting a range of needs. These standards cover moving in, the care provided, daily routines and lifestyle, complaints, safety, comfort and cleanliness, how staff are employed and trained, and how the service is managed and developed. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those living at the home What the service does well: Before moving to the home, residents, or relatives on their behalf, may visit to look around and ask questions to make sure they are making the right choice. Residents have a choice of activities that they enjoy, and visitors are made welcome to the home. One of the comments was “you get up when you want, there’s cards, people come in to entertain us, there’s music and bingo, the food’s good.” They feel that the manager will listen to them if they have any problems. One person said “if you went to the manager with anything she’d sort it out. She’s very fair”. The home is tidy and clean and residents like their rooms. Staff have training in a good range of topics so that they can meet the residents’ needs. Pendleton Court Care Centre DS0000006726.V335764.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. The summary of this inspection report can be made available in other formats on request. Pendleton Court Care Centre DS0000006726.V335764.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 Pendleton Court Care Centre DS0000006726.V335764.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): 1 & 3: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assured that the service is suitable for them before moving in. EVIDENCE: Residents have an assessment of their needs carried out, by the manager, or a senior nurse, before admission. The assessment includes a visit to the person in their own home, or in hospital, by talking with the individual or with family members. One resident new to the home said “ it’s a lovely place; the manager visited me before I came and told me about the home”. Assessments are also obtained from health and social services agencies. The assessment includes physical and social care needs, helping to ensure that admissions to the home only take place if the manager is confident that the assessed needs of the individual can be met. Those considering moving to the home are invited and encouraged to Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 9 visit so that they can have a look around, and meet staff and other residents before making a decision. A relative recalled looking around the home and being given a pack. The pack includes an informative brochure and service users’ guide. As prospective residents may have difficulty reading or understanding the information, it would be of benefit to some residents to have the brochure and guide provided in a different format; for example, in large print, or using photos or other media so that they are better able to access and understand the information. Standard 6 is not applicable to this home. Pendleton Court Care Centre DS0000006726.V335764.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 adequate. This judgement has been made using available evidence including a visit to this service. Inadequate reviews of care plans and the poor management of medication do not ensure that residents’ health and personal care needs are properly met. EVIDENCE: Care plans contained some information about personal preferences in addition to care needs. For example, social profiles in some plans included newspapers taken, alcohol, dietary and beverage preferences and religious needs. Risk assessments were also documented with regard to nutrition, pressure areas, mobility and falls. Monthly evaluations, however, did not take account of changes to make sure information for staff was up to date, and this was reflected in the repetition of “care continued as plan”. The manager said that care plan training took place in April, and improvements to care planning are being introduced in recognition of these shortfalls. Observations during the visit highlighted a need to ensure residents maintain dignity in their dress by, for example, making sure they have matching slippers. The manager addressed this during the inspection. It was evident that Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 11 some residents have dementia care needs and arrangements have been made to provide training for staff in order that they can better communicate with and understand people who have dementia. The residents consulted said that the manager is caring and they are happy with the care. A relative said of her mother “She has been here two months and she is very happy. There’s a good atmosphere. She had stopped talking at home and now she is talking again. She tells me she has a say in her own life”. District nurses visiting the home did not express any concerns about the care they observed. The manager has made many improvements to the way medication is handled since the last inspection by the Pharmacist Inspector three weeks ago. The manager has done weekly audits of medicines and she found a number of errors had been made. The staff responsible for administering medicines have had supervision sessions and training meetings have been held. The manager had also made sure that all these staff had been assessed as competent in medicines administration. It was therefore very disappointing and of serious concern, at this inspection, to find that staff were still not handling medicines safely. The most serious concern found was, that residents were still not being given medicines as prescribed by the doctor. This was not the only example of poor record keeping nurses were failing to sign for medication given and are thus could put the residents health at risk from harm. The nurses also failed to record the quantity of medicine when it arrived in the home, this was seen when the medication records for two new residents were looked at. These records could not provide evidence that the new residents had been given their medication properly and they could not provide evidence that all medicines were accounted for or that residents had been given the correct dose. The manager of the home has taken these issues very seriously and sent the Commission details of the actions she has taken to address these issues. Pendleton Court Care Centre DS0000006726.V335764.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. Residents are satisfied that the service meets their expectations and preferences in respect of daily routines and meals. EVIDENCE: Residents confirmed that a wide range of recreational activities are provided and relatives are actively involved in social events at the home. Parties are frequently held at weekends and evenings so that relatives can come, and the manager has initiated an annual ball enjoyed by residents, relatives and staff. Residents talked about entertainers, games, music, bingo, singing, the home’s bar and a horse-racing game. One said “The manager’s nice – she’s really got things going, I’ve been on trips out.” Another said “you get up when you want, there’s cards, people come in to entertain us, there’s music and bingo, and the food’s good. The manager is very caring and she puts us first”. Residents’ religious needs are met by means of attendance at church, and priests visiting the home. Meals at the home are well thought out, nutritious and varied. The assistant cook was enthusiastic and had completed the Level 2 NVQ in professional cookery. He accompanied the manager on training for a new computer system Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 13 to be introduced at the home. This, when implemented, will enable menu planning that addresses the individual nutritional needs and special diets of residents. All residents consulted said the food is good, but none knew what was on the menu that day, and staff when asked did not know. It would assist residents to practice choice at mealtimes if staff knew the menu for each day when asked. The manager agreed to address this immediately. Pendleton Court Care Centre DS0000006726.V335764.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. Residents are confident that any issue they raise will be dealt with promptly, and they are safeguarded by the staff knowledge of adult protection policies. EVIDENCE: The complaints procedure is displayed in the home and included in the service users’ guide. Residents had confidence in the manager to address issues. One person said “if you went to the manager with anything she’d sort it out. She’s very fair”. However, the procedure should be simplified and in plain English so that it is accessible to people not wishing to approach the manager. Advocacy information is displayed, and there are regular relatives’ meetings to ensure that people have an opportunity to express their views. Complaints and their outcomes are recorded. There have been no complaints since the last inspection in February this year. The manager and staff are familiar with the procedures regarding the protection of residents. Guidance on the local multi-agency procedures is available for reference. This knowledge, along with safe recruitment processes, help to safeguard residents Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 15 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 benefit from living in a well-maintained, clean and comfortable environment. EVIDENCE: The home is a converted stone house in a peaceful and attractive residential area, and has well maintained gardens for residents’ use. The furnishings are homely in nature and residents’ bedrooms were seen to be comfortable and personalised. Residents said “It’s a lovely place” and “The cleaners always do their job. Its very clean”. There is a choice of communal areas and a bar has been installed for social events. Regular fire safety checks are carried out to ensure the environment is safe, and suitable infection control measures are in place. Aids to mobility were provided to promote residents’ independence. Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. The arrangements for employing, training and supporting care staff ensure that the needs of residents are met. EVIDENCE: Staffing levels appeared sufficient to meet the care needs of residents. Several staff members have worked at the home for a long time and this provides good continuity of care for residents. In addition to nurses and care staff, the service employs domestic and laundry staff, a maintenance person and activities coordinator. Staff records indicate that robust recruitment procedures are followed, with all necessary background checks carried out prior to employment. Good training and supervision arrangements are in place with several care staff having NVQ qualifications in care. At present several elements of the induction are completed in one day. The manager was advised to introduce a gradual and comprehensive induction for new staff so that they develop a good understanding of the home’s policies and practices. Residents made several positive comments about the staff, such as “the carers are nice, on the kind side”. One said “some staff talk to you but others just get on with it.” Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 17 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. Residents feel the service is run in their best interests. EVIDENCE: Residents and staff expressed confidence in the manager in respect of her experience and willingness to listen to suggestions. The hairdresser who has been coming into the home for a number of years said the manager had helped to create a “friendly atmosphere”. The manager does obtain the views of residents and visitors, but now needs to develop a quality assurance plan that shows people how their views are being used to improve the service. Inspection certificates relating to environmental health and safety matters were satisfactory. Residents’ personal allowances are well managed with accurate records of transactions maintained. Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 18 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2) Requirement Timescale for action 02/07/07 2. OP9 13 (2) Residents’ changing needs must be reflected in care plans so that staff are aware of changes and the actions to take to meet those needs. 15/05/07 1. Medication must be administered in strict accordance with the prescribers’ directions. To ensure that residents’ health is not harmed. (The previous timescales of 30/03/07 and 25/04/07 have not been met) 2. Medication must be accounted for at all times by means of an accurate audit trail. To ensure that it can be evidence that residents get the right doses of medication. (The previous timescales of 30/03/07 and 25/04/07 have not been met) 3. All records regarding medication must clear and accurate which can provide evidence that residents’ health is Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 20 not at risk from harm. (The previous timescales of 30/03/07 and 25/04/07 have not been met) 3 OP33 24(1) A development plan must be produced that shows people how their views are being used to improve the service and outcomes for residents. 01/08/07 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. Refer to Standard OP1 Good Practice Recommendations The service users’ guide should be provided in different formats; for example, in large print, or using photos or other media so that residents are better able to access and understand the information. The complaints procedure should be simplified and in plain English so that it is accessible to residents and relatives. The manager was advised to introduce a gradual and comprehensive induction for new staff so that they develop a good understanding of the home’s policies and practices. 2 3 OP16 OP30 Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Pendleton Court Care Centre DS0000006726.V335764.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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